Chronic Obstructive Pulmonary Disease (COPD) 8.18 · The nurse reviews the arterial blood gases of...

Chronic Obstructive Pulmonary Disease (COPD) 8.18.18

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

COPD Description

�Airflow limitation not fully reversible• progressive• Abnormal inflammatory response of lungs

� Includes• Chronic bronchitis• Emphysema


COPDEtiology�Risk factors• Cigarette smoking• Occupational chemicals and dust• Air pollution• Infection • Heredity• Aging


COPDPathophysiology

�Defining features• Irreversible airflow limitations during forced

exhalation due to loss of elastic recoil• Airflow obstruction due to mucous

hypersecretion, mucosal edema, and bronchospasm


COPDPathophysiology


COPDClinical Manifestations

�Develops slowly�Diagnosis • Cough*• Sputum production• Dyspnea• Exposure to risk factors



�Dyspnea• exertion (early) stages/ rest (late)• Chest breathing• accessory and intercostal muscles• Inefficient breathing

� Chest tightness with activity



�underweight with adequate caloric intake

�Chronic fatigue

�What physical finding will you find on exam?


Case Study

�G.S., a 77-year-old man at the hospital� shortness of breath� morning cough

�swelling in his lower extremities.�difficulty breathing when he walks short

distances ie. bathroom.


Case Study

�G.S. subjective c/o:�“ sleeps in a recliner to make it easier to breathe”� “feels shoes are tight at the end of the day”

�He is placed on oxygen at 2 liters/minute via nasal cannula.


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Case Study� Dx: mild to moderate COPD� Hx: smoked a pack of cigarettes/day for

30 years. �heart disease and GERD.

Discuss questions:•How does his history contribute to his diagnosis?•Why does he experience swollen ankles?•What other complications is he at risk for?



COPDCor Pulmonale

�Hypertrophy of right side of heart• Result of pulmonary hypertension• Late manifestation • Eventually causes right-sided heart failure


Pathophysiology of Cor Pulmonale


COPDCor Pulmonale

�Dyspnea�Distended neck veins�Hepatomegaly with right upper

quadrant tenderness�Peripheral edema�Weight gain


COPDCor Pulmonale

�Diagnostic studies• ECG• Chest x-ray• Right-sided cardiac catheterization• Echocardiogram• BNP levels


COPD Exacerbations

�Signaled by change in usual• Dyspnea• Cough• Sputum


Case Study�G.S. shares that he has experienced

“attacks” like this in the past year, but this one was a bit worse.

�He states that he and his wife had visited their daughter and her 3 kids who were sick with colds.

• What is the likely cause of this exacerbation?• What would you anticipate in regard to treatment?• What is G.S. at risk for with exacerbation?



COPDExacerbations

� poorer outcomes�Primary causes• Bacterial and viral infections

�Signs of severity• Use of accessory muscles• Central cyanosis


COPD Exacerbations

�Treatment• Short-acting bronchodilators• Corticosteroids• Antibiotics• Supplemental oxygen therapy


COPDAcute Respiratory Failure

�Caused by• Exacerbations• Discontinuing bronchodilator or corticosteroid

medication• Overuse of sedatives, benzodiazepines, and

opioids• Surgery or severe, painful illness involving

chest or abdomen


COPDDepression and Anxiety

� experience many losses.� If patient becomes anxious because of

dyspnea, teach pursed lip breathing.


COPDDiagnostic Studies

�Diagnosis confirmed by spirometry• Reduced FEV1/FVC ratio• Increased residual volume



�Chest x-ray�History and physical�COPD Assessment Test (CAT)�Modified Medical Research Council

(mMRC) Dyspnea Scale�6-minute walk test to determine O2

desaturation in the blood with exercise�BODE index



�ABG typical findings in later stages� Low PaO2�↑ PaCO2�↓ pH�↑ Bicarbonate level found in late

stages of COPD


Case Study

�G.S.’s arterial blood gases show a slight ↓ PaO2 and ↑ PaCO2, and his chest x-ray shows flattening of his diaphragm.

�O2 saturation is 88%.�His FEV1/FVC is 65%, and he states he is having

difficulty completing ADLs without frequent rest periods.

�What interventions would be of benefit to G.S. at this time?



COPDCollaborative Care

�Global Initiative for Chronic Obstructive Lung Disease (GOLD)

�American College of Physicians clinical guidelines

�Smoking cessation• Biggest impact in risk reduction• Accelerated decline in pulmonary function

slows to almost nonsmoking levels.


Case Study� G.S. is given a short-acting bronchodilator via

nebulizer.� He will also be given a SABA inhaler and an ICS for

home use.� He is started on azithromycin (Zithromax).

• Why was a nebulizer used in the hospital?• What is the rationale for the SABA?• How should he use his ICS?• Will G.S. need oxygen for home use?




�O2 therapy is used to• Keep O2 saturation > 90% during rest, sleep,

and exertion, or• PaO2 greater than 60 mm Hg.



�Long-term O2 therapy improves• Survival• Exercise capacity• Cognitive performance• Sleep in hypoxemic patients



�O2 delivery systems: high- or low-flow.• Low-flow is most common.• Low-flow is mixed with room air, and delivery

is less precise than high-flow.• High-flow fixed concentration

�Venturi mask�Humidification



�Complications of oxygen therapy• Combustion • CO2 narcosis• O2 toxicity• Absorption atelectasis• Infection



�Long-term O2 therapy (LTOT) at home improves• Prognosis• Mental acuity• Exercise intolerance



�Respiratory and physical therapy• Breathing retraining• Effective coughing• Chest physiotherapy

�Percussion�Vibration�Postural drainage



�Respiratory and physical therapy• Airway clearance devices• High-frequency chest wall oscillation

�The Vest


Case Study�G.S. is going to be discharged to home. �He is given an Acapella device to assist him

with expulsion of mucus. �His wife is present, and you begin to teach

them about home care.

�What will your teaching plan include?




�Nutritional therapy • Weight loss and malnutrition are common. • Why?

• Tx: �Rest at least 30 minutes A.C.�Bronchodilator

�Other interventions?


COPDCollaborative Care� Surgical therapy• Lung volume reduction surgery

• Bullectomy

• Lung transplantation�Single lung—Most common because of donor

shortages�Prolongs life�Improves functional capacity�Enhances quality of life


COPDCollaborative Care�Minimally invasive treatment• Airway bypass

�Bronchoscopic procedure�Used to reduce hyperinflation


Case Study�G.S. appears fatigued and has difficulty

answering the many questions he is asked. �His wife expresses concern that he has not

been sleeping well.

�What areas could be addressed with G.S. in regard to health promotion?

�How can his wife and family help?



Case Study

�G.S. comes into the clinic in one week for follow-up.

�He is breathing much easier and states that he is able to perform ADLs with less distress.

�He and his wife ask about how to prevent further breathing difficulties?



The nurse reviews the arterial blood gases of a patient. Which result would indicate the patient has later stage COPD?

a. pH 7.32, PaCO2 58 mm Hg, PaO2 60 mm Hg, HCO3 30 mEq/L

b. pH 7.30, PaCO2 45 mm Hg, PaO2 55 mm Hg, HCO3 18 mEq/L

c. pH 7.40, PaCO2 40 mm Hg, PaO2 70 mm Hg, HCO3 25 mEq/L

d. pH 7.52, PaCO2 30 mm Hg, PaO2 80 mm Hg, HCO3 35 mEq/L

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Chronic Obstructive Pulmonary Disease (COPD) 8.18 · The nurse reviews the arterial blood gases of...

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