Nursing Care of Patients with Gas Exchange Disorders: COPD, Bronchitis/Emphysema

Chronic Obstructive Pulmonary Disease

• A disease state characterized by airflow limitation that is not fully reversible. Includes diseases that cause airflow obstruction (emphysema and chronic bronchitis).

• Characterized by exacerbations and remission, progressive and chronic.

Men and Emphysema

Are 7 times more likely to be diagnosed with emphysema then women

Women and Emphysema

It’s prevalence is increasing but decreasing amongst men

COPD diagnosis across the racial line

Whites are diagnosed more than blacks but increase death rate for ethnic groups

Primary Cause of COPD

Environmental exposure to cigarette smoking but this cause is also very modifiable

Chronic Bronchitis Also Known As

Blue bloater

BLUE acronym

• Blue skin

• Long term chronic cough

• Unusual breath sounds

• Edema peripherally

Emphysema Also Known As

Pink puffers

PINK acronym

• Pink skin and pursed lip breathing

• Increases chest (barrel chest)

• No chronic cough

• Keeps on tripodding

Chronic Bronchitis

• Excessive accumulation of mucus & secretions & inflammation causing chronic cough

Chronic Bronchitis Pathophysiology

• Productive cough lasting 3 or more months in two consecutive years.

• Cause: Cigarette smoke

• Chronic inflammatory process with vasodilation.

• Congestion and edema of bronchial mucosa

• Goblet cells increase in size and number

• Narrowed airways and excess secretions obstruct airflow-expiration first then inhalation

• Ciliary function is impaired, can’t clear airway

• Recurrent infection occurs

Emphysema Pathophysiology (Simple)

• Destruction of walls of alveoli

• Enlargement of abnormal air spaces

• Macrophages and CD-8 T lymphocytes increase and destroy lung tissue

• Alveolar wall destruction

• Surface area for diffusion is reduced

• Elastic recoil is lost

• Reduced volume of air that is passively expired

Emphysema Contributing Factors

• Chemical

  • Smoking

  • Airborne irritants

  • Occupational toxins

  • Environment

• Microbiological

  • Organisms

• Physiological

  • Genetic abnormality

  • Alpha1- antitrypsin deficiency: (Substance that inhibits the digestive action of enzymes on the connective tissue of the lungs (Prolastin

Emphysema Chemical Contributing Factors

• Smoking

• Airborne irritants

• Occupational toxins

• Environment

Emphysema Microbiological Contributing Factors

• Organisms

Emphysema Physiological Contributing Factors

• Genetic abnormality

• Alpha1- antitrypsin deficiency: (Substance that inhibits the digestive action of enzymes on the connective tissue of the lungs (Prolastin)

Cigarette Smoking COPD

• Causes mucus secreting glands to hypertrophy and increase production of mucus

• Impair ciliary movement

• Inhibits function of alveolar macrophages

• Produces abnormal dilation of distal air spaces with destruction of alveolar walls

Smoking Cessation

Is the single most cost-effective intervention to reduce the risk of developing COPD and stop its progression

Emphysema Pathophysiology pt. 1

• Tobacco smoke causes a breakdown of elastin in connective tissue in lungs

• Destruction of the alveoli septa

  Airway obstruction, air trapping, dyspnea, & frequent infections

• Mild hypoxemia

• Hyperinflation of alveoli

Emphysema Pathophysiology Pt. 2

• Destruction of alveolar walls & capillaries causing an increase in dead space

• Airways narrow, Airflow limitation

• Lose elasticity as more alveoli are destroyed

• Blebs & bulla may develop

• Mucus hypersecretion

• Ciliary dysfunction

• Alveolar gas exchange abnormalities and pulmonary vascular disease.

Blebs and Bullae

Air pockets in the lung that have developed due to emphysema

Clinical Manifestations of Emphysema

• Hyper resonance upon percussion

• Early stage-fatigue, little cough, mild dyspnea on exertion

• Later stage-thin, pursed lip breathing, marked dyspnea at rest

• Wheezing and chest discomfort

• Dyspnea-worse with exercise, particularly difficult with activities at or above shoulder level, involving significant arm work.

• Progressive increased effort to breath, air hunger, gasping, heaviness

Clinical Manifestations of COPD

• Chronic cough (smoker’s cough)

• Copious, thick, tenacious sputum

• Dyspnea/DOE/orthopnea / tachypnea

• Adventitious breath sounds

• Use of accessory muscles, thin

• Pursed lip breathing

• Barrel chest

• Fatigue

• Weight loss

• Clubbing

• Cyanosis

• Cor pulmonale: Heart weakening

• Cardiac enlargement

Cor Pulmonale

Heart weakening

Complications of Emphysema

• Respiratory Insufficiency

• Respiratory Failure

• Pneumonia

• Atelectasis

• Pneumothorax

• Pulmonary Hypertension

• Right sided heart failure (Cor Pulmonale)

Diagnostic Test

• H&P

• Pulmonary Function Tests

• Ventilation perfusion scan

• Serum alpha1 –antitrypsin level

• ABG- arterial blood gas

• Pulse oximetry

• CBC

• CXR

• Spirometry

Spirometry Machine

Tests to see how far and how much air you can blow out

Gold Criteria for COPD Severity

• Classification of Airflow Limitation Severity in COPD (Based on Post-Bronchodilator FEV1)

• GOLD I-Mild-FEV1/FVC <0.7 and FEV1>80% predicted

• GOLD 2-Moderate-FEV1/FVC <0.7 and 50%< FEV1 <80% predicted

• GOLD 3-Severe-FEV1/FVC <0.7 and 30%< FEV1 <50% predicted

• GOLD 4-Very Severe-FEV1/FVC <0.7 and FEV1 <30% predicted

FEV

Forced Expiratory Volume

FVC

Forced Vital Capacity

Gold 1-Mild

FEV1/FVC <0.7 and FEV1>80% predicted

Gold 2-Moderate

FEV1/FVC <0.7 and 50%< FEV1 <80% predicted

Gold 3-Severe

FEV1/FVC <0.7 and 30%< FEV1 <50% predicted

Gold 4-Very Severe

FEV1/FVC <0.7 and FEV1 <30% predicted

Nursing Diagnosis

• Ineffective

• Impaired

• Imbalanced

• Compromised

Ineffective Airway Clearance

Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway

Ineffective Airway Clearance Related Factors

Excessive mucus, retained secretions, foreign body in airway, smoking, exposure to smoke; secondhand smoking

Ineffective Airway Clearance Objective Defining Characteristics

• Absence of cough; ineffective cough

• Diminished breath sounds; adventitious breath sounds [rales, crackles, rhonchi, or wheezes]

• Excessive sputum

• Alteration in respiratory rate or pattern

• Difficulty verbalizing

• Wide-eyed look; restlessness

• Orthopnea

• Cyanosis

Ineffective Airway Clearance Associated Conditions

Airway spasm, allergic airway, asthma, chronic obstructive pulmonary disease, exudate in alveoli; hyperplasia of bronchial walls; infection; neuromuscular impairment; presence of artificial airway

Impaired Gas Exchange

Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane

Impaired Gas Exchange Subjective Defining Characteristics

• Dyspnea

• Visual disturbance

• Headache upon awakening

• [Sense of impending doom]

Impaired Gas Exchange Objective Defining Characteristics

• Confusion

• Restlessness; irritability

• Somnolence

• Abnormal arterial blood gases (ABGs)/arterial pH; hypoxia/hypoxemia; hypercapnia; decrease in carbon dioxide (CO2) level

• Cyanosis; abnormal skin color

• Abnormal breathing pattern; nasal flaring

• Tachycardia; [dysrhythmias]

• Diaphoresis

Impaired Gas Exchange Associated Conditions

Alveolar-capillary membrane changes; ventilation-perfusion imbalance

Imbalanced Nutrition

Intake of nutrients insufficient to meet metabolic needs.

Imbalanced Nutrition Objective Defining Characteristics

• Body weight 20% or more below ideal weight range; [decreased subcutaneous fat or muscle mass]

• Weight loss with adequate food intake

• Food intake less than recommended daily allowances

• Hyperactive bowel sounds; diarrhea; steatorrhea

• Weakness of muscles required for mastication or swallowing; insufficient muscle tone

• Pale mucous membranes; capillary fragility

• Excessive hair loss [or increased growth of hair on body (lanugo); cessation of menses]

• [Abnormal laboratory studies (e.g., decreased albumin, total proteins; iron deficiency; electrolyte imbalances)]

Nursing Interventions

• Assess respiratory status

• Maintain airway

• Provide hydration

• Provide adequate nutrition

• Maintain O2 therapy

• Assess vital signs

• Assess for CO2 narcosis

• Administer Meds

• Provide pulmonary hygiene/positioning

• Provide emotional support

• Refer to pulmonary rehab

• Provide patient/family teaching

Hypoxemia

Is the respiratory drive for COPD, too high supplemental O2 will suppress breathing

CO2 Narcosis

High CO2 levels in the bloodstream, can look like a patient is drowsy or almost in a coma

Nursing Interventions (Respiratory and Circulatory Focused)

• Oxygen therapy- low flow O2- usually no more than 2 L/min.

• Stimulant to breath is a low PO2 level instead of increased PCO2- hypoxic drive.

• Hypoxemia stimulates respiration in the patient with severe COPD, increasing oxygen flow to a high rate may greatly increase the patients blood level. This will suppress the respiratory drive, causing increased retention of carbon dioxide and CO2 narcosis (respiratory depression). Without the hypoxic drive, the patient will experience: Clinical manifestations of confusion, restlessness, drowsiness.

• If the patient has chronic CO2 retention (COPD) then hypoxia is the stimulus to breathe. Too much O2 could suppress the hypoxic drive and cause respiratory depression and death.

Oxygen Therapy

Low flow O2, usually no more than 2L/min

Bronchodilators

• Adrenergic stimulants – (beta-Adrenergic Agonist affect receptors causing smooth muscle relaxation and bronchodilation.

  • Adverse effects of bronchodilators: nervousness, muscle tremors, tachycardia, palpitations

Methylxanthines

Theophylline relaxes bronchial smooth muscles, used as a long term bronchodilator.

Anticholingeric Agents

Ipratropium Bromide (Atrovent) blocks action of acetylcholine, resulting in bronchodilation,

Work more slowly than adrenergic stimulants

Corticosteroids

Anti-inflammatory, lowest possible dose is used, do not stop abruptly

Antibiotics

During acute exacerbations of COPD

Beta agonist & anticholinergic MDI (Metered- dose inhaler)

May be given via nebulizer

Diuretics

If cor pulmonale is present this helps by reducing fluid volume in the body which would then decrease the workload on the heart and help it pump more efficiently

Combivent

The combined form of two bronchodilators: Albuterol (Proventil, Ventolin) + ipratropium = Duoneb

Atrovent (ipratropium)

An anticholinergic

Albuterol

An sympathomimetric

Bronchodilators

Dilates or enlarges the airways by relaxing the muscles surrounding the airways

Albuterol and ipratropium function

Causes the muscles of the airway to relax

Inhaled Steroids

• Asmanex® (mometasone)

• Alvesco® (ciclesonide)

• Flovent® (fluticasone)

• Pulmicort® (budesonide)

• Qvar® (beclomethasone HFA)

• Aerobid® (flunisolide)

• Azmacort® (triamcinolone)

Asmanex

mometasone

Alvesco

ciclesonide

Flovent

fluticasone

Pulmicort

budesonide

Qvar

beclomethasone HFA

Aerobid

flumisolide

Azmacort

triamcinolone

Patient Teaching of Inhaled Steroid Side Efffects

• Thrush

  • a yeast infection of the mouth or throat

  • causes a white discoloration of the tongue

  • most common side effects with inhaled steroids

  • using a spacer with an inhaled metered-dose inhaler reduces the risk of thrush.

• Cough or Hoarseness

  • Rinsing your mouth (and spitting out the water) after inhaling the medicine

Thrush

• A yeast infection of the mouth or throat

• Causes a white discoloration of the tongue

• Most common side effects with inhaled steroids

• Using a spacer with an inhaled metered-dose inhaler reduces the risk of this.

Cough or Hoarseness

Rinsing your mouth (and spitting out the water) after inhaling the medicine

COPD Nursing Interventions

• Smoking Cessation

• Teach pursed lip & diaphragmatic breathing

• Teach hand washing

• Instruct patient to get immunizations: (Influenza and Pneumococcal)

• Vaccinations reduce serious illness and mortality in patients with COPD.

• Encourage increased fluid intake

• Unless patient has Cor Pulmonale

• Keep HOB elevated

• Teach early signs of infection & report to HCP

• Teach proper use of inhalers

• Pulmonary rehabilitation

• Psychoactive drugs

COPD and temperature extremes

Can aggravate COPD, and should be avoided

Alpha1-antitrpsin (a1AT)

This replacement therapy may benefit emphysema patients with genetic deficiency of enzyme a1AT. This is given weekly intravenously.

Pursed-Lip Breathing

• Inhale through the nose with the mouth closed

• Exhale slowly through pursed lips, as in whistling, breathe out slowly through mouth, without puffing cheeks

• Spend twice as long on exhalation

• Use abdominal muscles to squeeze out every bit of air

Diaphragmatic Breathing

• Lie on back with knees bent

• Place one hand on the abdomen, the other on the chest

• Place hand over abdomen to create resistance

• Begin breathing from your abdomen, while keeping chest still

• Exhale slowly

Acute Exacerbation of COPD

• Increased breathlessness often accompanied by cough,

• Sputum production,

• Wheezing,

• Chest tightness,

• Worsening respiratory status defined as COPD exacerbation,

• Infection and air pollution are the most common causes.

Discharge Criteria for COPD, Bronchitis, Emphysema

• Use of inhaled bronchodilators less frequently than every 4 hours

• Clinical and ABG stability for at least 12-24hrs

• Assess ability to eat, sleep and ambulate

• Adequate patient understanding of home therapy and arrangements.

Evaluate Patient Outcomes

Treatment of Acute Exacerbations of COPD

• Oxygen-First goal is to alleviate hypoxemia with a desired PaO2>60mm Hb or SaO2 of >90%.

• Perform Rapid Assessment determine if life threatening

• Administer short acting bronchodilators

• Oral or IV steroids

• Antibiotic if respiratory infection suspected

Acid-Base Balance

The normal composition of the body fluids depends not only on fluid & electrolyte concentrations but also upon acid/base concentrations.

What is an Acid

Substance that can provide hydrogen ions in chemical reactions

What is a Base

Substance that accepts hydrogen ions in chemical reactions

What is pH

An indicator of hydrogen ion(H+) concentration and measures the acidity or alkalinity of the blood

pCO2

Arterial carbon dioxide (PaCO2) concentration

• Normal range 35-45

• Breaks down to acid and water in body

HCO3

Bicarbonate

• Normal Range 22-26

• Buffer for acid

pH= measurent of acid or base in body

• Normal range 7.35-7.45 (slightly alkaline-neutral 7.0)

• A change in 0.2 in either direction is considered serious

• Below 7.35– acidosis

• Above 7.45-- alkalosis

Maintenance of Acid-Base Balance

• Buffer System

• Respiratory System

Buffer System

• Prevents major changes in pH of body fluids by removing or releasing H+

• Normally 20:1 ratio (20 parts bicarbonate(HCO3-) : 1 part carbonic acid (H2CO3))

(Bicarbonate-carbonic acid)

Respiratory System

Controls the amount of CO2 in the blood by adjusting ventilation

Renal System

Regulates the HCO3 level via regeneration of HCO3 as well as reabsorbing them from renal tubule cells and can excrete or restore H+ ions to help restore balance

Acidosis

• pH< 7.35

• pCO2 ↑

• Head fullness

• Mental cloudiness

• EKG changes

• Muscle twitching

Alkalosis

• pH > 7.45

• pCO2 ↓

• Always caused by hyperventilation

• Lightheadedness

• Numbness/tingling

• Tinnitus

Respiratory Acidosis

• Acid-base imbalance caused by decrease in pulmonary ventilation-Hypoventilation

• Retention of Carbon Dioxide (↑ carbonic acid)

Respiratory Acidosis Contributing Factors

• Any contributing factor that causes Hypoventilation

• Pulmonary edema, pneumonia, asthma, opiate overdose, obstruction, trauma, surgery, COPD, Stroke, Neuromuscular disease, etc.

Respiratory Acidosis Clinical Manifestations

• Tachycardia

• Dyspnea

• Shallow respirations

• Confusion

• Altered LOC

• pH ↓7.35

• pCO2 ↑42 mm/Hg

Respiratory Acidosis Nursing Diagnosis

Impaired Gas Exchange, Activity Intolerance, Ineffective breathing pattern, Ineffective tissue perfusion, Risk injury

Respiratory Acidosis Interventions

• Treat underlying cause

• Promote rest, Suction, Oxygen

• Position HOB, Chest physiotherapy

• Emotional support, Encourage fluids

• Assessment

• Medication

Respiratory Alkalosis

• Acid-base imbalance caused by increase in pulmonary ventilation rate- Hyperventilation

• Too much carbon dioxide “blown off” (↓carbonic acid)