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Unite 5: Chapter 24 Management of Patients With Chronic Pulmonary Disease�

COPD
Bronchiectasis
Asthma �

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Objectives

Describe the pathophysiology of COPD, Bronchiectesis, Asthma, and Cystic fibrosis
Discuss the risk factors associated with these conditions and nursing interventions to minimize these factors
Use the nursing process as a framework to care for patients with COPD, bronchiectasis, asthma, & cystic fibrosis

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Glossary

COPD: Disease state characterized by airflow limitation that is not fully reversible; sometimes referred to as chronic airway obstruction or chronic obstructive lung disease.
Bronchiectasis: Chronic, irreversible dilation of the bronchi and bronchioles that results from destruction of muscles and elastic connective tissue; dilated airways become saccular and are a medium for chronic infection.
Emphysema: A disease of the airways characterized by destruction of the walls of over distended alveoli.
Asthma: A disease with multiple precipitating mechanisms resulting in a common clinical outcome of reversible airflow obstruction.

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Chronic Obstructive Pulmonary Disease (COPD)�and Associated Respiratory Diseases

Characterized by airflow limitation that is not fully reversible (e.g., Chronic Bronchitis and Emphysema)
COPD: is a preventable and treatable slowly progressive respiratory disease of airflow obstruction involving the airways, pulmonary parenchyma, or both.
Asthma compared to COPD has abnormal airways characterized primarily by reversible inflammation.
COPD can coexist with Asthma.
Both diseases have the same major symptoms.

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Chronic Obstructive Pulmonary Disease

Most patients with COPD present with overlapping signs & symptoms of Emphysema & Chronic Bronchitis, which are two distinct disease processes.
COPD may include disease that cause airflow obstruction (e.g., Emphysema & Chronic Bronchitis)

Chronic abnormal inflammatory response to:

Environmental pollutants
Irritants
Tobacco smoke

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Pathophysiology - COPD

Airflow limitation is progressive, associated with abnormal inflammatory response to noxious particles or gases.
Chronic inflammation damages tissue, increased number of goblet cells & enlarged submucosal glands both lead to hyper secretion of mucus.
Repair process cause scar tissue in airways and narrowing of the airway
Scar tissue in the parenchyma decreases elastic recoil (compliance)
Scar tissue in pulmonary vasculature causes thickened vessel lining and hypertrophy of smooth muscle (pulmonary hypertension)

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Chronic Bronchitis

Is the presence of cough and sputum production for at least 3 months in each of 2 consecutive years.
Smoke & environmental pollutants irritate the airways, resulting in inflammation, hypersecretion of mucus, bronchial walls thicken, and bronchial airways narrow.
Constant irritation increase the number of mucous secretion gland & goblet cells leading to increase mucous production.
Mucous may plug airways & reduces ciliary function.

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Chronic Bronchitis

Alveoli adjacent to the bronchioles become damaged, fibrosed and alveolar macrophage function diminishes (unable to resist infections).
A wide range of viral, bacterial, & mycoplasmal infections can produce acute episodes of bronchitis.
Exacerbation of chronic bronchitis are most likely to occur during winter when viral & bacterial infections are more prevalent.

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Pathophysiology of Chronic Bronchitis

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Emphysema

Abnormal distention of air spaces beyond the terminal bronchioles with destruction of the walls of the alveoli.
The alveolar surface area in direct contact with pulmonary capillaries decreases.
This cause increases in “dead space (lung area where no gas exchange can occur),” impaired oxygen diffusion (gas exchange).
Hypoxemia results
Increased pulmonary artery pressure may cause right-sided heart failure (Cor pulmonale)

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Emphysema

Alveoli walls are destroyed as result of recurrent infections --- decrease of surface area in contact with pulmonary capillaries --- impaired O2 diffusion & CO2 elimination --- hypoxemia & hypercapnia --- respiratory acidosis
Resistance to pulmonary blood flow --- forcing the Rt ventricle to maintain a higher BP in the pulmonary artery --- Rt side HF (Cor pulmonale)

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Changes in Alveolar Structure

Normal

Abnormal

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Risk Factors - COPD

Tobacco smoking (80% to 90%)
Passive smoking
Increased age
Air pollution (Indoor/outdoor )
Exposure to occupational dusts and chemicals
Genetic abnormalities, Alpha₁-antitrypsin deficiency; an enzyme inhibitor that protect the lung parenchyma from injury. (<1%):
This deficiency leads to rapid development of lobular emphysema

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Clinical Manifestation - COPD

The three primary symptoms:
Chronic cough
Sputum production
Dyspnea: may be sever and interfere with patients activities, worsen with exertion or sometimes at rest.
Weight loss
Use of accessory muscles
COPD with primary emphysema:
Barrel chest
Shoulders heave upward (Retraction of the supraclavicular fossa)

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Normal Chest vs. Barrel-Shaped Chest

Characteristics of normal chest wall and chest wall in emphysema. A. The normal chest wall and its cross-section. B. The barrel-shaped chest of emphysema and its cross-section.

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Typical Posture of a Person With COPD

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PHYSICAL EXAMINATION - COPD

Airflow obstruction

Wheezing during auscultation
Prolongation of forced expiratory time

Hyperinflation of lungs

Low diaphragmatic position
Decreased intensity of heart and breath sounds
Barrel chest

Severe disease

Pursed-lip breathing
Use of accessory respiratory muscles
Retraction of intercostal spaces

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Assessment and Diagnostic Findings

Pulmonary Function Tests:
Spirometry to evaluate airflow obstruction

in respiratory obstruction ratio of forced expiratory volume per second (FEV1)/forced vital capacity (FVC) is less than 70%

Bronchodilator reversibility testing to rule out Asthma
ABGs
Chest X-ray & high resolution CT scan
Alpha₁-antitrypsin deficiency

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Spirometry

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Complications - COPD

Respiratory failure
Pneumonia
Chronic atelectasis
Pneumothorax
Pulmonary arterial hypertension (Cor pulmonale).

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Medical Management - COPD

Smoking Cessation
Pharmacologic Therapy
Oxygen Therapy
Pulmonary Rehabilitation
Nutrition and COPD
Noninvasive Positive Pressure Ventilation
Surgical Management

Bullectomy
Lung Volume Reduction Surgery (LVRS)
Lung Transplantation

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SMOKING CESSATON INTERVENTION

Smoking cessation is the only measure that will slow the progression of COPD
Intervention – set a quit date
Refer to group smoking cessation clinics
Pharmacologic therapy with nicotine replacement therapy (NRT) in highly dependent smokers who:

Smokes a pack or more per day
Requires 1^st cigarette within 30 min of waking up
Finds it difficult refraining from smoking in places where it is forbidden

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PHARMACOLOGIC THERAPY

Bronchodilators

Short-acting: Beta₂-agonists and anticholinergics. Variable onset of action with duration of 4 to 6 hrs.
Long-acting: Salmeterol, Formoterol, Theophylline, or Oral beta2-agonists. Effects lasts 12-24 hrs. Commonly used as maintenance therapy in COPD

Anticholinergic agents (short & long acting)
Corticosteroids: systemic or inhaled to improve symptoms but not lung function.
Mucolytic agents, Antitussive, Vasodilators
Antibiotics: in acute exacerbations where there is increased sputum or sputum purulent

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OXYGEN THERAPY - COPD

Oxygen therapy can be administered as long-term continuous therapy, during exercise, or to prevent acute dyspnea during an exacerbation to keep oxygen saturation above 90%.
Oxygen should be prescribed when:

Arterial PaO₂<55 mmHg at room air
Put patient on long- term O₂ therapy for more than 15 hrs
COPD patients may be more O² sensitive
Administering too much O² result in retention of CO² and decrease respiratory drive.

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NUTRITION - COPD

Nutritional assessment
Malnutrition occurs in 1/4 to 1/3 of patients with moderate to severe COPD

Depletion of fat mass and fat-free mass
Elevated resting energy expenditure

Nutritional supplements alone do not reverse weight loss

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Nursing Management - COPD

Assessing the patient
Health history
Inspection and examination findings
Review of diagnostic tests
Monitor patient for dyspnea & hypoxemia

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Nursing Management - COPD

Achieving Airway Clearance
Decrease the quantity & viscosity of sputum
Administer bronchodilator nebulizers & other medications properly as prescribed
Eliminate pulmonary irritants (smoking)
Instruct patient to perform diaphragmatic breathing and effective coughing.
Chest physiotherapy
Increased fluid intake

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Nursing Management - COPD

Improving Breathing Patterns

Shifting from upper chest respiration to diaphragmatic deep breathing and pursed-lip breathing to control the rate and depth of breathing

Pursed-lip breathing: slow expiration, prevent collapse of small airway
Inspiratory muscle training and breathing exercises
Inspiratory muscle training: Patient (inhale) breathes against resistance for 10 to 15 minutes/day and resistance gradually increases to strengthen respiratory muscles

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Nursing Management - COPD

Improving Activity Tolerance
Education include pacing activities throughout the day or using supportive devices
Evaluate activity tolerance & limitations
Promote independent activities of daily living

Need to delay activities for an hour or so after waking up and moving around

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Nursing Management - COPD

Monitoring & Managing Potential Complications
The nurse must assess for various complications of COPD
Monitors for personality & behavioral changes
Monitors increasing dyspnea, tachypnea & tachycardia
Monitors pulse oximetry values
Controlled bronchopulmonary infections

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Nursing Management

Patient teaching about

COPD, medications at home, nutrition, respiratory therapy treatment, smoking alleviation, coping with COPD, and planning for the future

Self-care activities

Encourage patient to coordinate diaphragmatic breathing with activities

Physical conditioning

Breathing and general fitness exercises to maintain physical fitness

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Nursing Management

Precautions to Oxygen therapy

Teach patient about proper flow rate, required number of hours for oxygen use, no smoking, and regular checking of pulse oximetry or ABGs

Coping measures

Anxiety, fatigue, depression, anger, diminished sexuality, and behavioral changes are expected.
Emphasis should be on controlling symptoms and increasing self-esteem
Support groups may be beneficial

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# Bronchiectasis

Bronchiectasis is a chronic, irreversible dilation of the bronchi and bronchioles.
Results from destruction of muscles & elastic connective tissue.
Caused by:

Airway obstruction, long term pulmonary infections
Diffuse airway injury
Congenital disorders
Genetic disorders
Abnormal host defenses
Idiopathic causes

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Bronchiectasis

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Bronchiectasis: Clinical Manifestations

Manifestations
Chronic cough
Purulent sputum in copious amounts
Clubbing of the fingers
Hemoptysis
Recurrent pulmonary infections

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Bronchiectasis: DX & Medical Management

Diagnostic Findings
Prolonged Hx of productive cough, with sputum
CT which shows bronchial dilations
Management
Postural drainage
Chest physiotherapy (CPT)
Bronchoscopic aspiration of

mucopurulent sputum

Smoking cessation
Antimicrobial therapy
Surgical intervention: removed diseased tissue
Segmental resection, Lobectomy, Pneumonectomy

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Bronchiectasis: Nursing Management

Focus is on alleviating symptoms and clearing pulmonary secretions
Assess nutritional status & ensure adequate diet
Patient Teaching:
Stop smoking
Eliminating factors that increase mucus production
Avoid people with URI
How to perform postural drainage

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# Asthma

Chronic inflammatory disease of the airways that causes airway hyperresponsiveness, mucosal edema, and mucus production.
Inflammation leads to recurrent episodes of asthma symptoms: cough, chest tightness, wheezing, and dyspnea.
It is reversible either spontaneously or with treatment.
Patient may experience symptom free periods alternating with acute exacerbations that last from minutes to hours or days.

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Asthma

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Asthma

Causes
Allergy is the strongest predisposing factor.
Chronic exposure to airway irritants or allergens (seasonal-grass, perennial-dust)
Common triggers for Asthma symptoms & exacerbations:
Airway irritant (air pollutants, cold, heat, strong odors or perfumes, smoke, occupational exposure)
Food (shellfish, nuts), Exercise
Stress or emotional upset, Respiratory infections
Medications & Gastroesophageal reflux

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Clinical Manifestation - Asthma

The Three Most Common Symptoms:
Cough, Dyspnea and Wheezing
Cough with or without mucus production
Generalized wheezing: first on expiration then during inspiration as well.
Chest tightness & dyspnea
Expiration with effort
Hypoxemia & Central cyanosis
Diaphoresis (excessive sweating) & Tachycardia

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Diagnostic Findings

History
Sputum & blood test: elevated Esonophilia & IgE
ABGs : respiratory alkalosis & hypoxemia
Pulmonary function test (PFT): reduced FEV1 and FVC

(normal PFT between exacerbations)

Patients with recurrent Asthma should tests to identify the substances that precipitate the symptoms.

PEFR is measured during a maximal exhalation that immediately followed a maximal inhalation. Keep in mind the values are technique dependent (effort dependent) so physicians should properly educate patients on proper usage each visit. Ideally, peak flows should be monitored every morning and evening, both before and after using inhaled medications, and at other times when the patient begins to experience symptoms
The utility of PEFR to detect the presence of airflow limitation is not particularly good, since the variability of PEFP among individuals is very large (+/- 30 percent). However it is still a useful method of monitoring changes or trends in the patient’s lung function
Misleading PEFR: value can fall during steroid burst as respiratory muscle weakens. Important to clinically correlate initial PEFR with more definitive diagnostic measures such as spirometry and flow-volume loops

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Complications - Asthma

Status Asthamaticus
Pneumonia
Respiratory Failure
Atelectasis
Dehydration as result of sweating & hyperventilation

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Medical Management - Asthma

Stepwise approach
Quick-relief Medications

Beta₂-adrenergic agonists (e.g., Bronchodilators like Ventolin)
Anticholinergics (e.g., Attrovent)

Long-acting Medications

Corticosteroids (Anti-inflammatory)
Long-acting beta₂-adrenergic agonists
Leukotriene modifiers (inhibitors lead to vasodilation)
Mast cell stabilizers (Cromolyn sodium)

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Metered-Dose Inhalers and Spacers

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Asthma- Nursing Diagnosis

Impaired gas exchange
Ineffective breathing pattern
Ineffective airway clearance
Activity intolerance
Ineffective coping
Knowledge deficit
Risk for injury

Ineffective breathing pattern�Ineffective airway clearanceIneffective Airway Clearance��Definition:��Inability to clear secretions or obstructions from the respiratory tract to maintain airway patency.��Maintaining a patent airway is vital to life. Coughing is the main mechanism for clearing the airway. However, the cough may be ineffective in both normal and disease states secondary to factors such as pain from surgical incisions/ trauma, respiratory muscle fatigue, or neuromuscular weakness. Other mechanisms that exist in the lower bronchioles and alveoli to maintain the airway include the mucociliary system, macrophages, and the lymphatics. Factors such as anesthesia and dehydration can affect function of the mucociliary system. Likewise, conditions that cause increased production of secretions (e.g., pneumonia, bronchitis, and chemical irritants) can overtax these mechanisms. Ineffective airway clearance can be an acute (e.g., postoperative recovery) or chronic (e.g., from cerebrovascular accident [CVA] or spinal cord injury) problem. Elderly patients, who have an increased incidence of emphysema and a higher prevalence of chronic cough or sputum production, are at high risk.��Ineffective airway clearance related to

The accumulation of secretions

Airway spasm

Data:

Cough

Discharge

Dyspneu

Cyanosis

Respiratory rate increased

Ronkhi

Wheezing

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a. Airway Management:

Open the airway with headtilt, chinlift, jaw thrust

Set the position to maximize ventilation

Use tools airway

Perform chest physiotherapy

Teach breath deeply and cough effectively

Perform suction

Auscultation of breath sounds

Give bronchodilators (Collaboration)

�

b. Oxygenation therapy

Provide humidification system of oxygen equipment

Monitor the flow of oxygen and the amount given

Monitor signs of oxygen toxicity

NANDA Ineffective Breathing PatternNIC NOC

Nursing Diagnosis for Ineffective Breathing Pattern��Definition: The exchange of air inspiration and / or expiration inadequate.��Ineffective breathing pattern related to

Hyperventilation

Hypoventilation syndrome

Damage muskuloskletal

Neuromuscular Dysfunction

Fatigue muscles of respiration

Data:

Changes in chest movement

Bradipnea, tachypnea

Decrease in inspiratory and expiratory pressures

Breath nostril

The use of auxiliary respiratory muscles

Increased vital signs

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Nursing Interventionsfor Ineffective Breathing Pattern�a. Airway Management:

�

Open the airway with headtilt, chinlift, jaw thrust

Set the position to maximize ventilation

Use tools airway

Perform chest physiotherapy

Teach breath deeply and cough effectively

Auscultation of breath sounds

Give bronchodilators (Collaboration)

�

b. Oxygen therapy

Provide humidification system of oxygen equipment

Monitor the flow of oxygen and the amount given

Monitor signs of oxygen toxicity

�

c. Monitoring of respiration

Monitor the frequency, rhythm and depth of breathing

Monitor the use of auxiliary respiratory muscles

�

d. Monitoring of vital signs

Monitor blood pressure, pulse, respiratory rate, temperature

Monitor blood pressure during sleep, sit, stand up if indicated

Monitor signs and symptoms of hypothermia or hyperthermia

Monitor rhythm and breath sounds

��Defi nition

Inspiration and/or expiration that does not provide adequate ventilation

Assessment

• History of respiratory disorder

• Respiratory status, including rate and depth of respiration, symmetry of chest expansion,

use of accessory muscles, presence of cough, anterior-posterior chest diameter, palpation

for fremitus, percussion of lung fi elds, auscultation of breath sounds, and pulmonary

function studies

• Cardiovascular status, including heart rate and rhythm, blood pressure, and skin color,

temperature, and turgor

• Neurologic and mental status, including level of consciousness and emotional

level

• Knowledge, including current understanding of physical condition and physical, mental,

and emotional readiness to learn

Defi ning Characteristics

• Accessory muscle use

• Altered chest excursion

• Altered respiratory rate or depth or both

• Assumption of three-point position

• Decreased inspiratory or expiratory pressure

• Decreased minute ventilation

• Decreased vital capacity

• Decreased tidal volume (adult tidal volume 500 ml at rest)

• Dyspnea

• Increased anterior-posterior diameter

• Nasal fl aring

• Orthopnea

• Prolonged expiration phase

• Pursed-lip breathing

• Shortness of breath

Expected Outcomes

• Patient’s respiratory rate will stay within 5 breaths/minute of baseline.

• Arterial blood gas (ABG) levels will return to baseline.

• Patient will report feeling comfortable when breathing.

• Patient will report feeling rested each day.

• Patient will demonstrate diaphragmatic pursed-lip breathing.

• Patient will achieve maximum lung expansion with adequate ventilation.

• Patient will demonstrate skill in conserving

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Nursing Management- Asthma

Assess patients respiratory status
Obtains a history of allergic reactions to medications before administering medications
Identifies medications the patient is taking
Administers medications as prescribed
Monitors patients response to medications
Administers fluid in case of dehydration
Educating patients about self care

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Patient Teaching

How to identify and avoid triggers
Proper inhalation techniques
How to perform peak flow

monitoring (measure the highest airflow during a forced expiration)

How to implement an action plan
When and how to seek assistance

Inhalers use

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Using a Peak Flow Meter