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• The Global Initiative for Chronic
Obstructive Lung Disease (GOLD) has
defined chronic obstructive pulmonary
disease (COPD) as “a preventable and
treatable disease with some significant extra
pulmonary effects that may contribute to
the severity in individual patients. Its
pulmonary component is characterized by
airflow limitation that is not fully reversible.
• The airflow limitation is usually progressive
and associated with an abnormal
inflammatory response of the lung to
noxious particles or gases” (GOLD, 2008, p.
• COPD may include diseases that cause
airflow obstruction (eg, emphysema, chronic
bronchitis) or any combination of these
disorders. Other diseases such as cystic
fibrosis, bronchiectasis, and asthma that were
previously classified as types of COPD are
now classified as chronic pulmonary
• Asthma is now considered a distinct,
separate disorder and is classified as an
abnormal airway condition characterized
primarily by reversible inflammation. COPD
can coexist with asthma. Both of these
diseases have the same major symptoms;
however, symptoms are generally more
variable in asthma than in COPD.

• Chronic bronchitis, a disease of the airways, is defined as the presence

of cough and sputum production for at least 3 months in each of 2
consecutive years. Although, chronic bronchitis is a clinically and
epidemiologically useful term, it does not reflect the major impact of
airflow limitation on morbidity and mortality in COPD (GOLD, 2008).
In many cases, smoke or other environmental pollutants irritate the
airways, resulting in inflammation and hypersecretion of mucus.
• In emphysema, impaired oxygen and
carbon dioxide exchange results from
destruction of the walls of over
distended alveoli. Emphysema is a
pathologic term that describes an
abnormal distention of the airspaces
beyond the terminal bronchioles and
destruction of the walls of the alveoli
(GOLD, 2008). This is the end stage of a
process that progresses slowly for many
• Stage 0 – At risk. Lung function normal, but chronic cough and sputum
production are present
• Stage 1 – Mild COPD. Mild airflow limitation, usually with chronic cough and
sputum production
• Stage 2 – Moderate COPD. Worsening airflow limitation, usually with
progressing manifestations including dyspnea on exertion
• Stage 3 – Severe COPD. Further worsening fo airflow limitation, increased
shortness of breath, and repeated exacerbations impacting quality of life
• Stage 4 – Very Severe COPD. Severe airflow limitation with significantly
impaired quality of life and potentially life-threatening exacerbations
Exposure to tobacco smoke. The most significant risk factor for COPD is long-term cigarette smoking.
The more years a person smoke and the more packs a person smoke, the greater the risk. Pipe
smokers, cigar smokers and marijuana smokers also may be at risk, as well as people exposed to large
amounts of secondhand smoke.
• People with asthma who smoke. The combination of asthma, a chronic inflammatory airway
disease, and smoking increases the risk of COPD even more.
• Occupational exposure to dusts and chemicals. Long-term exposure to chemical fumes,
vapors and dusts in the workplace can irritate and inflame the lungs.
• Exposure to fumes from burning fuel. In the developing world, people exposed to fumes from
burning fuel for cooking and heating in poorly ventilated homes are at higher risk of developing COPD.
• Age. COPD develops slowly over years, so most people are at least 40 years old when
symptoms begin.
• Genetics. The uncommon genetic disorder alpha-1-antitrypsin deficiency is the cause of some
cases of COPD. Other genetic factors likely make certain smokers more susceptible to the disease.
• Respiratory infections. People with
COPD are more likely to catch colds, the flu and
pneumonia. Any respiratory infection can make it
much more difficult to breathe and could cause
further damage to lung tissue. An annual flu
vaccination and regular vaccination against
pneumococcal pneumonia can prevent some
• Heart problems. For reasons that aren't
fully understood, COPD can increase the risk of
heart disease, including heart attack. Quitting
smoking may reduce this risk.
• Lung cancer. People with COPD
have a higher risk of developing lung cancer.
Quitting smoking may reduce this risk.
• High blood pressure in lung arteries.
COPD may cause high blood pressure in the
arteries that bring blood to the lungs
(pulmonary hypertension).
• Depression. Difficulty breathing can
keep you from doing activities that you
enjoy. And dealing with serious illness can
contribute to development of depression.
Although the natural history of COPD is variable, it
is generally a progressive disease characterized by
three primary symptoms: chronic cough, sputum
production, and dyspnea.
Other signs and symptoms of COPD may include:
• Wheezing
• Chest tightness
• Blueness of the lips or fingernail beds
• Frequent respiratory infections
• Lack of energy
• Unintended weight loss (in later stages)
• Swelling in ankles, feet or legs
Pulmonary function testing is
performed to establish the diagnosis
and evaluate the extent and progress
of COPD. Results are based on
calculated norms for each person by
age, height, sex, and weight; note these
as well as all current medications on
the requisition. In COPD, the total
lung capacity and residual volume
typically are increased. The forced
expiratory volume (FEV1) and forced
vital capacity (FVC) are decreased due
to narrowed airways and resistance to
• Instructions to patients
• Do not smoke for one hour before test
• Do not drink alcohol within four hours of test
• Do not eat a large meal within two hours of test
• wear loose clothing
• Do not perform vigorous exercise within 30 minutes of test
• Look for physician’s instructions regarding inhaler medications
• The patient is asked to take the deepest breath they can, and then exhale into the sensor as
hard as possible, for as long as possible, preferably at least 6 seconds. It is performed by a
technician using a spirometer that has a volume collecting device attached to a recorder that
demonstrates time and volume simultaneously.
Ventilation-perfusion scanning
may be performed to determine
the extent of ventilation/perfusion
—that is, the extent to which lung
tissue is ventilated but not
perfused (dead space), or perfused
but inadequately ventilated
(physiologic shunting) A
radioisotope is injected or inhaled
to illustrate areas of shunting and
absent capillaries
• Explain to the client:
• Inform the client of the scanning schedule and explain that the study takes 30 minutes.
• That a sedative can be administered before the study to promote relaxation
• Inform the client that a breathing mask is used to administer the radiopharmaceutical for the
ventilation study, and allay anxiety associated with this procedure.
• History should include information about the pulmonary status, recent x-ray results, and the
determination of whether the client can lie flat or needs to elevate the head on pillows to
facilitate breathing during the procedure.
• That a minute amount of radioactive material will be administered by IV injection and that this
does not cause harm to the client or those in contact with him or her
• That the radioactive material is excreted by the body, usually in the urine
• That scanning will take place immediately after the injection or at a later
time, depending on the
• material used, with a machine that moves over the area to be examined
• That a medication to enhance scanning can be administered before the
• That the only discomfort experienced is the injection of the
Prepare for the procedure:
• Obtain a history to ascertain last menstrual period date and possible
pregnancy in women of
• childbearing age, known and suspected cerebral disorders, allergy to
iodine, assessment information of neurological system, tests and procedures
conducted and results, or therapeutic interventions performed.
• Administer any ordered medications such as potassium iodine to block
thyroid uptake of the radionuclide or potassium chloride to block choroid
plexus uptake if a radionuclide other than 99mTc is used.17
• Have the client void before the study to prevent discomfort or

• Advise the client of the time to return for additional imaging, if

• Inform the client that the radioactive substance is eliminated
from the body within 6 to 24 hours and that fluid intake should be
increased to encourage this process.
• Phlebitis: Note and report redness, pain, and swelling at the IV
site. Elevate arm, and apply warm compress to the site
Serum alpha1-antitrypsin levels may be drawn to screen for deficiency,
particularly in patients with a family history of obstructive airway disease,
those with an early onset, women, and nonsmokers. Normal adult serum
alpha1-antitrypsin levels range from 80 to 260 mg/dL. Fasting is not
required prior to this test
• Arterial blood gases (ABGs) are drawn to
evaluate gas exchange, particularly during
acute exacerbations of COPD. Patients
with predominant emphysema often have
mild hypoxemia and normal or low carbon
dioxide tension. Respiratory alkalosis may
be present due to an increased respiratory
rate. Predominant chronic bronchitis and
airway obstruction may cause marked
hypoxemia and hypercapnia with
respiratory acidosis. Oxygen saturation
levels are low due to marked hypoxemia.
• Allen’s test is done prior to
arterial puncture.
• Arterial puncture of radial artery,
femoral artery, brachial artery is done.
• After puncture, pressure dressing
must be applied on the site.
• Heparinized syringe may be used
for withdrawal.
• The sample is kept on ice &
transported to laboratory as soon as
• Pulse oximetry is used to
monitor oxygen saturation of
the blood. Marked airway
obstruction and hypoxemia often
causes oxygen saturation levels
less than 95%. Pulse oximetry
may be continuously monitored
to assess the need for
supplemental oxygen.
• It should be applied on
the nail bed.
• The nail should not
have an impaired circulation.
• The sensor should be
working i.e a red light must
be seen,
• The probe must be
applied to a monitor.

• Exhaled carbon dioxide (capnogram or ETCO2) may be

measured in ventilated patients to evaluate alveolar
ventilation. The normal ETCO2 reading is 35 to 45 mmHg;
it is elevated when ventilation is inadequate, and decreased
when pulmonary perfusion is impaired. ETCO2 monitoring
can reduce the frequency of ABG determinations.

• CBC with WBC differential often shows increased RBCs and

hematocrit (erythrocytosis) as chronic hypoxia stimulates increased
erythropoiesis to increase the oxygen-carrying capacity of the blood.
Polycythemia, increased numbers of all blood cells, may be evident.
Increased WBC count and a higher percentage of immature WBCs
(bands) are often indicative of bacterial infection.
• Immediately after blood is drawn, pressure is applied (with cotton or
gauze) to the puncture site. Resume your normal activities and any medications
withheld before the test.
• Blood may collect and clot under the skin (hematoma) at the puncture
site; this is harmless and will resolve on its own. For a large hematoma that
causes swelling and discomfort, apply ice initially; after 24 hours, use warm, moist
compresses to help dissolve the clotted blood.

• Chest x-ray may

show flattening of
the diaphragm due
to hyperinflation and
evidence of
pulmonary infection
if present.
• Nurses may need to reduce anxiety in some patients, particularly in those who are very young or confused.
Some may be anxious about the exposure to radiation, and need to be given as much information as possible about the
test, and to be reassured that the benefits of having the test far out way the very small risk involved.
• Some physical preparation is sometimes required, especially for more extensive investigations involving
contrast media.
• Simple, loose clothing is important to gain access to that part of the body under examination. This may mean
a loose fitting gown for hospital patients. The patient may need a dressing gown and footwear for privacy and warmth
while away from bed.
• If the investigation involves contrast medium, check to see if the patient has any allergies, particularly to
iodine or seafood (which may indicate an iodine allergy). Report any allergies the patient has to the radiography staff.
• Some specialized X-ray investigations may require nothing by mouth for a few hours before the test, or a
particular bowel preparation. Often, the radiography department will issue specific instructions when the appointment
is made. Nurses should ensure these instructions are carried out for all hospital patients.
• Check to see if a female patient is, or could be pregnant. Exposure of the unborn fetus to X-rays can be
damaging to the child.
• After the test, the patient should be returned to their normal activities if these have been disturbed, i.e.
eating and drinking, as quickly as possible.
• Smoking cessation can not only prevent COPD
from developing, but also can improve lung
function once the disease has been diagnosed.
Forced expiratory volume (FEV1) improves, and
survival is prolonged, largely due to lower rates
of lung cancer and heart disease. Sustained
quitting is difficult; only 6% of smokers succeed in
long-term abstinence from smoking. Use of
nicotine patches or gum and an antidepressant
such as bupropion (Wellbutrin, Zyban) or
varenicline (Chantix) improve the chances of
success (Fiore et al., 2008).
• a. Immunization against
pneumococcal pneumonia and
yearly influenza vaccine are
recommended to reduce the risk of
respiratory infections. A broad-
spectrum antibiotic is prescribed if
infection is suspected. Recent
studies indicate that patients with
purulent sputum and increased
dyspnea will likely benefit from
antibiotic therapy, even if no other
signs of infection are present.
Prophylactic antibiotics may be
ordered for patients who
experience four or more disease
exacerbations per year (Fishman et
al., 2008).
• Bronchodilators relieve bronchospasm by altering smooth muscle tone and
reduce airway obstruction by allowing increased oxygen distribution
throughout the lungs and improving alveolar ventilation. Although regular use
of bronchodilators that act primarily on the airway smooth muscle does not
modify the decline of function or the prognosis of COPD, their use is central
in the management of COPD (GOLD, 2008). These agents can be delivered
through a metered-dose inhaler or other type of inhaler, by nebulization, or via
the oral route in pill or liquid form. Several classes of bronchodilators are
used, including beta-adrenergic agonists (short- and long-acting),
anticholinergic agents (short- and long-acting), methylxanthines, and
combination agents. These medications may be used in combination to
optimize bronchodilation. Long-acting bronchodilators are more convenient
for patient use. Bronchodilators are key to symptom management in stable
• Corticosteroids. Although inhaled and systemic corticosteroids may improve
the symptoms of COPD, they do not slow the decline in lung function. Their
effects are less dramatic than in asthma. A short trial course of oral
corticosteroids may be prescribed for patients to determine whether
pulmonary function improves and symptoms decrease. Long-term treatment
with oral corticosteroids is not recommended in COPD and can cause steroid
myopathy, leading to muscle weakness, decreased ability to function, and, in
advanced disease, respiratory failure (GOLD, 2008). COPD, medication
therapy includes regular treatment with one or more bronchodilators and
inhaled corticosteroids for repeated exacerbations. Combination long-term
beta2-agonists plus corticosteroids in one inhaler may be appropriate;
examples include formoterol/budesonide (Symbicort) and salmeterol/
fluticasone (Seretide).
• Alpha1-antitrypsin (1AT) replacement therapy is
available for patients with emphysema due to a
genetic deficiency of the enzyme. Although
expensive and inconvenient (1AT is administered
weekly by intravenous infusion), it has been shown
to reduce the rate of airflow decline and
• Oxygen therapy can be administered as long-
term continuous therapy, during exercise, or
to prevent acute dyspnea during an
exacerbation. The goal of supplemental
oxygen therapy is to increase the baseline
resting partial arterial pressure of oxygen
(PaO2) to at least 60 mm Hg at sea level and
an arterial oxygen saturation (SaO2) at
least90% (GOLD, 2008). Long-term oxygen
therapy (more than 15 hours per day) has
also been shown to improve quality of life,
reduce pulmonary arterial pressure and
dyspnea, and improve survival (GOLD, 2008).
Oxygen therapy is variable in COPD
patients; its aim in COPD is to achieve an
acceptable oxygen level without a fall in the
pH (increasing hypercapnia)
• A bullectomy is a surgical option for
select patients with bullous
emphysema. Bullae are enlarged
airspaces that do not contribute to
ventilation but occupy space in the
thorax; these areas may be surgically
excised. These bullae compress areas
of the lung and may impair gas
exchange. Bullectomy may help reduce
dyspnea and improve lung function. It
can be performed via a video-assisted
thoracoscope or a limited
thoracotomy incision.
• Treatment options for patients with end-stage COPD
(stage IV) with a primary emphysematous component
are limited, although lung volume reduction surgery is
a palliative surgical option in a selected subset of
patients. This subset includes patients with
homogenous disease or disease that is focused in one
area and not widespread throughout the lungs. Lung
volume reduction surgery involves the removal of a
portion of the diseased lung parenchyma. This reduces
hyperinflation and allows the functional tissue to
expand,resulting in improved elastic recoil of the lung
and improved chest wall and diaphragmatic
mechanics. This type of surgery does not cure the
disease or improve life expectancy, but it may
decrease dyspnea, improve lung function, and improve
the patient’s overall quality of life (GOLD, 2008).
• Lung transplantation is a viable option
for definitive surgical treatment of end-
stage emphysema. It has been shown to
improve quality of life and functional
capacity in a selected group of patients
with COPD. Limited not only by the
shortage of donor organs, it is also a
costly procedure with financial
implications for months to years
because of complications and the need
for costly immunosuppressive
medication regimens (GOLD, 2008).
• Pulmonary rehabilitation for patients with COPD is well
established and widely accepted as a means to alleviate
symptoms and optimize functional status (Ries, Bauldoff,
Carlin, et al., 2007). The primary goals of rehabilitation are
to reduce symptoms, improve quality of life, and increase
physical and emotional participation in everyday activities
(GOLD, 2008).
• Nurses play a key role in identifying potential
candidates for pulmonary rehabilitation and in
facilitating and reinforcing the material learned
in the rehabilitation program. Not all patients
have access to a formal rehabilitation program.
• However, nurses can be instrumental in
teaching patients and families as well as
facilitating specific services, such as respiratory
therapy education, physical therapy for exercise
and breathing retraining, occupational therapy
for conserving energy during activities of daily
living, and nutritional counseling. Patient
education is a major component of pulmonary
rehabilitation and includes a broad variety of
• Pursed-lip breathing helps
slow expiration, prevents
collapse of small airways,
and helps the patient
control the rate and
depth of respiration. It
also promotes relaxation,
enabling the patient to
gain control of dyspnea
and reduce feelings of
• The patient may have difficulty bathing or dressing and may
become fatigued. Activities that require the arms to be
supported above the level of the thorax may produce
fatigue or respiratory distress but may be tolerated better
after the patient has been up and moving around for an
hour or more. The nurse can help the patient reduce these
limitations by planning self-care activities and determining
the best times for bathing, dressing, and other daily
• The patient is taught to coordinate diaphragmatic breathing with activities such as
walking, bathing, bending, or climbing stairs.
• The patient should bathe, dress, and take short walks, resting as needed to avoid fatigue
and excessive dyspnea.
• Fluids should always be readily available, and the patient should begin to drink fluids
without having to be reminded. If management of secretions is a problem and some type
of postural drainage or airway clearance maneuver is to be performed at home, the
nurse or respiratory therapist instructs and supervises the patient before discharge or
in an outpatient setting.
• Physical conditioning techniques include breathing exercises and general exercises intended to
conserve energy and increase pulmonary ventilation.
• Graded exercises and physical conditioning programs using treadmills, stationary bicycles, and
measured level walks can improve symptoms and increase work capacity and exercise
• Any physical activity that can be performed regularly is helpful. Walking aids may be beneficial
(GOLD, 2008).
• Lightweight portable oxygen systems are available for ambulatory patients who require
oxygen therapy during physical activity
• The nurse explains the proper flow rate and required number of
hours for oxygen use as well as the dangers of arbitrary changes in
flow rate or duration of therapy.
• The nurse should caution the patient that smoking with or near
oxygen is extremely dangerous.
• The nurse also reassures the patient that oxygen is not “addictive” and
explains the need for regular evaluations of blood oxygenation by
pulse oximetry or arterial blood gas analysis.

• Nutritional assessment and counseling are important aspects in the

rehabilitation process for patients with COPD.
• Nutritional status is important in COPD and is reflected in severity of
symptoms, degree of disability, and prognosis. Significant weight loss is
often a major problem, but excessive weight can also be problematic
although it occurs less often.

• The nurse should provide education and support

to spouses or significant others and families,
because the caregiver role in end-stage COPD
can be difficult.

• Assessment involves
obtaining information
about current symptoms
as well as previous disease
manifestations. In addition
to the history, nurses
review the results of
available diagnostic tests.
• The nurse monitors the patient for dyspnea and hypoxemia.
• If bronchodilators or corticosteroids are prescribed, the nurse must administer the
medications properly and be alert for potential side effects.
• The nurse instructs the patient in directed or controlled coughing, which is more
effective and reduces the fatigue associated with undirected forceful coughing.
• Directed coughing consists of a slow, maximal inspiration followed by breath-holding for
several seconds and then two or three coughs. “Huff” coughing may also be effective.
• The technique consists of one or two forced exhalations (“huffs”) from low to medium
lung volumes with the glottis open. Chest physiotherapy with postural drainage,
intermittent positive pressure breathing, increased fluid intake, and bland aerosol mists
(with normal saline solution or water) may be useful for some patients with COPD.
• Inspiratory muscle training and breathing
retraining may help improve breathing
• Training in diaphragmatic breathing reduces
the respiratory rate, increases alveolar
ventilation, and sometimes helps expel as
much air as possible during expiration.
• Pursed-lip breathing helps slow expiration,
prevent collapse of small airways, and
control the rate and depth of respiration. It
also promotes relaxation, which allows
patients to gain control of dyspnea and
reduce feelings of panic.
• The nurse evaluates the patient’s activity tolerance and
limitations and uses teaching strategies to promote
independent activities of daily living.
• The patient may be a candidate for exercise training to
strengthen the muscles of the upper and lower extremities
and to improve exercise tolerance and endurance. Use of
walking aids may be recommended to improve activity
levels and ambulation (GOLD, 2008).
• The nurse must assess for various complications of COPD, such as life-threatening respiratory
insufficiency and failure, as well as respiratory infection and chronic atelectasis, which may increase the
risk of respiratory failure.
• The nurse monitors for cognitive changes (personality and behavioral changes, memory impairment),
increasing dyspnea, tachypnea, and tachycardia, which may indicate increasing hypoxemia and impending
respiratory failure.
• The nurse monitors pulse oximetry values to assess the patient’s need for oxygen and administers
supplemental oxygen as prescribed.
• The nurse also instructs the patient about signs and symptoms of respiratory infection that may worsen
hypoxemia and reports changes in the patient’s physical and cognitive status to the physician.
• The nurse instructs the patient to report any signs of infection, such as a fever or change in sputum color,
character, consistency, or amount. the nurse should encourage the patient with COPD to be immunized
against influenza and S. pneumoniae, because the patient is prone to respiratory infection. the nurse
should quickly evaluate the patient for potential pneumothorax by assessing the symmetry of chest
movement, differences in breath sounds, and pulse oximetry.
• The nurse to assess the knowledge of patients and family members
about self-care and the therapeutic regimen.
• The nurse should also consider whether they are comfortable with
this knowledge. Familiarity with prescribed medications’ potential side
effects is essential.
• The nurse instructs the patient to avoid extremes of heat and cold.
• The nurse may direct the patient to community resources such as
pulmonary rehabilitation programs and smoking cessation programs to
help improve the patient’s ability to cope with his or her chronic
condition and the therapeutic regimen and to give the patient a sense
of worth, hope, and wellbeing.
• In addition, the nurse reminds the patient and family about the
importance of participating in general health promotion activities and
health screening