Oxygenation

NUR 112

Chronic Obstructive Pulmonary Disease (COPD)

A preventable and treatable, but not fully reversible slowly progressive respiratory disease of airflow obstruction involving the airways, pulmonary parenchyma, or both

What is the forth leading cause of death in the United States for people of all ages?

COPD

What are some examples of chronic pulmonary diseases?

Bronchiectasis

Asthma

Cystic Fibrosis

What are the two distinct diseases processes that may be present with in COPD patients?

Chronic Bronchitis

Emphysema

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.

How does chronic bronchitis affect cilia?

Cilia in the airway of the lungs is destroys or function is reduced

How does chronic bronchitis affect the bronchial walls and bronchial airways?

Bronchial walls thicken

Bronchial airways narrow

Mucous may plug airways-Inflammation occurs

How does chronic bronchitis affect alveoli?

Alveoli become damaged, fibrosed, and alveolar macrophage function diminishes

Patients with chronic bronchitis are more susceptible to what?

Respiratory infection

How does emphysema affect oxygen and carbon dioxide exchange?

Impaired oxygen and carbon dioxide exchange results from destruction of the walls of overdistended alveoli.

Emphysema

Abnormal distention of the airspaces beyond the terminal bronchioles and destruction of the walls of the alveoli

What can hypercapnia lead to?

Respiratory acidosis

Hypercapnia

Increased carbon dioxide tension in arterial blood

Cor pulmonale

One of the complications of emphysema, is right-sided heart failure brought on by long-term high blood pressure in the pulmonary arteries

How does hypoxemia affect pulmonary artery pressures?

May further increase pulmonary artery pressures

What are the two main types of emphysema?

Panlobular

Centrilobular

Panlobular (panacinar) Emphysema

With this type of emphysema, there is destruction of the respiratory bronchiole, alveolar duct, and alveolus. All airspaces within the lobule are essentially enlarged, but there is little inflammatory disease.

Panlobular emphysema signs/symptoms.

A hyperinflated (hyperexpanded) chest

Marked dyspnea on exertion

Weight loss

How does panlobular emphysema affect expiration?

Instead of being an involuntary passive act, expiration becomes active and requires muscular effort.

Centrilobular (centroacinar) Emphysema

Takes place mainly in the center of the secondary lobule, preserving the peripheral portions of the acinus (i.e., the terminal airway unit where gas exchange occurs).

What frequently happens with centrilobular (centroacinar) emphysema and what does that lead to?

Frequently, there is a derangement of ventilation–perfusion ratios, producing chronic hypoxemia, hypercapnia, polycythemia (i.e., an increase in red blood cells), and episodes of right-sided heart failure. This leads to central cyanosis and respiratory failure. The patient also develops peripheral edema.

Risk Factors For COPD

Exposure to tobacco smoke

Older adults

Occupational exposure (dust,chemicals)

Pollution

Genetic abnormalities - deficiency of alpha1-antitrypsin

What is alpha1-antitrypsin?

An enzyme inhibitor that normally counteracts the destruction of lung tissue by certain other enzymes

Exposure to tobacco smoke accounts for an estimated ____ of cases of chronic obstructive pulmonary disease

80-90%

What are the three primary symptoms of COPD?

Chronic cough

Sputum production

Dyspnea

Why would dyspnea cause a patient to loss weight?

It interferes with eating and the work of breathing is energy depleting

What is the A-P diameter and transverse diameter ratio for a normal adult?

A-P 1

Transverse 2

What is the A-P diameter and transverse diameter ratio for a person with a barrel chest?

A-P 1

Transverse 1

What does FEV1 stand for?,

\

Forced expiratory volume in 1 s

What does stand for FVC?

Forced vital capacity.

COPD is classified into ____ grades depending on the severity measured by pulmonary function tests.

4

COPD grade 1 severity

Mild

COPD grade 2 severity

Moderate

COPD grade 3 severity

Severe

COPD grade 4 severity

Very severe

COPD grade 1 pulmonary function

FEV1/FVC

COPD grade 2 pulmonary function

FEV1/FVC

COPD grade 3 pulmonary function

FEV1/FVC

COPD grade 4 pulmonary function

FEV1/FVC

Complications of COPD

Respiratory insufficiency and failure

Pneumonia

Chronic atelectasis

Pneumothorax

Cor pulmonale (pulmonary arterial hypertension)

Medial management of COPD

Promote smoking cessation
Reducing risk factors
Providing supplemental oxygen therapy
Pneumococcal vaccine
Influenza vaccine
Pulmonary rehabilitation
Managing exacerbations

What is a normal SpO2 range for a patient with COPD?

88-92%

What is the best way to deliver oxygen to a patient with COPD?

Venti Mask

Medications to treat COPD

Bronchodilators, MDIs

Corticosteroids (Beclomethasone)

Antibiotics

Mucolytics

Antitussives

Low-Flow Systems (Oxygen Delivery)

Cannula (nasal and reservoir)

Nasal (oropharyngeal) catheter

Simple mask

Partial rebreathing mask

Nonrebreathing mask

Disadvantages of a nonrebreathing mask

Poorly fitting, must remove to eat

Disadvantages of a partial rebreathing mask

Warm, poorly fitting, must remove to eat

Disadvantages of a simple mask

Poorly fitting, variable FiO2, must remove to eat

Disadvantages of a nasal (oropharyngeal) catheter

Nasal mucosa irritation; catheter should be changed frequently to alternate nostril

Disadvantages of a cannula (nasal and reservoir)

Easily dislodged, from nares, skin breakdown over ears or nares, nasal mucosal and/or pharyngeal mucosal drying, air swallowing, variable FiO2

Advantages of a nonrebreathing mask

High O2 concentration

Advantages of a partial rebreathing mask

Moderate O2 concentration

Advantages of a simple mask

Simple to use, inexpensive

Advantages of a nasal (oropharyngeal) catheter

Inexpensive, does not require a tracheostomy

Advantages of a cannula (nasal and reservoir)

Lightweight, comfortable, inexpensive, continuous use with meals and activity

Nonrebreathing mask O2 percentage setting

80-95%

Partial rebreathing mask O2 percentage setting

50-75%

Simple mask O2 percentage setting

40-60%

Nasal (oropharyngeal) catheter O2 percentage setting

24-44%

Cannula O2 percentage setting

24–28%

32–40%

44%

Nonrebreathing mask flow rate

10-15 L/min

Partial rebreathing mask flow rate

8-11 L/min

Simple mask flow rate

5-8 L/min

Nasal (oropharyngeal) catheter flow rate

1-6 L/Min

Cannula (nasal and reservoir) flow rate

1-2 L/min

3-5 L/min

6 L/min

High-Flow Systems (Oxygen Delivery)

Venturi mask

Transtracheal oxygen catheter

Aerosol mask

Tracheostomy collar

T-piece

Face tent

Disadvantages of a pose dose

Must carefully evaluate function individually

Advantages of a pose dose

Deliver O2 only on inspiration, conserve 50–75% of O2 used

Pulse dose flow rate

10-40 mL/breath

What type of device is a pulse dose (or demand)

Oxygen-Conserving Device

Disadvantages of a face tent

Bulky and cumbersome

Disadvantages of a t-piece

Heavy with tubing; no need for surgery for placement

Disadvantages of a tracheostomy collar

Requires surgery to place; needs cleaning and suctioning to maintain patency of airway

Disadvantages of a aerosol mask

Uncomfortable for some

Disadvantages of a transtracheal oxygen catheter

Requires frequent and regular cleaning, requires surgical intervention, with associated risk for surgical complications

Disadvantages of a venturi mask

Must remove to eat

Advantages of a face tent

Good humidity, fairly accurate FiO2

Advantages of a t-piece

Good humidity, comfortable, fairly accurate FiO2

Advantages of a tracheostomy collar

Good humidity, comfortable, fairly accurate FiO2

Advantages of a aerosol mask

Good humidity, accurate FiO2

Advantages of a transtracheal oxygen mask

More comfortable than other high-flow systems, concealed by clothing, less oxygen liters per minute needed than nasal cannula

Advantages of a venturi mask

Provides low levels of supplemental O2

Precise FiO2, additional humidity available

Face tent O2 percentage

28-100

T-piece O2 percentage

28-100

Tracheostomy collar O2 percentage

28-100

Aerosol mask O2 percentage

28-100

Transtracheal oxygen catheter O2 percentage

60-100

Venturi mask O2 percentage

24, 26, 28

30, 35, 40

Face tent flow rate

8-10 L/min

T-piece flow rate

8-10 L/min

Tracheostomy collar flow rate

8-10 L/min

Aerosol mask flow rate

8-10 L/min

Transtracheal oxygen catheter flow rate

1/4-4 L/min

Venturi mask flow rate

4-6 L/min

6-8 L/min

Surgical management of COPD

Bullectomy- emphysema- to reduce large areas of airspace

Lung volume reduction- removal of a portion of diseased lung

Lung transplant

Hypoxemia

Decrease in arterial oxygen tension in the blood

Hypoxia

Decrease in oxygen supply to the tissues and cells

What may occur when too high a concentration of oxygen (greater than 50%) is administered for an extended period?

Oxygen toxicity

What are the symptoms of oxygen toxicity?

substernal discomfort, paresthesias, dyspnea, restlessness, fatigue, malaise, progressive respiratory difficulty, refractory hypoxemia, alveolar atelectasis, and alveolar infiltrates evident on chest x-rays.

How to prevent oxygen toxicity

Use lowest effective concentrations of oxygen

PEEP or CPAP prevent or reverse atelectasis and allow lower oxygen percentages to be used