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- Chronic inflammatory disorder of the airways characterized by recurrent episodes of airway obstruction.
- Inflammation is in response to some kind of trigger
- Occurs in reversible episodes
- Treatment / medication opens and clears the airway
Airway hyper-responsiveness leads to . . ?
What symptoms do we associate with asthma?
- Breathlessness (dyspnea)
- Chest Tightness
- Increased mucous production
Asthma - Signs and Symptoms
- Cough: hacking, paroxysmal, irritative, and nonproductive
- Prolonged expiratory phase
- Audible wheezes
- Malar flush and red ears
- Lips, deep, dark red color
- May sit upright with shoulders in a
- hunched-over position, hands on the bed or chair, and arms braced (“tripod
- May speak with short, panting, broken phrases
- Coarse, loud breath sounds
- Uses accessory muscles to breathe
Asthma - Chronic Patho
- Chronic asthma leads to structural changes to
- the airways (called “remodeling”) involving sub-basement membrane fibrosis
- which may contribute to persistent abnormalities in lung function.
- Loss of lung compliance
- Hyperinflation of alveoli
- Long Term = leads to COPD
- Increased attacks leads to Increased tissue damage
Asthma - Triggers
- Allergens - molds, pollens, animal dander, cockroach allergen, dust mites
- Cold Air & Cockroaches
- Exercise (EIA)
- Occupational Exposure
- Food - (big 8)fish, shellfish, milk, egg, soy, wheat, peanuts, and tree nuts such as walnuts, cashews ... Also food additives: Sulfites, food colorings, & gums
- Stress and/or other. . .
- Psychological Issues
- Air Pollution
- Second-hand Smoke
- Any respiratory infection (cold, flu, pneumonia, etc.) can trigger an asthma attack or can make a person more sensitive to their asthma attack triggers.
Asthma - Diagnosis
- Clinical Manifestations
- Health History - Personal or family history of asthma, sinusitis, GERD, rhinitis, nasal polyps, allergic skin conditions (e.g. atopic dermatitis,
- Pulmonary Function Testing (PFT’s)
- Peak Expiratory Flow Rate (PEFR)
- Forced Expiratory Volume in 1 second (FEV1)
- National guidelines vary:
- FEV1 as a % of predicted
- <80% = mild
- <60% = moderate
- <40% = severe
- <80% = mild
- <50% = moderate
- <30% = severe
- (NICE guidelines)
- PFT’s can be done before and after administration of a short-acting bronchodilator to confirm the reversibility of the obstructive process.
- Forced Vital Capacity (FVC)
- FEV1/FVC ratio
- (All decreased during an asthma attack)
- Other Tests:Chest X-ray (generally normal between attacks)
- CBC (may show eosinophilia).
- Immunoglobulins (increased IgE)
- Allergy skin testing +/or radioallergosorbent test (RAST).
- ABG’s (generally only done during
- severe attacks such as in Status Asthmaticus).
Asthma - Home monitoring/testing
- Peak flow meter (home testing):
- Measures peak flow rate (PEFR)
- Effort dependent
- Assesses central, not peripheral airway obstruction
- Used with patients who have poor symptom recognition or labile asthma
- Dips in peak flow rate precede onset of clinical asthmatic symptoms.
- Peak flow rate should be performed at least once a day & recorded.
- Peak flow rate values are divided into 3 zones:
- Green: ≥80% of baseline
- Yellow: 50–80% of baseline
- Red: 50% of baseline
- Specific peak flow rate guidelines should be individualized for each patient based on the best measurement obtained during a 14-day period when the child is well.
- NO - Nitrous oxide monitoring
Asthma - Classification
- Step 1 = Mild Intermittent
- Symptoms 2 days per week or less or 2 nights /month or less.
- Step 2 = Mild Persistent
- Symptoms > 2/week but < 1/day or > 2 nights per week.
- Step 3 = Moderate Persistent
- Symptoms daily and > 1 night per week.
- Step 4 = Severe Persistent
- Symptoms continual during the day and frequent at night.
- See Table 29-5 of Lewis
Asthma - Treatment Goals
- Maintain normal activity levels.
- Maintain normal pulmonary function.
- Prevent chronic symptoms and recurrent exacerbations.
- Provide optimum drug therapy with minimum or no adverse effects.
- Assist the client in living as normal and happy a life as possible.
Asthma - Treatment
- EVERY patient must have an:
- ASTHMA TREATMENT PLAN!
- Identify and avoid triggers of asthma attacks.
- When exposure to triggers is unavoidable,
- careful use of prophylactic pre-medication before exposure to trigger (i.e. use inhaler prior to sports).
- Desensitization if possible
- “Rescue medications” for acute exacerbations
- “Maintenance medications” for long term control
Asthma - Pharmacology
- “Quick-relief” (“rescue” medications)
- “Long-term control” (“maintenance” drugs)
- Each STEP in the classification has recommendations for treatment
- Two general categories of agents:
- Antiinflammatory agents
- - Systemic or Inhaled
- - Systemic or Inhaled
Asthma - Pharm 1
- Step 1 - Mild Intermittent
- Long term Relief - No dailymedication needed, For severe exacerbation, a course of sys corticosteroids recommended
- Quick Relief - Short-acting Beta2-agonists inhaled
Asthma - Pharm 2
- Step 2 - Mild persistent
- Long term Relief - Preferred treatment: low-dose inhaled corticosteroids. Alternative treatment: cromolyn, leukotriene modifier, nedocromil, or sustained-release theophylline.
- Quick Relief - short acting inhaled Beta2-agonists
Asthma - Pharm 3
- Step 3 - Moderate Persistent
- Long term Relief - Preferred treatment: low- to medium-dose inhaled corticosteroids and long-acting inhaled β2-agonists.
- Alternative treatment: increase inhaled corticosteroids within medium-dose range or low- to medium-dose inhaled corticosteroids and either leukotriene modifier or theophylline.
- If needed (in patients with recurring severe exacerbations):
- Preferred treatment: increase inhaled corticosteroids within medium-dose and add long-acting inhaled β2-agonists.
- Alternative treatment: increase inhaled corticosteroids within medium-dose range and add either leukotriene modifier or theophylline.
Asthma - Pharm 4
- Step 4 - Severe Persistent
- Long term Relief - Preferred treatment: high-dose inhaled corticosteroids and long-acting inhaled β2-agonists and, if needed, oral corticosteroids.
- Short term Relief - Short-acting inhaled β2-agonists
Asthma - Anti-inflammatory Antiasthmatic Agents - Corticosteroids
- Corticosteroids (Inhaled) - routine/long term
- - Cornerstone in long-term control of asthma
- Budesonide (Pulmicort), Fluticasone (Flovent) - [increase risk of yeast infection], Mometasone (Asmanex), Fluntisolide (AeroBid) and Beclomethasone (Vanceril).
- - Not indicated for rapid relief of acute asthma attack.
- - Few systemic effects
- - Can lead to oral thrush, irritated throat, dry mouth etc.)
- Budesonide (Rhinocort), Fluticasone (Flonase), and Mometasone (Nasonex)
- - Nasal spray forms of three of the above medications
- - Helpful when nasal allergies are the trigger for asthma attacks.
Asthma - Anti-inflammatory Antiasthmatic Agents - Corticosteroids
- Inhaled: Reduce airway inflammation and hyperresponsiveness more than any other inhaled agents; inhibit production and release of cytokines and arachidonic acid–associated metabolites; enhance β-adrenoceptor responsiveness; side effects include oral thrush; may minimally affect growth velocity at moderate or high doses.
- Dosage individualized to each patient. Agents vary in topical potency and systemic bioavailability; available as pMDIs, dry-powder inhalers (DPIs), or nebulized. Fluticasone (Flovent) 44, 110, 220 mcg/puff pMDI; budesonide (Pulmicort) 200 mcg/puff DPI; 250- and 500-mcg vials for nebulizer; beclomethasone (Beclovent, Vanceril, Qvar) 40, 42, 80, 84 mcg/puff; triamcinolone (Azmacort) 100 mcg/puff; flunisolide (Aerobid) 250 mcg/puff
- Oral: Used for asthma exacerbations or for severe asthma that cannot be otherwise controlled. Exacerbations: Prednisone 1–2 mg/kg/d for 3–7 days or longer; usually tapered if >7 days of therapy required or if systemic steroids are used frequently.
- Ongoing therapy: 0.5–1 mg/kg/d daily or every other day for patients with severe asthma. Undesirable side-effect profile. When used daily, assess bone density and for cataract formation at least yearly.
- IV: Methylprednisolone (Solumedrol) 1-2 mg/kg IV q6–12h until improved and able to take oral medication
- ALWAYS HAVE PATIENT RINSE MOUTH AFTER USING STEROID INHALERS.
Asthma - Anti-inflammatory Anti-asthmatic Agents
- Leukotriene Modifiers (antagonists)
- Leukotriene's (chemical substances released by some leukocytes) are strong chemical mediators of what three processes that are the hallmarks of asthma?
- - Inflammation
- - Broncho-constriction
- - Mucous production
- NOT for rescue - maintenance only
Asthma - Leukotriene Modifiers
- Singulair (montelukast sodium) - Very popular due to its ease of use (once per day PO), effectiveness and safety.
- ----Side Effects: Stomach upset, Headaches,Liver test abnormalities, Skin rashes, Rarely, Churg Strauss syndrome – form of autoimmune vasculitis
- ----Mental Side effects: agitation, aggression, anxiousness, dream abnormalities, hallucinations, depression, insomnia, irritability, restlessness, suicidal thinking and behavior, suicide, tremor
- Accolate (zafilukast) - - PO, take 1 hr before meal/2 hr after meal; affects metabolism of erythromycin & theophylline
- ----Side Effects: HA, dizzy, N/V, diarrhea, fatigue, ABD pain
- Zyflo (zileuton) - has different mechanism of action that Montelukast and has potential for liver damage and drug interaction (monitor LFT’s)
- ----Side Effects: increased LFTs, dizzy, insomnia, dyspepsia, ABD pain
- ----Monitor: LFTs, interferes with warfarin (Coumadin) & theophylline
Asthma - Anti-inflammatory antiasthmatic agents - Mast cell stabilizers
- Prevent the degradation of mast cells and thus prevent the release of inflammatory mediators.
- Used only as an adjunct to other therapy and in patients with aggressive allergic component to their asthma
- ---Cromolyn (Intal)
- - Not for use during acute attacks. Maintenance only.
- - No longer considered first line
Asthma - Anti-inflammatory antiasthmatic agents - Bronchodilators
- Agents that actively relax and “open up” the airways.
- Can be used for both long-term management and quick relief of asthma symptoms.
- Classified as:
- - - Adrenergic (Beta2-adrenergic agonists--short acting and long-acting) agents
- - - Anticholinergic agents
- - - Xanthines
- - - Combination drugs
Asthma - Anti-inflammatory antiasthmatic agents - Bronchodilators - Beta2-adrenergic agonists (short acting)
- Occasionally used on a set schedule but are better used PRN for quick relief.
- There is a tendency for overuse
- Loss of effectiveness
- Rebound bronchospasm
- Must be used with great caution in patients
- with cardiac disorders (causes rapid increase of
- heart rate, dysrhythmias, which impedes coronary circulation)
Asthma - Anti-inflammatory antiasthmatic agents - Bronchodilators - Beta2-adrenergic agonists (short acting)
- Albuterol (Proventil) - Also has Beta1 side-effects, Used as an inhaled nebulized drug during severe asthma attacks (e.g. rescue medication, status asthmaticus)
- Levalbuterol (Xopenex) - Very effective drug, few side effects, expensive and loses its effectiveness if used too often.
- Pirbuterol (Maxair) - Newer agent with fewer side effects but seldom covered by insurance plans.
Asthma - Anti-inflammatory antiasthmatic agents - Bronchodilators - Long-acting Beta2-adrenergic agonists (LABA)
- Should not be used alone and may in fact, worsen asthma. Generally now are part of combination drugs (or are used in conjunction with anticholinergics or corticosteroids*).
- Used for prophylaxis of bronchospasm not for acute attacks.
- Salmeterol (Serevent) an MDI version
- Formoterol (Foradil) a newer drug that has shown good promise but has a “tricky” Dry Powder delivery system (DPI), can have Beta1 side effects and can affect glucose levels
- Both LABA’s now carry a “black box warnings”* -- MORE PATIENTS ON LABA’S DIE THAN PATIENTS ON OTHER ANTIASTHMA DRUGS. MAY PRECIPITATE SEVERE ASTHMA EXACERBATIONS.
Asthma - Anticholinergics - Bronchodilator
- Block the action of acetylcholine (neuro transmitter that causes bronchoconstriction)
- Ipratropium (Atrovent) --Short-acting agent with great versatility, Can be used for maintenance therapy for bronchospasm in asthma, COPD, allergic rhinitis, and “cough-variant asthma”
- Contraindicated in patients with BPH and narrow angle glaucoma.
Asthma - Xanthines - Bronchodilator
- Rarely used now.
- Classic Xanthine is Theophylline (oral form) and Aminophylline (IV).
- May still be used in severe cases of asthma.
- Older asthmatics may still be on these
- Many side effects (Beta1, plus nausea /vomiting, epigastric pain, diarrhea).
Asthma - Combination Drugs
- Formerly recommended for only Step 3 – 4
- Have increasingly been used effectively and safely in less severe asthmatic patients.
- Ipratropium and albuterol (Combivent)
- Fluticasone and salmetrol (Advair)...a DPI
- Budesonide and fomoterol (Symbicort)...MDI
Asthma - Other Meds
- One more option (especially for allergic asthma uncontrolled by inhaled corticosteroids)
- Omalizumab (Xolar) - antibody to IgE that is given Sub Q once or twice a month.
- Rarely used - expensive and carries some risk of cancer and anaphylaxis (carries a black box warning).
Asthma - Key Nursing Role
- Review client’s health history, home, work or school, and play environment (children).
- Perform a comprehensive physical assessment with focus on the respiratory system.
- Assist in development of Asthma Treatment Plan
- Assist family and client in management of asthma symptoms by reducing exposure to allergens.
- Assist with allergen testing.
Asthma - Key Assessment
- Feeling of suffocation, difficulty speaking in complete sentences
- Signs of hypoxemia - restlessness, increased anxiety, inappropriate behavior, increased pulse and blood pressure, and pulsus paradoxus (a drop in systolic pressure during the inspiratory cycle greater than 10 mm Hg).
- Increased RR(usually greater than 30 breaths per minute) with the use of accessory muscles. Percussion = hyperresonance, auscultation = inspiratory or expiratory wheezing. Coughing produces thick, stringy mucus.
- Diminished or absent breath sounds, - Severely diminished breath sounds, often referred to as the “silent chest,” are an ominous sign, indicating severe obstruction and impending respiratory failure. Diminished or absent breath sounds may also indicate atelectasis or pneumothorax.
Asthma - Key Nursing Roles
- Assist with pulmonary function tests.
- Provide emotional support client and family.
- Referral for financial and social assistance
- Monitor client's and family's progress with asthma care - effects on home and school life.
- Promote good nutrition, exercise, sleep and hydration.
- Administration of PEFR test and medications during asthma exacerbation
- Asthma education
Asthma - Patient/Family Teaching 1
- Recognition and management of symptoms (Use of Peak Flow Meter, How to use the Asthma Action Plan)
- Reducing exposure to asthma triggers
- Desensitization (allergy testing & shots)
- Medications - schedule of maintenance doses and indications for rescue medication
- Home Monitoring
- Managing asthma exacerbation during illness
- Importance of nutrition and hydration
Asthma - Patient/Family Teaching 2
- Play activities, and involvement in exercise
- Community resource education
- Avoidance of over-the-counter medications without health care provider’s clearance
- Correct use and cleaning of medication delivery system (MDI, DPI, spacer, nebulizer)
- Encourage self-management techniques and strategies—diaries of asthma symptoms, related factors, PEFR records etc.
Asthma -EMERGENT CARE - Nursing Role
- During acute attacks
- Remain CALM – speak slowly and in a low voice
- Monitor respiratory status
- Provide supplemental oxygen
- Place the patient in an upright, tripod position to facilitate breathing
- Encourage pursed-lipped breathing, relaxation methods
- “Talk down” the patient by giving firm direction and holding eye contact.
- CONTROL the ENVIRONMENT
Asthma - Complications
- Severe acute asthma can result in complications such as:
- rib fractures,
- status asthmaticus.
Asthma - STATUS ASTHMATICUS
- Status Asthmaticus refers to a severe, potentially life-threatening asthma attack that is resistant to normal treatment.
- Extremely poor air movement leads to significant respiratory distress, respiratory acidosis, hypercapnia, tachycardia, hypertension, pulsus paradoxus
- BP > mmHg on inspiration
Asthma - Status Asthmaticus - Clinical Manifestations
- Increased airway resistance as a consequence of edema, mucous plugging, and severe bronchospasm with subsequent air trapping, hyperinflation, hypoxemia, and respiratory acidosis.
- More severe and prolonged clinical manifestations similar to those of asthma.
- Extreme anxiety, fear of suffocation, severely increased work of breathing, and diaphoresis are common.
- Absence of diaphoresis may indicate significant dehydration.
- Sternocleidomastoid, intercostal, and supraclavicular muscle retractions reflect increased work of breathing.
- If obtainable, the peak expiratory flow rate (PEFR) is usually less than 150 L/min.
Asthma - Precipitating Factors for Status Asthmaticus
- Viral illnesses, colds, sinusitis
- Ingestion of aspirin or other NSAIDs
- Emotional stress, environmental pollutants or other allergen exposure
- Abrupt discontinuation of drug therapy (especially corticosteroids)
- Abuse of aerosol medication
- Ingestion of β-adrenergic blockers
- Beta blockers are contraindicated in Asthmatic patients because they can all have some beta 2 spill-over which results in bronchial constriction
Asthma - Status Asthmaticus - Treatment
- Continuous nebulized Beta2-adrenergic agonist (Albuterol) often combined with ipratropium.
- IV corticosteroids followed by inhaled corticosteroids
- Sub Q. Epinephrine or terbutaline (Brethine)
- Supplemental O2, continuous SPO2 monitoring, cardiac monitoring, ABG’s (with administration of NaHCO3 to correct acidosis), IV fluids to prevent dehydration
- Intubation with endotracheal tube and mechanical ventilation may become necessary for ventilation, oxygenation and secretion management
- Progressive Airflow disease that is not fully reversible with treatment
- Characterized by acute exacerbations and remissions
- Associated with an abnormal inflammatory response of the lungs to noxious particles or gases
- Primary cause is cigarette smoking.
- Although COPD affects the lungs, systemic consequences also develop.
COPD - Etiology
- Risk factors
- Cigarette smoking
- Occupational chemicals and dust -- Mining, Carpentry, Asbestos
- Air pollution
- 2nd hand smoke
- Lung Infections lead to remodeling of lung tissue
- Heredity - a-Antitrypsin (AAT) deficiency, Genetic risk factor for COPD, Accounts for <1% to 2% of COPD
COPD - Aging
- Some degree of emphysema is common due to physiological changes of aging lung tissue
- Gradual loss of elastic recoil.
- Lungs become rounded and smaller
- Loss of alveolar supporting structures.
- Decreased number of functional alveoli.
- Decreased arterial O2 levels.
- Thoracic cage changes from osteoporosis and calcification of costal cartilage (“barrel chest”)
COPD - Phathophysiology
- Mucus hypersecretion
- Dysfunction of cilia
- Hyperinflation of lungs
- Gas exchange abnormalitie
COPD - Four disease comprise nearly all of COPD
- Bronchiectasis (which we will not cover)
- Chronic Bronchitis, and
- What about in the Pediatric Population?
- (hint: it is an autosomal recessive genetic disorder and is diagnosed with a “sweat test”)
- Answer = Cystic Fibrosis
COPD - Two major types
- Chronic bronchitis - presence of chronic productive cough for 3 months in each of 2 consecutive years in a patient in whom other causes of chronic cough have been excluded.
- Emphysema is an abnormal permanent enlargement of the air spaces distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis.
- Commonly Emphysema, Asthma, and Chronic Bronchitis coexist!
COPD - Supporting structures of lungs are destroyed by repeated infection, inflammatory responses, and remodeling
- Air goes in easily, but remains in the lungs
- “Air Trapping” causes hyper-inflation of the lungs
- Bronchioles tend to collapse
- This increase in residual capacity (the extra air left in the lungs) changes the appearance of the chest and gives it what classic type of appearance? ”Barrel – chested “ (more so with emphysema).
COPD - Pulmonary vascular changes
- Blood vessels thicken
- Capillary bed destruction
- Surface area for diffusion of O2 decreases
- Gas exchange abnormalities
- Pulmonary hypertension develops
- Cor pulmonale……Definition?______________
COPD - Clinical Manifestation
- Develops slowly
- Diagnosis is considered with
- --Sputum production
- --Exposure to risk factors
- Intermittent cough is earliest symptom
- Dyspnea usually prompts medical attention
- --Occurs with exertion in early stages
- --Present at rest with advanced disease
- Use of Accessory muscles to breathe
- --Progressive respiratory distress
- --Tracheal Tug
- --May see supraclavicular or intercostal retractions
- --Raising shoulders to assist breathing
COPD - Clinical Manifestation
- Chronic fatigue
- Progressive weight loss
- Characteristically underweight even with adequate caloric intake
- Bluish-red color of skin -- Polycythemia and cyanosis
- Barrel chest, use of accessory muscles
- Diminished breath sounds
- Pursed lip breathing, tripod positioning
- Intermittent cough with sticky mucous
- --Early = dyspnea only with exertion
- --Late = dyspnea at rest
- Weight loss, anorexia
COPD - Clinical Manifestations - Physical examination findings
- Prolonged expiratory phase
- Decreased breath sounds
- ↑ Anterior-posterior diameter of the chest
COPD - Complications
- Exacerbations of COPD
- Acute respiratory failure
- Peptic ulcer disease - The incidence of peptic ulcer disease is increased in persons with COPD; hypersecretion of gastric acid resulting from increased arterial CO2 and decreased arterial O2 tension. This occurs only in patients who chronically retain CO2. The ulcers are more commonly in the duodenum rather than stomach and do not cause pain. It is important to test gastric aspirates and feces for occult blood.
- Cor pulmonale - enlargement of the right ventricle of the heart as a response to increased resistance or high blood pressure in the lungs (pulmonary hypertension) - right sided heart faliure - peripheral edema
COPD - Exacerbations Sx
- Change in usual dyspnea, cough, and/or sputum
- Sputum purulence – often associated with Pneumonia
- May also have malaise, insomnia, fatigue, depression, confusion, decrease in exercise tolerance, increased wheezing, increased cough, or fever without other causes.
- “Flares” require changes in management
- Frequent Exacerbations associated with poorer outcomes
- As the severity of COPD increases, exacerbations of COPD are associated with poorer outcomes. Exacerbations of COPD may be treated at home or in the hospital intermediate care unit or intensive care unit, depending on the severity. The primary causes of exacerbations of COPD are tracheobronchial infection and air pollution. Bacteria account for 33% to 75% of the cases of infection.2,31 The most common organisms causing exacerbations are H. influenzae, M. catarrhalis, and S. pneumoniae. Other causes of COPD exacerbations include viruses.
COPD - Diagnostic Studies
- Diagnosis confirmed by pulmonary function tests
- History, and physical examination
- Chest x-ray
- Spirometry, Pulmonary Function Testing
- ABG’s – low PaO2 & high PCO2
- ↑ BNP if heart failure suspected
- 6-Minute walk test to determine O2 desaturation in the blood with exercise
- ECG can show signs of right ventricular failure - The typical ECG changes in COPD are: (1) prominent P waves in leads II, III and aVF; (2) rightward shift of the QRS axis in the frontal plane; ...Lead 1 sign = flattened P and T waves in Lead 1
COPD - Spirometry findings
- Reduced FEV/FVC ratio
- Increased residual volume
COPD - ABG finding
- Low PaO2
- ↑ PaCO2
- ↓ pH
- ↑ Bicarbonate level found in late stages COPD
COPD - Collaborative Care - Primary Goals of care
- Prevent progression of disease
- Relieve symptoms
- Prevent/treat complications
- Prevent/treat exacerbations
- Promote patient participation
- Improve nutritional status
- Improve quality of life and reduce mortality risk
COPD - Collaborative Care
- Irritants should be evaluated and avoided
- Exacerbations treated promptly
- Smoking cessation
- --Most effective intervention
- --Accelerated decline in pulmonary function slows and usually improves aftersmoking cessation
COPD - Drug Therapy
- --Relaxes smooth muscle in the airway
- --Improves ventilation of the lungs
- --↓ Dyspnea and ↑ in FEV1
- --Inhaled route is preferred
- same medications as Asthma (Corticosteroids, inhaled and/or systemic)
- Pneumonias are treated with Antibiotics
COPD - O2 therapy
- Reduce work of breathing
- Maintain PaO2
- Reduce workload on heart
COPD - Concept of Hypoxic Drive and CO2 narcosis
- Patients with COPD have chronically elevated CO2 levels
- The stimulation to breath caused by CO2 accumululation no longer exists
- They are driven to breath by low O2 levels
- In the past (and some nurses even today) we were told NOT to give O2 to COPD clients
- BUT – currently we monitor their PaO2 carefully and give O2 to maintain PaO2 as close to >90% as possible
- DO NOT ARBITRARILY GIVE OR LIMIT OXYGEN ADMINISTRATION!
COPD - Complication of O2 therapy
- O2 toxicity
- Absorption atelectasis
- Drying out mucousa - needs humidified O2
COPD - Surgery therapy 1
- Lung volume reduction surgery -- Remove 30% of most diseased lung to enhance performance of remaining tissue
- Bullectomy -- Used for emphysema, Large bullae (Fibrotic knots) are resected to improve lung function
- Lung transplantation -- Single lung—most common due to donor shortages - comorbidity
- See Table 28-22 for lung surgeries to know
COPD - Surgery Therapy 2
- VATs (Video Assisted Thoracic surgery)
- 3 – 4 small incisions on the chest
- Endoscopic camera
- Can be used to diagnose and treat a variety of conditions of the lung, pleura, and mediastinum
- Chest tube placed at end of surgery until lung re-expands
- Complications = bleeding, diaphragmatic perforation, air embolism, tension pneumothorax
COPD - Respiratory and physical therapy
- Breathing retraining—pursed-lip breathing, Possibly abdominal breathing and inspiratory muscle training
- Teach effective coughing
- Flutter mucus clearance device
- Incentive Spirometers
COPD - Respiratory, Nursing, and Physical Therapy
- Aerosol nebulization therapy
- Chest physiotherapy
- --Postural drainage
- Provide tissues, suctioning and frequent (q 2 hours) mouth care
- Encourage PO fluids to thin secretions
COPD - Nutritional Therapy - 1
- Weight loss and malnutrition are common
- --Pressure on diaphragm from a full stomach causes dyspnea
- --Difficulty breathing while eating leads to inadequate consumption
- --Rapid respirations make it hard to chew and swallow
COPD - Nutritional Therapy - 2
- Rest at least 30 minutes prior to eating
- Use bronchodilator prior to meal
- Prepare foods in advance.
- Eat 5 to 6 small meals (high calorie, high protein) to avoid bloating and early satiety.
- Cold foods may cause less fullness than hot foods.
- Take fluids between meals, (not with meals)
- Avoid foods that require a great deal of chewing, exercises and treatments 1 hour before and after eating and gas-forming foods.
COPD - Nursing Intervention 1
- Assess lung sounds, breathing, and appearance frequently
- Vital Signs with SPO2
- Obtain sputum culture before giving ABX
- Plan care activities to allow rest times
- Administer medications on time – bronchodilators are always given 5 minutes before inhaled steroids
- Avoid giving benzodiazapines, opiods, or other sedatives that may decrease respiratory drive
COPD - Nursing Intervention 2
- GI Prophylaxis
- Gastrocult / Hemocult
- Monitor Labs, ABG’s, chest xray reports – be on the lookout for increasing respiratory failure
- Be on the lookout for signs of Respiratory Failure. Recognize it when it occurs, and facilitate transfer of patient to ICU for Ventilation support**
- **KNOW YOUR PATIENT’S DNR STATUS
- FACILITATE SIGNING END OF LIFE ADVANCED DIRECTIVES
COPD - Nursing Implementation
- Assess Psychosocial adjustment—COPD sufferers have very high rates of depression.
- --When to seek medical intervention.
- --How to avoid infections
- --Medication regime
- --How to use MDI, PDI, Spacers
- --Address end-of-life decisions (e.g. code status, advanced directives, does patient want to go on ventilator if necessary?)