COPD- CHRONIC OBSTRUCTIVE PULMONARY Types of COPD include:

DISEASE
 Emphysema “pink puffers”
Definition: Pulmonary disease that causes chronic
 Chronic bronchitis “blue bloaters”
obstruction of airflow from the lungs
Pathophysiology of COPD
Keys Point for COPD:
Normal breathing:
 Limited Airflow (due to thick and swollen
bronchioles that have become deformed with Inhaled oxygen travels down through the trachea
excessive sputum production and this narrows which splits at the carina into bronchial tubes starting
the airways) with the primary bronchus then into smaller airways
called secondary and tertiary bronchi which divide
 Inability to fully exhale (due to loss of elasticity
into bronchioles and the oxygen goes into the
of the alveoli sacs from damage and the sacs
alveolar sacs where gas exchange happens. As the
start to develop air pockets)
alveoli inflate and deflate with ease, inhaled oxygen
 Irreversible once developed…cases vary among attaches to the red blood cells and carbon dioxide
people from mild to severe…managed with enters the respiratory system to be exhaled.
lifestyle changes and medications.
What happens in breathing with COPD?
 Happens gradually….most people start to
In conditions such as chronic bronchitis “blue
notice signs and symptoms middle-aged and
bloaters”:
will present with dyspnea with activity they
could normally tolerate, recurrent lung The name “blue bloaters” is due to cyanosis from
infections, chronic cough etc. “hypoxia” and bloating from edema AND increase in
lung volume. The bloating is from the effects of the
 COPD is a term used as a “catch all” for
diseases that limit airflow and cause dyspnea.
lung disease on the heart which causes right-sided
heart failure.
In chronic bronchitis, the bronchioles become
damaged that leads them to be thick and swollen and
deformed. This is accompanied by more sputum
production. This limits the ability of the person being
able to completely exhale the air taken in. So, when
they take another breath in, it will increase the air
volume even more (because they have retained air
from the previous breath), and this leads to
hyperinflation.
Also, less oxygen is getting into the blood and more
carbon dioxide is staying in the blood. This leads.
To low blood levels and high carbon dioxide levels.
Patients will have cyanosis due to a decreased oxygen
level. To compensate, the body increases RBC
production and cause blood to shift elsewhere which
increases pressure in the pulmonary artery leading to
pulmonary hypertension. Pulmonary hypertension
leads to right-sided heart failure (which is why you
will start to see bloating. edema in the abdomen and
legs)
In conditions such as emphysema “pink puffers”:
The name comes from hyperventilation (puffing to
breathe) and pink complexion (they maintain a
relatively normal oxygen level due to rapid breathing)
rather than cyanosis as in chronic bronchitis.
In emphysema, the alveoli sacs lose their ability to
inflate and deflate due to an inflammatory response
in the body. So, the sac is unable to properly deflate
and inflate. Inhaled air starts to get trapped in the
sacs and this causes major hyperinflation of the lungs
because the patient is retaining so much volume.
Hyperinflation causes the diaphragm to flatten. The
diaphragm plays a huge role in helping the patient
breathe effortlessly in and out. Therefore, in order to
fully exhale, the patient starts to hyperventilate and
use accessory muscles to get the air out now. This
leads to the barrel chest look and during inspect it
may be noted there is an INCREASED
ANTEROPOSTERIOR DIAMETER.
The damage in the sacs cause the body to keep high
carbon dioxide levels and low blood oxygen levels.
Inhaled oxygen will not be able to enter into the sacs
for gas exchange and carbon dioxide won’t leave the
cells to be exhaled.
The body tries to compensate by causing
hyperventilation (increasing the respiratory rate…
hence puffer) and the patient will have less
hypoxemia “pink complexion” than chronic bronchitis
who have the cyanosis because pink puffers keep
their oxygen level just where it needs to be from
hyperventilation.
Signs & Symptoms of COPD
Remember: Lung Damage
Lack of energy
Unable to tolerate activity (shortness of breath)
Nutrition poor (weight loss) due to energy used
breathing especially with emphysema
Gases abnormal (high PCO2 >45 and low PO2
<90)..respiratory acidosis
Accessory muscle usage during
breathing, Abnormal lung sounds: diminished, coarse
crackles (chronic bronchitis) or wheezing
Modification of skin color from pink to cyanosis in
lips, mucous membranes, nail beds (“blue bloaters”)
Anteroposterior diameter increased (barrel chest)
….emphysema  “pink puffers”
Gets in the Tripod Position during dyspnea (stands
leaning forward while supporting body with hands on
knees or an object)
Extreme dyspnea
In turn over time, people with COPD will be
stimulated to breathe due to low oxygen levels
RATHER than high carbon dioxide levels.
Complications of COPD
 Heart Disease (remember heart and lungs work
together in replenishing the body with oxygen)
…heart failure
 Pneumothorax (spontaneous due to forming of
air sacs)
 Risk for Pneumonia
 Cancer (especially lung)
How is COPD Diagnosed?
Spirometry: A test where a patient breathes into a
tube that measure how much volume the lungs can
hold during inhalation and how much and fast air
volume is exhaled.
 Measuring the FVC (Forced Vital Capacity): a
low reading shows restrictive breathing….it
measures the largest amount of air a person
exhales after breathing in deeply in one
second.
 Forced Expiratory Volume: measures how
much air a person can exhale within one
second. A low reading shows the severity of
the disease.
Nursing Interventions for COPD
Monitor Respiratory System:
 Assess lung sounds (may need suction) and
sputum production…obtain a culture if
ordered…at risk for pneumonia
 Keep oxygen saturation (88%-93%) why
between this ranges?
 Patients with COPD are stimulated to
breathe due to LOW OXYGEN
SATURATION rather than high carbon
dioxide levels….which is the opposite for
people for healthy lungs. If they are
given too much oxygen it will reduce
their need to breathe…causing
hypoventilation and carbon dioxide
levels will increase to toxic levels.
 Given oxygen as prescribed in low amounts 1-2
liters
 Monitor effort of breathing and teach about
pursed-lip and diaphragmatic breathing
 Pursed-lip breathing: used for when patient Patient Education for COPD
starts to get dyspneic. This technique increases
 Nutrition needs: eating high calorie, protein
the oxygen level and encourages them to
rich meals that are small but frequent and
breathe out longer (remember these patient
staying hydrated if not contraindicated….avoid
don’t fully exhale very well). It is similar to like
large heavy meals due to compression on the
blowing out a birthday candle.
lungs from the stomach
 Diaphragmatic breathing: uses abdominal
 Avoiding sick people, irritants, hot humid
muscles for breathing rather than accessory
(smothering) or very cold weather
muscles
 Stop smoking or being around people who
 helps make diaphragm stronger which is
smoke
weak
 Vaccination up-to-date: annual flu shot and
 slows down breathing rate to allow
Pneumovax every 5 years because it is very
breathing to be easier
hard for people with COPD to recover from
 decreases energy used to breathe illnesses
 used along with pursued breathing  Pursed lip and diaphragmatic breathing
technique techniques
 Administering breathing treatments as needed:  Administering medications: be familiar with
bronchodilators, nebulizer etc. Respiratory groups, side effects, and patient teaching
therapy helps play a role in this as well
(medications are discussed in more detail
below)
Medication Regime for COPD
Remember the
mnemonic: Chronic Pulmonary Medications Save Lun
gs
Corticosteroids: decreases inflammation and mucous
production in airway… given: oral, IV, inhaled and
used in combination with bronchodilator like:
 Symbicort: combination of steroid and long
acting bronchodilator
 Other corticosteroids: Prednisone, Solu-
medrol, Pulmicort
 Side effects: easy bruising, hyperglycemia, risk
of infection, bone problems (long term use)
 Patient education: rinse mouth after
using inhaled corticosteroids…can
develop thrush, use corticosteroid
inhaler AFTER using bronchodilator
inhaler
Methylxanthines: Theophylline (most commonly
given orally) type of bronchodilator used long term in
patients who have severe COPD
 Remember: Narrow therapeutic range of 10 to
20 mcg/mL
 Increases risk for digoxin toxicity and decreases
the effects of lithium and Dilantin
Phosphodiestrace-4 inhibitors: “Roflumilast”  used
for people who have chronic bronchitis and it works
by decreasing COPD exacerbation…not a
bronchodilator
 Side effects: can cause suicidal thoughts
(remember the word “last” in the drug’s
name…it could be the patient’s last days if they
are not assessed for this side effect) and can
cause weight loss.
Short-acting bronchodilators: relaxes the smooth
muscle of the bronchial tubes and are used in
emergency situations where quick relief is needed
 Albuterol (beta 2 agonist) and Atrovent
(anticholinergic)
Long-acting Bronchodilators: relaxes the smooth
muscle of the bronchial tubes (same as short-acting
bronchodilators BUT their effects last longer) used
over a longer period of time….taken once or twice a
day
 Beta 2 agonist: salmeterol, anticholinergics:
Spiriva
 Patient education: let them know which drug is
short and long-acting, how to use inhaler  and
to use bronchodilator inhaler BEFORE steroid
inhaler  (wait 5 minutes in between)
 WHY?  TO OPEN UP THE AIRWAYS SO
THE STEROID CAN GET IN THERE AND
DO ITS JOB
 Side effects of beta 2 agonist: increased heart
rate, urinary retention
 Side effects of anticholinergic: dry mouth,
blurred vision
COPD QUIZ
1. True or False: COPD is reversible and tends
to happens gradually.*
True
False
2. A patient is presenting with chronic
obstructive pulmonary disease. The patient
has a chronic productive cough with dyspnea
on excretion. Arterial blood gases show a low
oxygen level and high carbon dioxide level in
the blood. On assessment, the patient has
cyanosis in the lips and edema in the
abdomen and legs. Based on your nursing
knowledge and the patient's symptoms, you
suspect the patient suffers from what type of
COPD?*
A. Emphysema
B. Pneumonia
C. Chronic bronchitis
D. Pneumothorax
3. A patient with emphysema may present
with all of the following symptoms EXCEPT?*
A. Barrel chest
B. Hyperinflation of the lungs
C. Hypoventilation
D. Hypercapnia
4. The term" blue bloaters" is used to describe
patients with?*
A. Pulmonary hypertension
B. Left-sided heart failure
C. Chronic Bronchitis
D. Emphysema
5. A patient is newly diagnosed with COPD
due to chronic bronchitis. You're providing
education to the patient about this disease
process. Which statement by the patient
indicates they understood your teaching
about this condition?*
A. "If I stop smoking, it will cure my condition."
B. "Complications from this condition can lead
to pulmonary hypertension and right-sided
heart failure."
C. "I'm at risk for low levels of red blood cells
due to hypoxia and may require blood
transfusions during acute illnesses."
D. "My respiratory system is stimulated to
breathe due to high carbon dioxide levels
rather than low oxygen levels.
6. An alarm beeps notifying you that one of
your patient's oxygen saturation is reading
89%. You arrive to the patient's room, and see
the patient comfortably resting in bed
watching television. The patient is already on
2 L of oxygen via nasal cannula. The patient is
admitted for COPD exacerbation. Your next
nursing action would be:*
A. Continue to monitor the patient
B. Increase the patient's oxygen level to 3 L
C. Notify the doctor for further orders
D. Turn off the alarm settings
7. You are providing teaching to a patient with
chronic COPD on how to perform
diaphragmatic breathing. This technique helps
do the following:*
A. Increase the breathing rate to prevent
hypoxemia
B. Decrease the use of the abdominal muscles
C. Encourages the use of accessory muscles to
help with breathing
D. Strengthen the diaphragm
8. A patient with severe COPD is having an
episode of extreme shortness of breath and
requests their inhaler. Which type of inhaler
ordered by the physician would provide the
FASTEST relief for the patient based on this
particular situation?*
A. Spiriva
B. Salmeterol
C. Symbicort
D. Albuterol
9. Which of the following statements are
incorrect about discharge teaching that you
would provide to a patient with COPD? Select-
all-that-apply:*
A. "It is best to eat three large meals a day
that are relatively low in calories."
B. "Avoid going outside during extremely hot
or cold days."
C. "It is important to receive the Pneumovax
vaccine annually."
D. "Smoking cessation can help improve your
symptoms."
10. A patient is ordered by the physician to
take Pulmicort and Spiriva via inhaler. How
should the patient take this medication?*
A. The patient should use the medications
every 2 hours for acute episodes of shortness
of breath.
B. The patient should use the Spiriva first and
then 5 minutes later the Pulmicort.
C. The patient should use the Pulmicort first A. Atrovent
and then the Spiriva 5 minutes later.
B. Prednisone
D. The patient should use the medications at
C. Roflumilast
the same exact time, regardless of the order.
D. Theophylline
11. In regards to question 10, which action by
the patient demonstrates they know how to 13. A patient is ordered at 1400 to take
properly use this medication?* Theophylline. You're assessing the patient’s
morning lab results and note that the
A. The patient rinses their mouth after using
Theophylline level drawn this morning reads:
the Spiriva inhaler.
15 mcg/mL. You're next nursing action is to?*
B. The patient rinses their mouth after using
A. Administer the dose at 1400 as ordered
the Pulmicort inhaler.
B. Notify the physician for further orders
C. The patient dispenses of the inhalers.
C. Hold the 1400 dose
D. The patient coughs 2 times after using the
Pulmicort inhaler. D. Collect another blood sample to confirm
the level
12. A patient with COPD is reporting
depression and thoughts of suicide. The
patient states, "I just feel like ending it all."
You assess the patient’s health history and
note that the patient was recently started on
which medication that could cause this side
effect:*
14. You are providing care to a patient with Answer Key:
COPD who is receiving medical treatment for 1. False
exacerbation. The patient has a history of 2. C
3. C
diabetes, hypertension, and hyperlipidemia.
4. C
The patient is experiencing extreme 5. B
hyperglycemia. In addition, the patient has 6. A
multiple areas of bruising on the arms and 7. D
8. D
legs. Which medication ordered for this 9. A, C
patient can cause hyperglycemia and 10. B
bruising?* 11. B
12. C
A. Prednisone 13. A
14. A
B. Atrovent
C. Flagyl
D. Levaquin