Topic 3 Obstructive Pulmonary Diseases

CF

An inherited, autosomal recessive genetic disorder that causes altered transport of sodium and chloride ions in and out of epithelial cells and airway obstruction due to changes in exocrine glandular secretions, resulting in increased mucus production

lungs, pancreas, biliary tract, reproductive organs

what does CF primarily affecet

6-8 months old

what is the median age of diagnosis for CF

• Decreased pancreatic functioning causes decreased absorption of nutrients leading to steatorrhea (large fatty BMs)

• Pancreatic issues can result in DM

• Presence of meconium ileus in newborns

• Persistent respiratory symptoms

• Failure to thrive

• Malnutrition

• Bronchiectasis

• Thick, sticky mucus

• Barrel chest

• Decreased absorption of vitamins and ezymes

• Abdominal distension

• Rectal prolapse

• Adult S/S may include new onset DM, infertility issues, frequent cough, URI, clubbing, weight loss, increased cough, decreased lung function

what are the clinical manifestations of CF

Sweat Chloride Test

The gold standard test for CF in which sweat is collected and analyzed; values >60 mmol/L are positive for CF

• relieving airway obstruction

• loosen mucus with CPT, percussion, vibrations

• controlling infection

• use aerosol and nebulizer to promote drainage

• Antibiotics to prevent complications from lung infections

• adequate home support and resources such as IV antibiotic therapy at home, independently

• use oral agents for mild exacerbations

• pancreatic insufficiency management

• aggressive pulmonary training (chest PT, IS, pursed lip breathing, breathing exercises, O2) to maintain airway clearance

what does interprofessional care for CF include

hemoptysis (blood sputum), respiratory failure

why are CF patients admitted to the ICU (SATA)

a. hemoptysis

b. respiratory failure

c. decreased oxygenation

d. clogged bile ducts

e. delayed growth

asthma

bronchial hyperreactivity with reversible expiratory airflow limitations (spontaneously or with treatment) that effects millions of adults each year and causes millions of ED visits

• inflammatory factors

  • respiratory infections

  • allergens

  • work

• irritants

  • temperature changes

  • exercise

  • cold air

  • stress and emotions

  • strong odors

• medications

• tobacco

• gastric reflux

• air pollutants

• food additives

what are different asthma triggers

asthma

exposure to triggers triggers inflammatory mediators such as edema of airway mucosa, muscle spasm, accumulation of secretions leading to vasodilation of BVs, itching, bronchospasms, and airway narrowing, and mucus production leading to problems on expiration

labored breathing, cough, wheezing, tightness in chest, troubles with airflow, sleep problems, feeling tired, allergies, common cold

what are the clinical manifestations of asthma

mild asthma

what severity of asthma:

dyspnea occurs with activity and patient may feel that he or she “can’t get enough air”

Usually treated at home with an inhaler or a short course of oral corticosteroids

moderate asthma

what severity of asthma:

Dyspnea interferes with or limits usual activities

requires office/ED visit

Frequent inhale SABA and oral systemic corticosteroids

severe asthma

what severity of asthma:

dyspnea at rest, speaks in words not sentences because of difficulty breathing, feeling of suffocation

requires ED visit and usually hospitalization, partial relief from SABA, oral systemic corticosteroids in combination with IV magnesium and ipratropium

life threatening asthma

what severity of asthma:

too dyspneic to speak, may be drowsy/confused, perspiring

requires ED/hospitalization and maybe ICU, minimal/no relief from SABA, IV corticosteroids with ipratropium, and IV mag

airways remodeling, respiratory related issues, fatigue, HA, lack of activity, pneumonia, influenza, acute renal failure, status asthmaticus

what are the complications of athma

• Peak expiratory flow rate (PEFR)

• Incentive spirometry to see lung volumes and capacities

• Fraction of exhaled Nitric Oxide (FENO)

• Serum eosinophils and IgE can suggest allergens

• Chest X-ray and S&C to rule out other disorders

what are the diagnostic studies used to diagnose asthma

peak flow expiratory rate (PFER)

A test of lung function that measures the maximum rate of airflow after forceful exhalation, which helps predict asthma attacks and monitor the severity of the disease

fraction of exhaled nitric oxide (FENO)

diagnostic study that helps to determine asthma and can gauge loss of asthma control and attacks and patient adherence to therapy

if symptoms worsen step up medications, if symptoms are controlled step down medications

what is the stepwise approach/medication guidlnes based on steps for asthma

step 1 medications for asthma

which step of asthma treatment:

• no preferred controller med

• consider low dose ICS

• Use SABA PRN for relief

step 2 medications for asthma

which step of asthma treatment:

• preferred controller med: low dose ICS

• alternative: LTRA, low dose theophyine

• SABA PRN for relief

step 3 medications for asthma

which step of asthma treatment:

• preferred controller med: low dose ICS/LABA

• alternative: med/high dose ICS, or low dose ICS + LTRA or theophylline

• SABA or low-dose ICS/formoterol PRN for relief

step 4 medications for asthma

which step of asthma treatment:

• preferred controller med: med/high ICS/LABA

• alternative: add tiotropium + med/high dose ICS + LTRA or theophyline

• SABA or low dose ICS/formoterol PRN for relief

step 5 medications for asthma

which step of asthma treatment:

• preferred controller med: hgih ICS/MBA + add on (tiotropium, anti-IgI, anti-IL5, etc.)

• alternative: add low dose OCS

• SABA or low-dose ICS/formoterol PRN for relief

• teach patient to identify/avoid known triggers and irritants

  • wash clothes in hot or cold water with detergent and bleach

  • use scarves/masks for cold air

  • avoid aspirin and NSAIDs

  • consider desensitization therapy

• promptly report URIs and sinusitis

• evaluate job environment

• weight loss/exercise

what are the nursing interventions for asthma

COPD

a progressive lung disease with persistent airflow limitation with an enhanced chronic inflammatory response in airway and lungs that is characterized by chronic inflammation of airways, lung parenchyma, and pulmonary BVs

cigarette smoking and noxious particles/gases

what are the main causes of COPD

cigarette smoking, infection, asthma, air pollution, occupational chemicals/dusts, aging, genetics

what are the RF of COPD

COPD

Airflow limitation is not fully reversible during forced exhalation due to loss of elastic recoil of the lungs and airflow obstruction from mucous hypersecretion, mucosal edema, and bronchospasm, Disease progression is marked by worsening abnormalities in airflow limitation, air trapping, and gas exchange which when severe can cause pulmonary HTN and systemic manifestations

hypoxemia (low O2) and hypercapnia (high CO2)

how does COPD affecet O2 and CO2 levelshy

hypoxemia

PaO2 < 60 mmHg and SaO2 < 88% on RA

hypercapnia

PaCO2 > 45 mmHg

• decreased elastic recoil and decreased chest wall compliance

• decreased functional alveoli and SA for gas exchange

• PaO2 decreased with age (normal for an older adult is 70 mmHg)

• Respiratory defense mechanisms are less effective

• increased burden of disease due to reduced lean body mass, decreased respiratory muscle strength, increased dyspnea, and lower exercise intolerane

• smoking cessation may be hard

• handling/coughing out secretions may be more difficult

how does COPD affect the aging adult

chronic cough, dyspnea that occurs with exertion and becomes progressive, wheezing/chest tightness, chest heaviness (can’t take a deep breath, gasping, increased effort to breathe, air hunger), digital clubbing, use of accessory muscles. muscles to breath, easily fatigued, barrel chest, tripod position, pursed-lip breathing, peripheral edema (ankles) → right HF, decreased breath sounds, weight loss/anorexia, pulmonary HTN, Cor Pulmonale, Acute exacerbations, acute renal failure (ARF)

what are the clinical manifestations of COPD

pulmonary HTN, cor pulmonale, acute exacerbations, ARF

what are the primary complications of COPD

• spirometry to confirm diagnosis if FEV1/FVC ration is < 70%

  • The lower the FEV1 the more severe the COPD

• chest X-ray

• serum a1-antitrypsin levels

• 6-minute walk test to test for exercise-induced hypoxemia

  • Qualify for O2 therapy if Pulse Ox at rest is < 88%

• ABGs

• ECG: normal or signs of right HF

• Echo, MUGA scan to evaluate heart function

• COPD assessment test/ questionnaire

what are teh diagnostic studies for diagnosis COPD

< 88% at rest

what does a patient’s pulse ox have to be to qualify for O2 therapy

oxygen therapy

what is the only treatment linked to improved survival for COPD patients

keep SaO2 > 90% during rest, sleep, and exertion, keep PaO2 > 60 mmHg, or levels as appropriate in moderate-severe COPD, too much O2 can decrease the drive to breathe so MUST be carefully monitored

what is the goal of oxygen therapy in COPD patients

pursed-lip breathing

breathing retraining exercise that prolongs expiration to reduce bronchial collapse and air trapping

diaphragmatic breathing

breathing retraining exercise that promotes the use of diaphragm instead of accessory muscles to achieve max inhalation and slow respiratory rate, in some patients may increase WOB and dyspnea

ACTs

airway clearance techniques that is often used with other treatments (bronchodilator) to loosen mucus to clear with coughing; ie. effective/huff coughing

effective/Huff coughing

airway clearance technique that conserves energy, reduces fatigue, and facilitates the removal of secretions

nothing specific, but a well-balanced diet, high in protein, moderate in carbohydrate, moderate to high in fat, 5-6 small meals per day, nutrition supplements between meals, dietician consult, increased protein and caloric needs

What is nutrition therapy for COPD

quit smoking, use good hand hygiene, take drugs as prescribed, early treatment of respiratory tract infections/exacerbation, vaccinations, avoid/control exposure to pollutants and irritants

what does health promotion look like for a COPD

• Exercise training leads to energy to energy conservation

• modify ADLs to conserve energy

• schedule daily/weekly activities, including plenty of rest periods

• regular exercise that is appropriate, safe, and easy to perform

what are activity considerations for those with COPD