COPD It Takes Your Breath Away Patti J

COPD It Takes Your Breath Away Patti J. Pagel, RN, BSN Alverno College MSN Program April, 2007 patti. pagel@aurora. org

Self-Study Tutorial Guide Instruction Page n Click on to go back to previous slide n Click on to go to the next slide n Click on to return to objectives n Click on True/False and learn the correct answer when presented in a slide n Click on Answer for multiple choice to check for correct answer n Click here to go back to review slides n Click on website link for further information

Welcome! Main Menu Click on subject to navigate to: Objectives Nursing Outcomes Pathophysiology Interventions Respiratory Review Patho Quiz Case Study Respiratory Quiz Signs & Symptoms References Or click on forward arrow to go to next slide

Intended Audience n This self-study tutorial on Chronic Obstruction Pulmonary Disease is intended for the following people: § Registered Nurses § Medical Assistants § Anyone interested in learning about COPD

Tutorial Objectives n Review respiratory system anatomy. n Increase understanding of the pathophysiology of COPD. n Recognize signs and symptoms of COPD. n Identify treatment options: n Non-pharmaceutical nursing interventions n Pharmaceutical interventions

Nursing Outcomes: n Respiratory Status: Ventilation - movement of air in and out of lungs n Respiratory Status: Airway Patency - open, clear tracheobronchial passages n Knowledge: Medications - extent of understanding conveyed about the safe use of medication Source: (Moorhead et al 2004) Microsoft clipart

Let’s Review: Respiratory Anatomy n Upper Respiratory Tract: Mouth, nose, throat (pharynx), larynx, trachea n Lower Respiratory Tract: Lungs, bronchi, alveoli n Medulla Oblongata Controls inspiration/expiration Microsoft clipart

Anatomy Review

Respiratory Review Let’s Take a Breath Together: n n n n Air is warmed and humidified. Cilia filter out dust particles. Macrophages destroy germs. Air goes to L and R bronchi. Then to the bronchioles. Through to the Alveoli. Oxygen and CO 2 exchange takes place. Used with permission: Jensen M. S. , Webanatomy 2007

Respiratory Review: Now your Breath is… n Alveoli fill with air. n Oxygen diffuses thru alveoli walls. n Oxygen diffuses to Capillaries and bloodstream. n Hemoglobin for transport of oxygen. n Oxygen to the heart and to the body. Used with permission: Jensen, M. S. , Webanatomy (2007).

Respiratory Review Let your air out… n Hemoglobin frees oxygen. n O 2 to cells. n CO 2 is the waste product. n Veins return CO 2 to heart. n Heart pumps CO 2 to lungs. n CO 2 passes alveoli to be exhaled Use with permission: Jensen, M. S. , Webanatomy (2007)

Respiratory Quiz n Respiratory Assessment: Understanding the anatomy of the lungs, where does the exchange of oxygen and CO 2 occur: A. Bronchioles B. Aveoli C. Bronchial Tubes Click on underlined best answer.

Respiratory Quiz: n Respiratory Assessment: What part of the body controls inspiration and expiration? A. Pituitary Gland B. Sympathetic Nervous System C. Medulla Oblongata Click on underlined best answer.

What is COPD? Chronic Obstructive Pulmonary Disease COPD is a group of respiratory disorders characterized by chronic, recurrent, irreversible obstruction of airflow in the pulmonary airways not fully reversible with inhaled bronchodilators. (Porth, 2005) (Punturieli, 2007)

Chronic Obstructive Pulmonary Disease (COPD) FACTS YOU SHOULD KNOW: n n n n FOURTH leading cause of death in United States. COPD refers to two lung diseases: Chronic Bronchitis & Emphysema. Smoking is a primary risk factor. Air pollution, second-hand smoke, history of childhood respiratory infections and heredity are other causes. Female smokers are almost 13 times as likely to die from COPD than women who have never smoked. 11. 4 million U. S. adults affected. $37. 2 billion cost to nation. Important cause of hospitalization in our aged population. Source: American Lung Association Fact Sheet August 2006

Chronic Obstructive Pulmonary Disease Fact you might not know… COPD patients most likely have been smoking 20 cigarettes per day for 20 or more years before they even get symptoms (Snider, 2006). Microsoft clipart

What Causes COPD? What do you think are the two causes of COPD? Find the two causes- click on word Cigarette Smoking Factory Work Obesity Cancer Diabetes Stroke Alcohol Abuse Inactivity Coronary Heart Disease Alpha 1 -antitripsin Deficiency Click HERE to learn more about COPD.

Pathogenesis of COPD Inflammation bronchial walls Fibrous bronchial walls Hypertrophy of submucosal glands Hypersecretion of mucus Cause airway obstruction & problems with ventilation & perfusion Loss of elastic lung fibers and alveoli tissue (Porth, 2005)

Types of COPD: n Chronic Bronchitis ----- -Obstruction of small airway -Inflammation of major & small airways n Emphysema -Enlargement of air spaces -Destruction of tissues n Alpha 1 - antitrypsin deficiency -inherited disorder -protective material produced in liver and transported to lungs to help combat inflammation -leads to destruction of alveoli (Porth, 2005)

Characteristics of: Chronic Bronchitis Cough with phlegm Shortness of breath Exercise Intolerance Expiratory phase of respiration long Wheezes and Crackles on auscultation Inability to maintain stable arterial blood gases n Hypoxemia n n n (Porth, 2005)

Characteristics of: Chronic Bronchitis n Doesn’t strike suddenly n Damage occurs before patients seek treatment n Pulmonary hypertension n Right heart failure with peripheral edema (Porth, 2005)

Chronic Bronchitis Diagnosis n Mucus producing cough most days of the month, three months of a year for two consecutive years (ALA). Microsoft Clipart

Characteristics: Emphysema n Dyspnea, slowly progressive n Abnormal Arterial Blood Gases n Use accessory muscles n Weight loss n Sputum production in morning, scant n Cough- minimal n Loss of lung elasticity n Destruction of alveoli walls and capillary beds (Porth, 2005)

Emphysema Diagnosis Careful history and physical examination Pulmonary function studies Forced Expiratory Volumes Chest radiographs Laboratory tests Microsoft clipart

COPD- Let’s Review n COPD is the fourth leading cause of death in the United States. n Heredity is the most common cause of COPD TRUE FALSE Click here to proceed to next slide

Pathophysiology Autonomic Nervous System Respiratory Centers: MEDULLARY & PONS Stretch Receptors Monitor Stretch of Lungs & Chest Wall Irritant Receptors Involved With Reflexes Causing Coughing & Sneezing Ventilation Central Chemoreceptor Respond to Arterial PCO 2 Peripheral Chemoreceptor Respond to Arterial PO 2 & PCO 2 (Freudenrich, 2007)

Factors that Influence the Respiratory Centers: Oxygen: Peripheral Receptor Monitors O 2 concentration of blood oxygen Concentration= Rate and Depth Breathing Carbon Dioxide: Central Receptor Monitors CO 2 Concentration in CSF CO 2 = Rate and Depth Breathing Hydrogen Ion (p. H): Peripheral & Central Sensitive to p. H of Blood and CSF Hydrogen Ion= Rate and Depth Breathing Craig C. Freudenrich, Ph. D. . "How Your Lungs Work". October 06, 2000 http: //health. howstuffworks. com/lung. htm (April 12, 2007)

The single most important driver of ventilation is CO 2 But can be deadly for the COPD Patient CO 2 CO 2 CO 2 Microsoft clipart

Example of receptors at work: You administer high flow supplemental oxygen to a patient with COPD and the patient stops breathing. What Happened to your patient?

You removed his drive to breathe! Specifically, patients with COPD retain CO 2 chronically. Administering oxygen removes the central chemoreceptor drive to breathe. The central chemoreceptor is not sensitive to small oxygen changes like when a person breathes deep but high flow oxygen administration extinguished the stimulus to breathe.

Arterial Blood Gases (ABG’s) SNAP SHOT OF YOUR PATIENT”S OXYGEN STATUS COPD PATIENT- 3 L O 2 Normal ABG Results p. H 7. 35 -7. 45 Pa. CO 2 35 -45 HCO 3 22 -26 Pa. O 2 80 -100 Abnormal ABG Results p. H 7. 32 Pa. CO 2 69 HCO 3 32 Pa. O 2 86 The abnormal ABG finding indicates your patient is retaining CO 2. What we don’t know just from the ABG result is if your patient is compensating or uncompensated. A complete history needs to be obtained. (Perry & Potter, 2006)

Pathophysiology COPD n Emphysema type of COPD: § Walls between many of the air sacs are destroyed leading to few large air sacs. § These large air sacs have less surface area for O 2 and CO 2 exchange. § Poor exchange of O 2 and CO 2 causes shortness of breath.

Pathophysiology COPD n Bronchitis type of COPD: § Airways inflamed and thickened § Increase number & size of mucus producing cells § Excessive mucus production § Coughing to remove mucus § Difficulty getting air in & out Used with permission: Jensen, M. S. , Webanatomy (2007).

Pathophysiology COPD Take a look at the next slide and note where the oxygen exchange takes place in the lungs.

O 2 and CO 2 Exchange Used with permission: http: //www. pbs. org/wgbh/nova/everest/exposure/body. html

Pathophysiology COPD Now take a look at the comparison of a healthy lung and a COPD emphysema lung.

With permission Copyright 2007 American Lung Association For more information about the American Lung Association or to support the work it does, call 1 -800 -LUNG-USA (1 -800 -586 -4872) or log on to www. lungusa. org.

Pathophysiology COPD Probably a good time to share with you the… WISCONSIN TOBACCO QUIT LINE: 1 -800 -QUIT-NOW (1 -800 -784 -8669) (UW WI Madison, 2005) Microsoft clipart

Pathophysiology Quiz Let’s see how you are doing. Which type of COPD leads to destruction of the surface area of the alveoli? Chronic Bronchitis or Emphysema

Pathophysiology Quiz What causes the central chemoreceptor in the medulla to signal the respiratory center to increase the rate and depth of respirations? A. Low oxygen in blood B. High oxygen in blood C. High CO 2 level in blood D. Gee, I need to review. CLICK HERE

Just checking in with you. How are you doing? Need to review more? Ready to move on? You are doing very well. We’re almost finished! Microsoft clipart

COPD- Signs and Symptoms Review… Chronic Cough- Major Factor in seeking care. Exercise intolerance- Fatigue Shortness of breath- At rest or activity (Kessenich & Dayer-Berenson, 2007)

What happens when your patient has an Exacerbation of COPD? These patients have sustained worsening of their usual state of health. They will exhibit: Worsening breathlessness Increased cough Increased sputum production (to yellow/green) (Bellamy, D. 2006)

What triggers a COPD Exacerbation? INFECTION AIR POLLUTION COLD WEATHER Weakened Immune System

COPD Patients n PINK PUFFER: early disease Emphysema n n Over ventilate to maintain relatively normal ABG’s until late in disease Red face n BLUE BLOATER: Chronic Bronchitis n n n Bronchial secretions and airway obstruction cause poor ventilation and perfusion; unable to compensate leading to hypoxia and cyanosis Clubbing Circumoral cyanosis (Porth, 2005) Microsoft Clipart

Barrel Chest- What’s this? COPD patients chest often looks barrel shaped. Why? These patients have a loss of lung elasticity. Airways collapse during expiration because pressure in lung tissue exceeds airway pressure. Air gets trapped causing increase in anteroposterior dimensions of the chest (Porth, 2005). Simply: Their lungs are chronically over inflated with air. Microsoft clipart

Pursed Lip Breathing- What’s this? COPD patients purse their lips to breath. WHY? Pursing your lips increases the resistance to the outflow of air. It helps to prevent airway collapse by increasing pressure (Porth, 2005). Simply: Pucker up. Try to blow air out. Feel the resistance? Microsoft clipart

Signs and Symptoms of CO 2 RETAINERS Labored Breathing Feeling of Air Hunger Nausea Confusion Dizziness Headache

Nursing Interventions Non Pharmaceutical SMOKING CESSATION AVOID EXPOSURE TO RESPIRATORY INFECTIONS ENCOURAGE FLU & PNEUMOCOCCAL VACCINES Microsoft clipart

Nursing Interventions Non Pharmaceutical POSITIONING: Sit patient on side of bed with bed side table. BREATHING: Encourage pursed lip breathing. Incentive Spirometry DIET: Small frequent nutritious meals Easily swallowed food Microsoft clipart

Nursing Interventions Non Pharmaceutical PULMONARY REHABILITATION PHYSICAL CONDITIONING SUPPORT IN PATIENT CARE COMMUNITY CARE Microsoft clipart

Nursing Interventions Pharmaceutical OXYGEN IS a drug not just something that sometimes makes the patient breathe better. Keep oxygen saturation above 90%. Follow physician order. Monitor ABG’s as ordered by physician. Dangerous side effects: Atelectasis Oxygen toxicity CO 2 retention (Perry & Potter, 2005)

Nursing Interventions Pharmaceutical BRONCHODILATORS Inhaled B 2 -adrenergic antagonists Anticholinergic agents- long and short acting Inhaled corticosteroids Oral corticosteroids IV corticosteroids Dangerous side effects: Monitor blood sugars Can increase heart rate Patients with fungal infections should use with caution (Perry & Potter, 2005)

Nursing Interventions Pharmaceutical- In patient care GIVING SOLUMEDROL: Methylprednisolone Sodium Succinate INDICATION FOR COPD: Inflammation DOSING: 40 mg-125 mg q 6 -8 hours IV NURSING CONSIDERATION: Give IV slow, over one minute Don’t discontinue abruptly Monitor fungal infection Monitor blood glucose (Perry & Potter, 2005)

Nursing Interventions Pharmacologic ANTIBIOTICS Can be used to treat an acute exacerbation of COPD due to bacterial infections. No evidence to support prophylactic use to prevent COPD exacerbation. Nursing: Check for patient allergies before administering antibiotic therapy. Patient education to take all medication is important. (Porth, 2005)

Nursing Interventions Pharmaceutical Anti-anxiety Medication COPD patients tend to become very anxious during an exacerbation. Collaborate with the physician to assess appropriate medication for your patient. This aspect of patient care is often times overlooked. Microsoft clipart

Nursing Intervention In Patient Care Often times the physician will order Solumedrol intravenously. Can you tell me what the normal dosing schedule would be for giving this drug on your unit? A. B. C. D. IV Solumedrol 300 mg every 2 hours IV Solumedrol 60 mg every 8 hours IV Solumedrol 2 gm every 6 hours for 72 hours IV Solumedrol 3 gm every 8 hours for 48 hours Click here to go to next slide.

Nursing Intervention In Patient Care Complete Respiratory Assessment Assess Co-morbidities Confirm allergies Review medications Monitor lab values: CBC, ABG’s, Lytes Collaborate with physician Educate patient and family Administer IV medications as ordered EVALUATE RESPONSE TO TREATMENT

Case Study Mr. Sigh A. Nosis Mr. Nosis is a 64 year-old- male who presents to the ER with complaints of SOB, wheezing and fatigue. His past medical history indicates a 32 -year history of smoking two packs of cigarettes a day. With only this information, what can you anticipate the ER physicians orders to include? A. Chest x-ray, Ct scan and lasix B. Chest x-ray, ABG’s, IV access C. Chest x-ray, ABG’s, exercise stress test

Case Study: Mrs. Bronk I. Tis Mrs. Tis comes to the clinic today for a follow up post hospital visit with acute exacerbation of COPD. She is a widow, elderly, frail looking woman. Which of the following concerns you? A. Oxygen saturation is 92% after a walk in the hall with you on room air. B. A weight loss of six pounds since her discharge four weeks ago.

This concludes the COPD Tutorial I hope you have enjoyed and learned about COPD. You can make an impact in the lives of the patients you care for with this disabling but many times preventable disease. Patti Pagel RN BSN Alverno College

References n American Lung Association. (2006). Chronic obstructive pulmonary n n n disease fact sheet. Retrieved February 16, 2007 from http: //lungusa. org. Anugwom, C. , & Dachs, R. (2006). Beta-blocker use in patients with COPD. American Family Physician. (74)11. , p 1858. Bay Area Medical Information. (2006). Overview of the respiratory system. Retrieved March 7, 2007 from http: //www. bami. us/Resp/COPD 2. html. Bellamy, D. , (2006). COPD exacerbations. Practice Nurse (32)6. , p 3542. Retrieved February 15, 2007 from http: //web. ebscohost. com/ehost/delivery? vid=4&hid=7&sid=cef 94 c 2 1 -be 5 a-4615 -a 3 a 7 -33. Freudnenrich, C. C. , (2007). How your lung works. Retrieved April 13, 2007 from http: //health. howstuffworks. com/lung. htm/printable. Goldsmith, C. , (2007). Fighting for breath with COPD. Nurseweek. Retrieved March 1, 2007 from http: //www. nurseweek. net.

References continued n n n n Kessenich, C. R. , & Dayer-Berenson, L. , (2007). Polypharmacy in the elderly. Nurseweek. Retrieved March 1, 2007 from http: //www. nurseweek. net Moorhead, S. , Johnson, M. , & Maas, M. , (2004). Nursing outcomes classification. Iowa outcome project (3 rd ed. ). St Louis, MO: Mosby. Nova. How the body uses O 2. Retrieved on March 19, 2007 from http: //www. pbs. org/wgbh/nova/everest/exposure/body. htm. Porth, C. M. , (2005). Pathophysiology: Concepts of altered health states. (7 th ed. ). Philadelphia: Lippincott, Williams & Wilkins. Perry, A. G. , & Potter, P. A. , (2006). Clinical nursing skills and techniques. (6 th ed. ). St. Louis, MO: Mosby, Elsevier. Punturieri, A. , Croxton, T. , Weinman, G. , & Kiley, J. P. , (2007). The changing face of COPD. American Academy of Family Physicians. (75)3. , February 1, 2007. Snider, G. L. , (2006). Diagnosis of chronic obstructive pulmonary disease. Uptodate. Retrieved February 12, 2007 from http: //www. utdol. com. University Wisconsin Madison (2005). Report: State tobacco quit line saves millions in health care costs. Retrieved April 16, 2007 from http: //www. news. wisc. edu/11228. html.

Illustration References: n American Lung Association website. Retrieved March 22, 2007 n n from www. lungusa. org. Jensen, M. , website. Retrieved April 12, 2007 from http: //www. msjensen. gen. umn. edu/webanatomy/default. htm. Microsoft Corp. (2006). Microsoft clipart. Retrieved February 26, 2007 from www. microsoftclipart. com. Nova website. Retrieved April 9, 2007 from http: //ww. pbs. org/nova/teachers. Rose, L. , website. Retrieved March 18, 2007 from http: //webschoolsolutions. com/patts/systems/ lungs. htm.

Special thank you… To everyone who supported the time, ideas, energy, frustrations, excitement, & trial runs to the completed project. I sincerely thank you. Roger Pam Christine David(s) Elizabeth Paula Georgia Kim Nicholas Vicki Patti Debbie Mom Kathy(s) Susanne Linda Randy Marcia Jeanine Pat Kris