CHRONIC OBSTRUCTIVE

PULMONARY DISEASE
CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Progressive chronic airflow

limitation associated with
abnormal inflammatory response
that is not fully reversible
Includes diseases that cause
airway obstruction
I. CHRONIC BRONCHITIS
Presence of cough and sputum production for at
least 3 months in each of 2 consecutive years
Smoke & environmental pollutants -- damage alveoli (inflammation)
Constant irritation→ increase in number of mucus
secreting gland and goblet cells, reduced ciliary
function, more mucus produced
scarred
Adjacent alveoli become damaged and fibrosed →
altered function
patient susceptible to respiratory infection of alveolar
macrophages
II. EMPHYSEMA
Abnormal distention of the airspaces and
destruction of the walls of over-distended
alveoli damage to the alveolar walls --> the alveolar surface in direct contact with the
pulmonary capillaries will decrease
no gas exchange
Increase in dead space & impaired oxygen
diffusion
Complication: Right sided heart failure
of the lungs
heart
(cor pulmonale) "heart of the lungs"
dependent edema
distended neck veins/ jugular veins
TYPES OF EMPHYSEMA
▪ Panlobar (panacinar)
Destruction of the respiratory bronchiole,
alveolar duct, & alveoli
All air spaces within the lobule - inflamed (little
inflammatory disease)
eventually leads to dyspnea at rest
Barrel chest, dyspnea on exertion, weight loss
Respiration becomes active & requires muscular
effort
hypoxia - decreased O2 in the tissues

▪ Centrilobar (centroacinar)
Pathologic changes: mainly in the center of the
secondary lobule
Produces hypoxemia, hypercapnia, polycythemia
vera, & episodes of right-sided heart failure
bluish discoloration of the lips
Central cyanosis, peripheral edema, & respiratory
failure
peripheral cyanosis - extremities
EMPHYSEMACOPD
RISK FACTORS
▪ Cigarette smoking
Smoking depresses the activity of the scavenger cells and
the respiratory tract’s cleansing mechanism
▪ Passive smoking
▪ Prolonged and intense exposure to occupational
dusts & chemicals, air pollution
▪ Host risk factor: Alpha1 antitrypsin deficiency
Enzyme inhibitor that protects the lung parenchyma
from injury
COPD
CLINICAL MANIFESTATIONS
may be intermittent, non-productive

▪ Primary symptoms: chronic cough, sputum

production, and dyspnea on exertion ==> dyspnea at rest

▪ Weight loss: dyspnea interferes with eating,

work of eating is energy depleting
▪ Use of accessory muscles for breathing
▪ Advanced emphysema: abdominal muscles also
contract on inspiration
Based on the results of Spirometry

Normal: at least 80%

ASSESSMENT
▪ Health history
▪ Physical assessment Nasal polypectomy
Nasal polypectomy

Pack Years = No. of packs consumed/day x No. of years the pt. has smoked
= 2 packs/day x 10 yrs
Pack years = 20
DIAGNOSTIC
▪ Spirometry
Evaluate airflow obstruction
Determined by the ratio of FEV1 (volume of air
that the patient can forcibly exhale in 1
second) to FVC (force vital capacity)
▪ Bronchodilator reversibility testing
- to determine maximum lung expansion

Rule out diagnosis of asthma & to guide initial

Spirometry & bronchodilators
treatment 1 Spirometry
Results:
Improved after bronchodilator was given = Asthma

▪ ABG
2 Bronchodilator
No improvement after bronchodilators = COPD
3 Spirometry again
1. and
Respiratory acidosis, Decrease in O2 saturation Spirometry
PO2
▪ Chest X-ray
Normal
Emphysema Chronic Bronchitis
COMPLICATIONS
▪ Respiratory insufficiency & failure
▪ Infection
▪ Pneumonia
▪ Chronic atelectasis
▪ Pneumothorax air inside the pleural cavity

▪ cor pulmonale LSHF

MEDICAL MANAGEMENT
Challenges: nicotine- addictive, setting, depression, habit

▪ Risk reduction 1 Explain the risks of smoking

2 Set a quit date
3 Refer to support groups or smoking cessation programs
Smoking cessation 4 Follow-up - 3-5 days after quit date (phone call, clinic visits)
5 Relapses: Assess and analyze what happened
Nicotine replacement
Bupropion SR (Wellbutrin) 1st line of pharmacotherapy
gum, inhaler, lozenges, nasal spray, transdermal patch, SL
tablets
nortriptyline (Aventyl)
Antidepressants
Clonidine (Catapress) anti-hypertensive agent; side effects may limit use
▪ Varenicline (chantix) – nicotinic acetylcholine
receptor partial agonist may assist in smoking cessation
▪ Pharmacologic Therapy
Bronchodilators: relieve bronchospasm &
reduce airway obstruction
Metered-dose inhaler
Classes: beta-adrenergic agonist, anticholinergic
agents, & methylxanthines
Corticosteroids
Other medications
■ Influenza vaccine: yearly
■ Pneumococcal vaccine: every 5-7 years
MANAGEMENT OF EXACERBATION
▪ Supplemental O2 therapy & rapid assessment : 1st
line treatment
▪ Short-acting bronchodilator + oral/IV corticosteroids
▪ OXYGEN THERAPY
Indicated for PaO2 of 55 mm Hg or less 80-100 mm Hg

Goal:
■ Increase PaO2 to at least 60 mmHg
■ Increase SaO2 to at least 90%
SURGICAL MANAGEMENT
▪ Bullectomy Bullae

Surgical excision of bullous emphysema

Done thoracoscopically or via limited thoracotomy
incision
▪ Lung Volume Reduction Surgery
Removal of a portion of the diseased lung parenchyma
▪ Lung Transplantation
Alternative for definitive treatment of end-stage
emphysema
PULMONARY REHABILITATION
Goals: Reduce symptoms, improve quality of life and increase
physical and emotional participation in everyday activities.
- For Grade II to IV COPD
- Minimum length: 6 weeks
▪ Programs: Pack years = No. of packs consumed per day x No. of years the pt. has smoked
Pack years = 2 packs per day x 5 years
Assessment Pack years = 10
Education
■ Smoking cessation
■ Physical reconditioning
■ Nutritional counseling
■ Skills training
■ Psychological support
 NURSING MANAGEMENT
▪ Patient Education
▪ Breathing Exercises
Diaphragmatic breathing -
Pursed-lip breathing

▪ DIAPHRAGMATIC BREATHING
Goal: To use and strengthen the diaphragm during breathing
▪ Place one hand on the abdomen and the other hand on the middle of
the chest
▪ Breathe in slowly and deeply through nose, letting the abdomen
protrude as far as possible
▪ Breathe out through pursed lips while tightening the abdominal
muscles
▪ Press firmly inward and upward on the abdomen while breathing out.
▪ Activity Pacing
▪ Self-care activities
▪ Physical Conditioning
Breathing exercises
Treadmills
Stationary bicycles
Measured level walks
▪ Oxygen therapy
Caution that smoking near O2 is dangerous!
▪ Nutritional Therapy
Assess caloric needs and monitor weight
▪ Coping Measures
NURSING PROCESS
▪ Assessment
Health history
Inspection and examination findings
Diagnoses
Impaired gas exchange related to
ventilation-perfusion inequality
Ineffective airway clearance related to
bronchoconstriction, increased mucus production,
ineffective cough, bronchopulmonary infection
Ineffective breathing pattern related to shortness
of breath, mucus, bronchoconstriction
Planning and Goals
Smoking cessation
Improve gas exchange, airway clearance,
improve breathing pattern
Nursing Interventions
Promoting Smoking Cessation
Improving Gas exchange
■ Monitor patient for dyspnea & hypoxemia
■ Administer medications: bronchodilators & corticosteroids
▪ Achieving Airway clearance
Directed coughing: controlled coughing
▪ Chest physiotherapy w/ postural drainage, intermittent
positive-pressure breathing, increased fluid intake, bland
aerosol mists
▪ Improving Breathing Patterns
Diaphragmatic breathing
Pursed-lip breathing
Intermittent Positive-Pressure Breathing (IPPB)
▪ Improving Activity Tolerance
▪ Enhancing Self-care strategies
Setting realistic goals
Avoiding temperature extremes
■ Heat increases body temp. → ↑se O2 requirements
■ Cold promote bronchospasm
▪ Modifying Lifestyle
▪ Enhancing Individual Coping Strategies
▪ Monitoring & Managing Potential Complications
END