MedSurg - Pulmonary Conditions

What are some risk factors for COPD?

Noxious agents: tobacco smoke, air pollution, biomass fuels

Genetic lung development of smaller volumes

What is the pathology of COPD?

Small airway inflammation, alveolar destruction/collapse, mucus hypersecretion

What is air trapping?

Increase difficulty in getting air out, big symptom with COPD. Results in 2nd degree loss of lung tissue

How does COPD impact health worldwide?

4th leading cause of death. Results in high health care costs and high personal costs

Is COPD curable?

No, there is no therapy to reverse lung damage and has a high mortality. Can be prevented

How is the severity of COPD assessed?

Spirometry; measures volume and speed of air inhaled or exhaled as a function of time

What is FEV1 in spirometry?

Forced expired volume in 1st second

What is FVC in spirometry?

Total volume of air exhaled from maximal inhalation to maximal exhalation

What is FEV1/FVC% in spirometry?

The ratio of FEV1 to FVC, expressed in percentage

What is PEFR in spirometry?

Fastest flow gas from lungs

How does FEV1/FVC % relate to severity of COPD?

< 70% = COPD diagnosis

What are patient teaching points for COPD?

1. Prevent progression

2. Relieve symptoms

3. Improve exercise tolerance

4. Teach self-management skills

How is COPD progression prevented?

Get influenza and pneumococcal vaccine. Make healthy lifestyle choices

What is the 5 "A's" model for facilitating smoking cessation?

Ask about tobacco

Advise all smokers to quit

Assess willingness to quit

Assist the patient in their attempt to quit

Arrange followup contact

Why are E-cigarettes bad?

Liquid containing nicotine and flavoring inside of them. Can lead to EVALI

How can COPD symptoms be relieved?

Bronchodilators

How do short acting bronchodilators work?

Activate beta 2 receptors in the bronchial smooth muscle, leads to bronchodilation. Immediate relief of dyspnea in <1min, last 4-8hrs.

What are examples of short acting bronchodilators?

Albuterol (SABA) and Ipratropium (SABA)

How do long acting bronchodilators work?

Activate beta 2 receptors in the bronchial smooth muscle, leads to bronchodilation. Daily relief that prevents exacerbations. Onset in about 5min, last 12-24hrs.

What are examples of long acting bronchodilators?

Salmeterol (LABA) and Tiotropium (LABA)

What is Step 1 of COPD medication prescription?

Quick acting bronchodilator; SABA, SAMA

What is Step 2 of COPD medication prescription?

Add long acting bronchodilator; LAMA or LABA

What is Step 3 of COPD medication prescription?

Add 2nd long acting bronchodilator; LABA or LAMA

What are inhaled corticosteroids (ICS)?

Anti-inflammatory agents with direct and indirect bronchodilating effects. EX: fluticasone, budesonide

What are the side effects of ICS?

Voice irritation, Cushing disease, cataracts, bruising, hoarse voice, throat irritation, cough, hyperglycemia. Must wash out mouth after use to avoid oral thrush

What is a combination inhaler?

Includes different agents for desired effects.

LABA+ICS, LABA+LAMA, LABA+LAMA+ICS

What is a meter dosed inhaler?

Pressurized inhaler that propels medication by gas

What is a dry powder inhaler?

Drug inhaled as a powder

How is an inhaler properly taken to ensure the medication reaches the lower lungs?

Inhale deeply, hold breath for 10s, wait for 1 min if using 2 doses

How is a DPI used?

Open, slide lever until it clicks, gently breathe out, do not exhale into device, seal lips around mouthpiece, inhale rapidly and deeply, hold breathe 10s, remove device from mouth and exhale, check if powder is gone; if not repeat, wait 1min between puffs

How is an MDI used?

Take off cap, shake inhaler, stand up, breathe out, put the inhaler in your mouth or put it just in front of your mouth, push down on the top of the inhaler as you breathe in, keep breathing in slowly, hold breath for 10s, breathe out.

What can a COPD patient do to be less short of breath?

Pursed lip breathing; inhale via nose with mouth closed, exhale over 4-6s through pursed lips, use when experiencing dyspnea, prevents air trapping

How does upper arm exercise impact breathing in COPD?

Increases SOB; impacts ADL because of brushing teeth, combing hair, shaving, etc. Exercise improves muscle tone

How do you teach a patient to effectively cough?

Sit in a chair, feet on floor. Take 3-4 breaths in through the nose and out the mouth. Grasp a pillow with crossed hands, cough while bending forward. Assists action of diaphragm and increases airflow

What is a normal SpO2 for COPD patients and when should oxygen be started?

Normal SpO2 is low, could be around 89%. Start oxygen if dropping below 89%

What are the benefits of pulmonary rehab?

Teaches self-management and how to use equipment properly, how to exercise with less SOB, reducing stress, and keeping patients active

How is COPD readmission prevented?

Patient teaching, inhaler device training, COPD action plan use, pharmacy reconciliation, followup call after discharge, referral to pulmonary rehab

What are signs of respiratory distress in COPD exacerbation?

Tripod position, accessory muscle use, pursed lip breathing, blue lips, jugular vein distention, decreased level of conciousness/agitation

What are some common risk factors for asthma?

Genetics; "atopic"

Environment; less exposure to allergens in childhood, occupational exposure

What are the consequences of the asthma risk factors?

Hyperreactive airway

Encounter with trigger; allergen, irritant, exercise

Release of inflammatory mediators

What is allergic asthma?

An initial allergen exposure causes allergen specific IgE antibodies to be synthesized and secreted. IgE antibodies bind to high-affinity receptors on mast cells. The next time the allergen is exposed, cross links on mast cell surface are followed by mediator release.

What causes non allergic asthma?

Strong odors, air pollution, chemicals, exercise

What are common asthma triggers?

Allergens; pollens, dust, mold, pets, food

Non-allergens; smoke, air pollution, chemicals, perfumes

Occupational; smoke

Why is asthma becoming more common / what is the Hygiene Hypothesis?

"Clean lifestyles" are resulting in lack of immunity development in children. Less contact with allergens leads to responding with s/s of asthma

What is the severe asthma phenotype?

Patients with high number of eosinophils, makes s/s difficult to control.

How is asthma self managed?

Identify and avoid triggers. Record symptoms; how often, when. Use a peak flow meter to show airflow effect. Have an asthma action plan

How does a peak flow meter work?

Measures the speed gas leaves the lungs.

Green; 80-100%

Yellow; 50-80%

Red; <50%

How is a peak flow meter used?

Move dial to bottom, stand up, deep breath, blow into device hard and fast, record value, repeat x3, use highest value

What are reliever medications for asthma?

Onset 1min, last 4-6hrs

Dilates airways; SABA, SABA+ICS

What are standard controller medications for asthma?

Onset 5min, last 12-24hrs

Reduce/prevent chronic inflammation; ICS

Dilate airways; LABA

Prevent release of mediators; LTRA

What are biological controller medications for asthma?

Last 2-4 weeks

Reduce effects of IgE / eosinophils; Anti-IL-5 / Anti IgE

What is the asthma rescue drug?

SABA

What is the typical sequence of medications used for asthma?

ICS (low dose), LABA, ICS (med dose)

When is a nebulizer used?

When albuterol makes a patient anxious

Can a LABA be used alone is asthma?

No- must be taken in combo with ICS. Black box warning; may mask airway inflammation, greater risk of severe exacerbation

What is status asthmaticus?

Severe, life-threatening bronchospasm that can develop slowly or gradually. Occurs because of inadequate treatment, non adherence, and severe asthma

What are some cues of asthma exacerbation?

Confusion, no wheezing, silent chest phenomenon, talks in 2-3 word sentences

What is the same between asthma and COPD?

Tests to monitor (PFTs) and inhaler technique

What is different between asthma and COPD?

Age at onset, causative factors, medications (sequence/drugs), patient response

What are sleep related breathing disorders?

Snoring, upper airway narrows, airway closes, obstructive sleep apnea (OSA)

What are some risk factors for OSA?

Men and women post menopausal

Fat distribution; tongue blocking airway

Anatomy; small upper airway

What parts of patient history help diagnose OSA?

Loud snoring, partner reports apnea, excessive daytime sleepiness, memory/learning/mood problems, impotence

How is OSA diagnosis confirmed?

Polysomnography (PSG) Sleep Study

What is the Apnea Hypopnea Index?

The combined average number of apneas and hypopneas that occur per hour of sleep

Normal <5, Mild 5-15, Mod 15-30, Severe >30

How are OSA symptoms managed?

Lifestyle changes; weight loss, avoid alcohol at night

Positive Airway Pressure (PAP)

What is Positive Airway Pressure (PAP)?

Pressure prevents airway closure. Must be used daily, very effective in decreasing s/s, adherence is poor.

CPAP, BiPAP, APAP

What does mandibular (jaw) advancement do?

Pulls lower jaw forward and repositions the tongue - opens the airway. Works with mild-moderate

What is hypoglossal nerve stimulation?

An impulse generator is placed in the chest at the intercostal muscle. Electrode stimulates hypoglossal nerve and moves the tongue forward to open airway during sleep

What are some consequences of OSA?

Cardiovascular disease; HTN

Impaired glucose metabolism; higher risk of metabolic syndrome

Behavioral issues; adverse effect reasoning, attention, memory, daytime sleepiness, fatigue, learning difficulties