CHRONIC OBSTRUCTIVE PULMONARY DISEASE Dr.Sarma@works2 CHRONIC OBSTRUCTIVE LUNG DISEASES ASTHMA COPD...

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CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Transcript of CHRONIC OBSTRUCTIVE PULMONARY DISEASE Dr.Sarma@works2 CHRONIC OBSTRUCTIVE LUNG DISEASES ASTHMA COPD...

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  • CHRONIC OBSTRUCTIVE PULMONARY DISEASE
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  • Dr.Sarma@works2 CHRONIC OBSTRUCTIVE LUNG DISEASES ASTHMA COPD REVERSIBILITY OF AIR WAY OBSTRUTION FULL NONE ASTHMA EMPHYSEMA CHRONIC BRONCHITIS
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  • 3 PREVALENCE of MORTALITY In 2000, the WHO estimated 2.74 million COPD deaths worldwide. In 1990, COPD was ranked 12 th leading cause of death. It is expected to be the third leading cause of death by 2020. 10 lacs Indians die in a year due to smoking related diseases. In India, 4,00,000 premature deaths annually due to use of biomass fuels, like cow dung cakes, open fires CauseDeaths CHD724,269 Cancer534,947 CVA158,060 COPD1,14,318 Accidents94,828 Diabetes64,574 (2000) * The Indian J Chest Dis & Allied Sciences 2009; 43:139-47
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  • 4 PREVALENCE of MORBIDITY Cigarette smoking is the primary cause. WHO estimates 1.1 Billion smokers in world. In India 1,49,00,000 chronic cases of COPD in the age group of 30 YearConsultations 19806.1 million 19857.4 million 199010.1 million 199511.8 million 200013.9 million 2025 1.6 billion ?
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  • 4000 chemicals (more than 60 carcinogens) are inhaled in cigarette smoke
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  • Dr.Sarma@works6 Every day 55000 Indian youth start tobacco use COLLEGE STUDENTS ( 2%) TENDER AGE GROUPS THE NUMBER OF WOMEN SMOKERS& PASSIVE SMOKERS IS ON RISE Currently there are 94 million smokers in India
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  • 7 Risk Factors for COPD Nutrition Infections Socio-economic status Aging Populations Genes (alpha 1 - anti-trypsin)
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  • TYPES OF COPD
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  • Simple concept.
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  • Dr.Sarma@works10 CHRONIC BRONCHITIS Normal bronchial architecture 1.Mucus gland hypertrophy 2.Smooth muscle hypertrophy 3.Goblet cell hyperplasia 4.Inflammatory infiltrate 5.Excessive mucus 6.Squamous metaplasia COPD
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  • Dr.Sarma@works14 PULMONARY VASCULAR CHANGES IN COPD Normal Pulmonary Artery 1.THICK VESSEL WALL 2.INFALMMATORY CELLS INFILTRATE 3.COLLAGEN DEPOSIT 4.DESTRUCTION OF CAPILLARY BED 3 4
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  • COPD Pathophysiology Fig. 29-7
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  • Did you know? The King of Pop suffered from Alpha-1 antitrypsin deficiency,
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  • Centrilobular (central part of lobule) Dilation and destruction of respiratory bronchioles and pulmonary capillary bed Prominent in upper lobes Panlobular (destruction of whole lobule) Affects respiratory bronchioles, alveolar ducts, and alveolar sacs. Prominent in lower lobes
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  • Clinical Manifestations Develops slowly around 50 yrs of age after 20 pack years of cigarette smoking Diagnosis is considered with Cough Sputum production Dyspnea Exposure to risk factors * Packets per day x Years of smoking = Pack Years
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  • Clinical Manifestations Intermittent Cough with expectoration Progressive Dyspnea Described by the patient as an increased effort to breathe, heaviness, air hunger, or gasping.
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  • Clinical Manifestations chest breathing Use of accessory such as those in the neck and intercostal muscles Decreased abdominal breathing flattened diaphragm from over distended lungs. Purse lip breathing on expiration. It helps to prevent airway collapse by increasing pressure.
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  • Clinical Manifestations Barrel Chest- Air gets trapped causing increase in antero posterior dimensions of the chest Characteristically underweight with adequate caloric intake Chronic fatigue
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  • COPD Clinical Manifestations Tripod position Patient may sit upright with arms supported on a fixed Surface.This optimises the function of pectoral muscles to expand thoracic cavity. Bluish-red color of skin Polycythemia and cyanosis Hemoptysis
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  • Poor ventilation and perfusion; unable to compensate leading to hypoxia and cyanosis Clubbing
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  • Over ventilate to maintain relatively normal ABGs Red face
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  • DIAGNOSTIC EVALUATION *Percussion : Hyperresonant depressed diaphragm, *Auscultation: Prolonged expiration reduced breath sounds; The presence of wheezing during quiet breathing Crackle can be heard if infection exist. The heart sounds are best heard over the xiphoid area.
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  • Para clinical examination CT: highlighting the pulmonary emphysema and emphysema bubbles. Blood examination In excerbation or acute infection in airway, leucocytosis may be detected. Screening for alpha 1 antitrypsin deficiency Sputum examination streptococcus pneumonia Haemophilus influenzae klebsiella pneumonia
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  • 6-Minute walk test to determine O 2 desaturation in the blood with exercise ECG can show signs of right ventricular failure ABG typical findings Low PaO 2 PaCO 2 pH Bicarbonate level found in late stages COPD
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  • Spirometry FEV 1 Forced expired volume in the first second FVC Total volume of air that can be exhaled from maximal inhalation to maximal exhalation FEV 1 /FVC% - The ratio of FEV 1 to FVC, expressed as a percentage.
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  • Dr.Sarma@works29 NORMAL AND COPD SPIROMETRY
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  • Dr.Sarma@works30 CHEST SKIAGRAMS OF EMPHYSEMA
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  • Dr.Sarma@works31 V- P MISMATCH NUCLEOTIDE IMAGING
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  • Dr.Sarma@works32 HRCT NORMAL CHEST
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  • Dr.Sarma@works33 HRCT EMPHYSEMA
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  • Post-bronchodilator FEV1 (% predicted) Management based on GOLD
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  • 37 1.Assess and monitor disease 2.Reduce risk factors 3.Manage stable COPD 4.Education 5.Pharmacologic 6.Non-pharmacologic 7.Manage exacerbations IF ONE QUITS SMOKING NO TOMORROW! 1.Studies have shown that with smoking cessation The rate of decline in lung function slows There will be definite clinical improvement in symptoms
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  • Dr.Sarma@works38 REHABILITATION For the lungs to get more air PURSED-LIP BREATHING (like breathing out slowly into a straw) INHALEEXHALE
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  • Dr.Sarma@works39 1. Sit comfortably and relax your shoulders. 2. Put one hand on your abdomen. Now inhale slowly through your nose. (Push your abdomen out while you breathe in) 3. Then push in your abdominal muscles and breathe out using the pursed-lip technique. (You should feel your abdomen go down) Note: Repeat the above maneuver three times and then take a little rest. This exercise can be done many times a day. REHABILITATION For the lungs to get more air DIAPHRAGMATIC BREATHING Sit comfortably and relax your shoulders Put one hand on your abdomen. Now inhale slowly through your nose. (Push your abdomen out while you breathe in) Then push in your abdominal muscles and breathe out using the pursed-lip technique
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  • Positions for Postural Drainage 41
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  • Cupped-Hand Position 42
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  • Flutter Mucus Clearance Device 43
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  • Methods of Oxygen Administration Fig. 29-11 C-F D. Tracheostomy Mask F. Standard Nasal Cannulas C. Venturi Mask E. Face Tent 44
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  • Simple Face Mask for Oxygen Administration Fig. 29-11 A 45 Plastic Face Mask with Reservoir Bag for Oxygen Administration
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  • You administer high flow supplemental oxygen to a patient with COPD and the patient stops breathing. What Happened to your patient?
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  • The single most important driver of ventilation is CO 2 But can be deadly for the COPD Patient Microsoft clipart CO 2
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  • You removed his drive to breathe!
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  • DIET PLAN Calories -1300 to 1800 Kcal/day Protein - 1 gm/kg/body weight Fat - 50 gm Fibers - 30 to 35 gms Potassium rich diet Salt 10 gm/day Hydration 3 litre /day
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  • 51 SURGERY 1.Single lung transplant 1.LVRS - Lung volume reduction surgery 1.Bullectomy
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  • COPD Complications Cor pulmonale Exacerbations of COPD Acute respiratory failure Peptic ulcer disease Depression/anxiety
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  • Pathophysiology of Cor Pulmonale
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  • COPD Acute Respiratory Failure Caused by Exacerbations Cor pulmonale Discontinuing bronchodilator or corticosteroid medication Overuse of sedatives, benzodiazepines, and opioids Surgery or severe, painful illness involving chest or abdomen
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  • Peptic Ulcer Disease Hyper secretion of gastric acid due to increased arterial co2 and decreased arterial o2. Commonly in duodenum and painless Depression may be four times more likely for COPD patients Depression/Anxiety Anxiety complicates Respiratory compromise Dyspnea Hyperventilation
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  • NURSING DIAGNOSES Impaired gas exchange related to ventilation perfusion mismatch Ineffective breathing pattern related to bronchoconstriction. Self care deficit (global) related to generalised weakness secondary to increased work of breathing Sleep pattern disturbance related to breathing difficulty Ineffective individual coping related to dyspnea, and hospitalisation.
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  • NURSING DIAGNOSES Contd ... Interrupted family process related to chronic condition. Risk for aspiration related to depressed cough/ gag reflexs, impaired swallowing or delayed gastric emptying. Risk for infection related to ineffective pulmonary clearance Risk for impaired skin integrity related to prolonged bed ridden. Anxiety related to outcome of disease Deficient knowledge regarding self management to be performed at home.
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  • Assessment Nursing diagnosis ObjectiveNursing interventionEvaluation Subjective data Patient verbalises that he has breathing difficulty Objective data confused, use of accessory muscles, restless Clinical findings Dyspnoea grade III, RR 26 /mtin, Auscultation: Wheeze both lung fields Documentary evidence ABG-Resp.acidosis pH 45mmHg PaO2
  • Nursing assessmentNursin g diagno sis GoalNursing interventionsEvaluation Subjective data: Patient verbalizes difficulty in breathing, tiredness, not able to lie down flat and cough Objective data: Dyspnoeic grade , shortness of breath, frequent sighs, use of accessory muscles of breathing, nasal flaring, cough Clinical findings: RR -> 24 breaths /minute Irregular breathing rhythm Increased AP diameter of chest IE ratio 2:4 Documentary evidence Respiratory acidosis Chest skiagram Consolidation of both lower lobes of lungs Ineffect ive breathi ng pattern related to decreas ed lung expansi on Main tain effect ive breat hing patte rn 1. Position patient in a semi to high Fowlers position to promote maximum diaphragmatic descent and lung expansion. Patient verbalized less breathing difficulty Patient will maintain normal respiratory rate Regular breathing rhythm Reduction in cough No use of accessory muscles for breathing IE ratio 1:2 Normal and Spo 2 > 95 % 2. Use additional pillows as needed to prevent slumping because slumping causes the abdominal contents to be pushed up against the diaphragm and restrict lung expansion. 3. Provide uninterrupted rest periods to increase strength and activity tolerance which in turn promotes participation in activities to improve breathing pattern. 4. Instruct patient to do deep breathing exercise as follows. a.)Sit up, stand or lean forward slightly while sitting on edge of bed or chair.b.)Take in a slow, deep breath c.)Pause slightly or hold breath for at least 3 secs. d.)Exhale slowlye.)Rest and repeat as tolerated. 5. Instruct patient to do pursed-lip breathing as it causes a mild resistance to exhalation, which creates positive pressure in the airways. This pressure helps prevent airway collapse and subsequently promotes more complete alveolar emptying
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  • Assessment Nursing diagnosis Objectiv e Nursing interventionEvaluation Subjective data: Patient verbalizes that I am not able to perform daily activities Objective data: Patient is unable to perform ADL Clinical findings: Limited ROM Muscle power- reduced ADL scale-0/5 Documentary evidence: BP-140/90 mm Hg PR-90/min RR-20/min Self care deficit global (Feeding, toileting, bathing, grooming) related to lack of coordinatio n, muscular weakness Resume s self care activitie s 1. Approach patient from his unaffected side and arrange call light beside table, helps the patient to compensate for alteration in sensory perception. Patient will verbalizes that his self care activities are resumed. Patient is able to perform activities of daily living. ROM, Muscle power, ADL score- increased. 2. Encourage the patient to brush his teeth, comb the hair, bathe and feed himself and to assist in toileting to promote the self care activities. 3. Perform back massage by following 5 steps to prevent the occurrence of bedsore. 4. Help the patient to resume most normal eating position (may sit on chair with pillow support) suited to the patients disability to ease the feeding.
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  • Assessment Nursi ng diagn osis GoalIntervention Evaluatio n Subjective data - Objective data Confusion, Altered gait/mobility diminished cognitive process, Unable to carry out self care activities, Clinical findings Blood pressure- 140/70 mm Hg Visual field deficits Muscle strength score- upper and lower limbs -1/5 Documented evidence Radioimaging studies reveals Consolidation of both the lower lobes of lung field, High risk for injury relate d to altere d senso ry perce ption, dimin ished menta l status, Help the patient to prevent from injury/ falls 1.Place articles within easy reach of the patient to prevent from chance of fall. 2.Orient the patient to surroundings in order to promote familiarity to the situation. 3.Teach the patient about the importance of wearing supportive shoes with good traction when ambulating because it provides better balance and protect from instability on uneven surfaces. 4.Ensure adequate lighting in all areas used by the patient. 5.Use side rails of appropriate height and length which decreases chance of fall from falls. 6.Involve family to aid with activities of daily living and prevent from falls. 7.Avoid use of restraints because they may increase agitation. 8.Provide safe environment which allows the patient to move about as freely as possible and relieves the family of constant worry of safety. 9.Educate the patient about certain medications that may affect the balance or increase risk for falls because polypharmacy has been associated with increased falls.. Patient regains normal range of body Temp:99F Pulse:98ea ts/min Resp:20br eaths/min
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  • Assessment Nursing diagnosis Goal/ Objective Nursing interventionsEvaluation Subjective data: Patient verbalizes on difficulty swallowing a Objective data: presence of NG tube. Clinical findings: Decreased/ absent gag reflex, Documentary evidence: SpO2 90% with 6L of O2. Risk for aspiratio n related to depresse d cough/ gag reflexs, impaired swallowi ng or delayed gastric emptying. Prevent the risk of aspiration 1.Elevate the head of bed at least 30 during feedings and for one hour after feeding to prevent reflux by use of reverse gravity. Experien ce no aspiratio n as evidence d by noiseless respirati ons, clear breath sounds; clear, odorless secretion s. 2.Instruct individual and family on activities that increase intra abdominal pressure. Instruct on safety when feeding. 3. Use appropriate measures to check the placement of nasogastric feeding tubes. Malplacement of nasogastric feeding tubes may result in aspiration of enteral formula. 4.Regulate gastric feedings using an intermittent schedule, allowing periods for stomach emptying between feeding intervals. 5. Aspirate the contents every 4 th hourly to determine the amount of the residual volume.
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  • AssessmentNursin g diagno sis GoalNursing interventionsEvaluation Subjective Data The patient verbalizes itching over the site/all over the body. Objective Data Skin-moist colour Skin turgor Clinical findings -Presence of excoriation Dehydration (Stage-) -Chronic bed ridden status (immobility) -Bradens scale-15/25 -Documented Evidence -Prolonged use of topical applicants Risk for imp aire d skin inte grity relat ed to prol ong ed bed ridd e n, patient maintai ns intact, moist and well- lubricat ed skin 1. Inspect the skin frequently for areas of redness, swelling. to detect early signs of infection The patient mainta ins intact and well lubrica ted skin. 2. Provide meticulous skincare to the skin folds that overlap and places where moisture collects. (Abdomen folds, under and between breasts, between buttocks or perineum)to reduce the skin breakdown. 3. Reposition the patient Q 2 hrly to relieve pressure over bony prominences. 4. Use pressure-reliving devices such as air/water mattress, pillows etc. to promote comfort of the patient. 5.Clip patients nails short and keep clean to prevent excoriation 6. Avoid use of perfumed soaps, lotions, deodrants on involved skin surface to prevent skin excoriation. 7. Encourage use of super fatted soap to maintain the moisture content in the skin. 8. Decrease environmental irritants such as heat, scratchy coverings to reduce vasodilatation and sensory stimulation. 9. Encourage adequate fluid intake (2000-3000ml/day) to prevent dehydration. 10. Elevate edematous areas to promote venous drainage.
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  • Nursing Outcomes: Respiratory Status: Ventilation - movement of air in and out of lungs Respiratory Status: Airway Patency - open, clear tracheobronchial passages Knowledge: Medications - extent of understanding conveyed about the safe use of medication
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  • All the best
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  • THANK YOU