Gas exchange & fatigue: COPD

Chronic obstructive pulmonary disease (COPD) (3)

• preventable disease

• decreased airflow to the lungs that is usually progressive

• chronic inflammatory response in the airways and lungs

What does the chronic inflammatory response in the airways and lungs do to the patient?

Impaired gas exchange & fatigue

COPD primary cause

Cigarette smoking and other noxious particles

Chronic obstructive bronchitis (4)

• Long term inflammation of the bronchial tubes

• Inflammation & swelling further narrows airway

• thick, sticky mucous blocks up the airways rather than clears'

• Productive cough, sputum, increased respirations, SOB, low O2

Emphysema (3)

• Destruction of the alveoli

• Air exchange occurs in the alveoli

• The alveoli have become stiff and air gets trapped making air exchange difficult

COPD pts usually have what 2 pathological changes

Chronic obstructive bronchitis and emphysema

COPD causes (4)

• Tobacco smoke: stimulates inflammatory response in lungs, damages alveoli sacs

• Occupational chemicals & dust

• Infection (recurring): chronic inflammation, damaged lungs

• Heredity – α1-Antitrypsin (AAT) deficiency: protein that protects you from infection

COPD cardinal signs (3)

• Dyspnea

• Difficulty breathing, Shortness of breath

• Limitations in activity

COPD signs & symptoms (10)

• Cough: intermittent, small amount mucus (in morning)

• Sputum production: exacerbated by cold, damp air & resp. infections

• Dyspnea

• Weight loss & anorexia (advanced)

• Prolonged expiratory phase

• Wheezes or ↓breath sounds

• Pursed-lip breathing

• Accessory muscle use

• Hypoxemia

• Bluish-red color of skin

Weight loss & anorexia in COPD (3)

• One possibility is that patients are in a hyper-metabolic state with increased energy requirements

• partly because of the increased work of breathing.

• Even when caloric intake is adequate, weight loss may still occur.

COPD s&s you may see during a physical examination (5)

• Prolonged expiratory phase of respiration

• Wheezes, or decreased breath sounds, or some combination is noted in some or all lung fields.

• Tripod position

• may naturally purse lips on expiration (pursed-lip breathing)

• use of accessory muscles, such as those in the neck, to aid with inspiration.

COPD diagnosis (3)

• History & physical exam

• Pulmonary function

• Spirometry: FEV1/FVC ratio less than 70%

FEV1

Forced expiratory volume in one second

FVC

Forced vital capacity

Spirometry range and meaning (4)

• Mild – SOB when hurrying or walking up slight incline (FEV1≥ 80%)

• Moderate – SOB causing patient to stop after a few minutes (FEV1≥ 50%)

• Severe – SOB resulting in patient too breathless to leave house (FEV1≥ 30%)

• Very Severe – FEV1<30%

COPD common diagnostic tests

• Pulmonary function tets measured with spirometry

• FEV1 (Forced Expiratory Volume) and FVC (Forced Vital Capacity)

• ABG

• ↓O2 sat

• ↑Hgb (in response to chronic low O2 levels)

FEV1 and FVC test (2)

• As COPD worsens the FEV-FVC ratio decreases

• COPD diagnosis: FEV-FVC ratio post bronchodilator less than 70

ABG results for COPD (2)

• PaO2 <80 mm Hg (hypoxemia)

• PaC02 >45 mm Hg (hypercarbia)

COPD complications (4)

• Cor pulmonale

• Acute exacerbations of COPD (AECOPD)

• Acute respiratory failure

• Depression & anxiety

Cor Pulmonale (3)

• Hypertrophy of right side of heart

• Heart works harder

• Treat: O2, Diuretics

Acute exacerbations of COPD (AECOPD): (3)

• Worsening of symptoms

• Infection

• Treat: Corticosteroids, Antibiotics

Acute respiratory failure (3)

• Can be caused by abruptly stopping medications

• Wait too long to contact HCP

• Treat: Intubation, ventilation, supportive care

COPD increases risk of what ?

Increases risk of heart failure

COPD Interprofessional care (8)

• Managed at home, unless AECOPD

• Smoking cessation

• Medication therapy

• Oxygen therapy

• Complications

• Surgery

• Pulmonary rehabilitation

• Nutritional therapy

COPD medication therapy (2)

• Bronchodilators

• Inhaled corticosteroids (ICS) (Symbicort) + Long acting B2 agonist (LABA) (Advair) – Pt. with high risk of AECOPD

COPD oxygen therapy

• Maintain O2 >90%

• Short-term (during exacerbations) or long-term

• Administered to treat hypoxemia

• Humidification: infections if not cleaning/changing supplies frequently

• Safety

COPD Complications

•Combustion: oxygen tanks are flammable

•Carbon dioxide narcosis: increased tolerance of CO2

•Oxygen toxicity: giving too much oxygen

•Absorption atelectasis

•Infection

Absorption atelectasis (4)

• Room air has nitrogen which helps fill alveoli

• Oxygen we administer does not have nitrogen 

• Giving too much oxygen can wash out the nitrogen

• Causing the alveoli to collapse

COPD Surgery (3)

• Severe COPD

• Lung volume reduction surgery

• Lung transplant

COPD Pulmonary rehabilitation (2)

• Exercise conditioning

• Breathing exercises (pursed-lip & diaphragmatic breathing, effective coughing)

  • Post-op do pursed lip breathing (in thru nose, out thru mouth)

COPD nutritional therapy (4)

• Meds before meals: best chance at eating the most

• 5-6 small meals: might be more effective

• ↑calorie & protein: don’t want to fill up on empty calories

• Fluids between meals: to thin secretions

COPD Nursing management (9)

• Health promotion

  • Prevention & early detection

  • Immunizations

• Education

  • Managing disease

• Exercise

  • Walking (build to 20 minutes/day, if possible)

• Ineffective breathing pattern: try different positions

• Inadequate airway clearance: encourage cough, thin fluids

• Reduced gas exchange: oxygen, meds to relax airway

• Inadequate nutrition: talk abt diet, weighing regularly

• Disturbed sleep pattern: medication, positioning, avoid caffeine

• Potential for infection: hand hygiene, clean equipment

COPD Coping (5)

• Energy conserving strategies: maybe pick all activities in one room

• Sexual activity: maybe take meds before, schedule a time

• Sleep

• Psychosocial considerations: how can we support

• End-of-life issues

Bronchoscopy (2)

• Larynx, Trachea & Bronchi visualized through a flexible fiber optic bronchoscope

• Procedure takes 30-45 minutes

Bronchoscopy preparation

• NPO 4-8 hours before

• Remove dentures

• Baseline vitals

• Medications (may be given in Endoscopy)

Bronchoscopy intra-op

• Sedation to decrease cough (risk for aspiration)

• Sitting or Supine: hyperextended neck

• Label specimen & send to lab

• Ongoing respiratory assessment

Bronchoscopy post-op

• Respiratory Assessment

• LOC

• NPO until gag reflex and cough present (usually 1-2h)

• Diet: NPO → ice chips → fluids, etc.

• Education: No driving, Deep breathing & coughing

• Observe for hemoptysis (coughing up blood, something may have been punctured) or temperature (sign of infection)

• Gargle with salt water or throat lozenges can relieve sore throat

Bronchoscopy potential complications

Theres lot of them!

Thoracentesis

• Pleural fluid is removed from the pleural cavity with a needle

• Can be done by aspirating fluid into syringe

• or insert cathater and leave insitu like a chest tube

Pleural effusion

• fluid between lungs & chest wall

• in pleural cavity. NOT in the lungs, puts pressure on lungs

• unsymmetrical chest expansion

• decreased breaths sounds where fluid is

Pleural effusion diagnosis and treatment

Dx: Chest CT

Tx: Thoracentesis 

Thoracentesis pre op

• Informed consent

• No fasting necessary

• Position for procedure

  • Minimize movement or coughing

  • Cough suppressant pre-procedure (if cough present)

• Radiograph or u/s often used to locate fluid

Thoracentesis intra-op (7)

• Sterile technique

• Tell client feel pressure

• VS

• Skin color

• O2 saturation

• Record amount of fluid removed

• Label & send to lab

Thoracentesis

• Apply dressing & monitor for leakage

• Respiratory assessment

• HOB elevated

• VS & O2 sats

• DB&C

• Post op X-ray

• Pain assessment

• Care of a chest tube

Thoracentesis complications

Pneumothorax, bleeding, infection (empyema)

Empyema

• Build up of pus in pleural space

• Tx: antibitoics

Vaping

• Cause serious lung damage

• Nicotine dependence

• Worsen lung disorders

  • asthma

  • COPD