Chronic Obstructive Pulmonary Disease is a group of chronic and progressive respiratory disorders that are characterized by an airway obstruction with little or no reversibility. Damage to the lungs continues to make breathing gradually more difficult over time. Two clinical conditions often associated under the diagnosis of COPD are chronic bronchitis and emphysema, which obstruct or limit airflow into the lung fields.
“Chronic bronchitis is the presence of chronic productive cough for three months in each of two consecutive years in a patient in whom other causes of chronic cough have been excluded. Emphysema is an abnormal permanent enlargement of the air spaces distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis” (Lewis, S., Heitkemper, M., Dirksen, S., O’Brien, P., & Bucher, L., 2007, p. 629).
Most patients diagnosed with COPD suffer from both pathological conditions, but manifestations can vary significantly from patient to patient. According to Medline Plus (n.d.),
“Your airways branch out inside your lungs like an upside-down tree. At the end of each branch are small, balloon-like air sacs. In healthy people, both the airways and air sacs are spring and elastic. When you breathe in, each air sac fills with air like a small balloon. The balloon deflates when you exhale. In COPD, your airways and air sacs lose their shape and become floppy, like a stretched-out rubber band” (Medline Plus, n.d., para.2).
These disease processes affect the bronchi, bronchioles and lung parenchyma with predominance on distal airway.
COPD is a growing health problem not only in the United States, but also worldwide. “In 2005, approximately one in 20 deaths in the United States had COPD as the underlying cause. Smoking is estimated to be responsible for at least 75% of COPD deaths” (Centers for Disease Control and Prevention, 2008, para.1). The Centers for Disease Control and Prevention (CDC) also estimates that there are “over 119,000 deaths, 726,000 hospitalizations, and 1.5 million hospital emergency department visits are caused by COPD annually”(Centers for Disease Control and Prevention, 2009, para. 2). Even more alarming are the statistics world-wide. The World Health Organization (WHO) (2007), revealed that “currently 210 million people have COPD and 3 million people died of COPD in 2005. WHO predicts that COPD will become the third leading cause of death worldwide by 2030” (World Health Organization, 2009, para.3). With statistics this rampant, what exactly are the manifestations that cause COPD?
There are several causes of COPD. Of all potential inhaled pollutants, cigarette smoking is the primary risk factor thought to contribute to COPD. Patients with a history of smoking a pack per day, over forty years, are especially predictive of COPD development. Exposure to passive cigarette smoking, air pollution, occupational hazards such as dust or fine particles (coal or silica dust, asbestos) and childhood respiratory disorders such as severe viral pneumonia can also contribute to the development of COPD. The elderly, patients with a low body weight and clients with a history of alcohol abuse are also susceptible.
Prognosis of COPD is highly dependent upon the degree to which the patients breathing is affected and the ability to manage dyspnea, the ability of the heart to oxygenate other body systems. It is also dependent upon how damaged the lungs are upon diagnosis and if they are able to continue to oxygenate the blood without difficulty. Early diagnosis of COPD can help identify predisposing factors; such as smoking, and help provide a better prognosis through smoking cessation and deep breathing exercises to help ensure that the disease does not progress. A late diagnosis, that has affected the patient’s ability to perfuse vital organs, can result in organ failure on multiple levels and prognosis can be very grim. Further evaluation may be needed to determine the full extent of damage from lack of tissue perfusion.
Chronic Obstructive Pulmonary Disease can be a result of chronic bronchitis and emphysema. An enlargement and multitude of mucous glands are produced with chronic bronchitis, resulting in an increased mucous production and a characteristic cough. Apart from the amount of mucous produced; the quality of the mucous also becomes more viscous in nature, making it harder for the patient to expel. Accumulation of excess mucus causes airway obstruction in the peripheral airway and therefore an increase in airway resistance. Lymphocytes, neutrophils and macrophages also accumulate which can lead to fibrosis or a formation of excess fibrous connective tissue in the lung fields as an attempt to repair the area.
Emphysema results in large part from an enlargement of airspaces distal to terminal bronchioles. The loss of elasticity of the lung tissue and the closure of small airways is due to the destruction of the alveolar walls. When the connective tissue is destroyed in the alveolar walls, protease is released, further destroying elastin and inhibiting the ability of the alveoli to recoil. Protease affects structural integrity of the alveolar wall. In a healthy individual, the ability of the alveoli to recoil helps to maintain the patency of the airway lumen, especially during expiration.
With COPD, there is airflow limitation due to loss of alveolar attachments, inflammatory obstruction of airways and obstruction of the terminal branches with mucus. Airways begin to narrow due to the inflammation, resulting in a loss of elastic recoil and loss of alveolar attachments. Ciliary function in COPD is also abnormally impeded. Cilia in the airway wall normally acts as a force to help thrust mucus or other foreign bodies toward the trachea for expulsion from the body. This function is often impeded by the thick and firm mucus often seen with chronic bronchitis. Lack of ciliary function increases the risk of recurrent infections in the lungs due to accumulation of these foreign particles within the lung fields. Destruction of the alveoli and profuse mucous accumulation destroys the ability of the body to deliver oxygen, resulting in hypoxia. The patient suffering from COPD often struggles to breathe and hypoxic-related dyspnea systemically affects other areas of the body often leading to pulmonary hypertension and heart problems such as heart attacks and right-sided heart failure. Patients with COPD are more prone to respiratory infections, lung cancer and depression. Signs and symptoms of COPD usually do not occur until significant damage to the lungs and other body systems have occurred.
Signs and Symptoms:
Patients with COPD usually present with signs and symptoms of both emphysema and chronic bronchitis to include a continuous hacking-type cough that produces a thick mucus which is often hard to expectorate. Patient may also complain of significant shortness of breath that presents particularly with exercise or exertion. Clients may also complain of difficulty sleeping with constant fatigue and an abrupt, unplanned weight loss. Patients typically also present with rapid breathing, barrel-like distention to chest and will sit “often in a tripod position, leaning forward with arms braced against their knees, chair, or bed. This gives them leverage so that their rectus abdominus, intercostals, and accessory neck muscles all can aid in expiration” (Jarvis, C., 2008, p. 449). Due to lack of oxygen the patient might also present with cyanosis of the skin, wheezing and chest tightness, with possible signs and symptoms of respiratory infection. Patients with COPD can also experience exacerbations, which are periods or episodes where the patients COPD symptoms can suddenly worsen. Exacerbations can be caused by influenza, infections or exertion. Other contributing factors include a rapid change in humidity or temperature, exposure to smoke or other pollutants, allergens and dust. According to report from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) (2009), COPD can be broken down into four various stages to include:
“Stage I: mild COPD: Characterized by mild airflow limitation predicted. Symptoms of chronic cough and sputum production may be present, but not always. At this stage, the individual is usually unaware that his or her lung function is abnormal. Stage II: moderate COPD: Characterized by worsening airflow limitation with shortness of breath typically developing on exertion, with a productive cough. This is the stage at which patients typically seek medical attention because of chronic respiratory symptoms or an exacerbation of their disease. Stage III: severe COPD: Characterized by further worsening of airflow limitation, patient experiences an even greater degree of shortness of breath, reduced exercise capacity, fatigue, and repeated exacerbations that almost always have an impact on patients’ quality of life. Stage IV: very severe COPD: Characterized by severe airflow limitation with the presence of chronic respiratory failure. Respiratory failure may also lead to effects on the heart such as cor pulmonale (right heart failure). At this stage, quality of life is very appreciably impaired and exacerbations may be life threatening” (GOLD Report, 2009, p.4).
With the varying manifestations in the progression of the disease, providers must take into account the assortment of challenges and medical interventions necessary in the treatment of COPD.
COPD: Medical Interventions
Diet Plan: Needs and Modifications:
Individuals with COPD have overall muscular weakness, including the respiratory muscles, that relates to systemic inflammatory process in the lungs. Diet is an important factor to take into consideration, especially in the elderly because the risk for malnutrition increases. COPD and malnutrition go hand in hand, “malnutrition and a low BMI of <20kg/m may be found in up to 30% of patients with advanced COPD and represent an independent risk factor for increased mortality and hospitalization” (Nazir & Erbland, 2009, p. 823).
Individuals who are underweight have an underlying problem that relates to an increased metabolism and the breakdown of essential nutrients for energy requirements. In these individuals it is best to modify their eating habits, with frequent breaks to decrease fatigue. It takes a lot of energy to metabolize food, “breathing and eating become harder, [the individual] may have to choose between taking a gasp of air or a bite of food” (O’Neill, 2004, para. 3). For those who are overweight, the problem as it relates to COPD is due to excess abdominal fat. Abdominal fat prevents the diaphragm from expanding completely, which causes a decrease in oxygen availability. This decrease in oxygen compromises the cardiovascular system due to the inadequate amount of oxygen being delivered to the heart and throughout the body.
Both malnourished and obese individuals need to monitor weight, food and fluid intake daily. According to Peggy O’Neil (2004), “intake of fluids, calories, protein, calcium and potassium all play a role in protecting immunity and easing breathing” (O’Neil, 2004, para. 8). The American Lung Association states that the “metabolism of each [nutrient] requires a different amount of oxygen and produces a different amount of carbon dioxide. Metabolism of carbohydrates produces the most carbon dioxide for the amount of oxygen used; metabolism of fat produces the least” (American Lung Association, 2010, para. 3). Good sources of fat should come from unsaturated fats such as nuts, olive oil, soy and avocados. Protein is essential for muscle repair and assists in the healing process when an infection or injury occurs. O’Neil recommends that “generally two cups of milk plus six ounces of protein from other sources each day provide four servings of high-quality protein, good sources of protein, which is adequate for someone with COPD” (O’Neil, para. 12). Potassium is “found in fruits, vegetables, dairy products and meats [and are] key to control blood pressure, muscle contraction, and nerve impulses transmission. Normal serum potassium levels help with optimal muscle contraction to aid breathing” (O’Neill, para. 15). Excessive need for increased nutritional intake is imperative for the adequate daily functioning and maintenance in the COPD client.
In order to facilitate sufficient digestion and proper absorption of food the patient should “remain upright after meals to prevent the stomach from pushing on his diaphragmâ€¦limit intake of carbonated beveragesâ€¦[and to consume] soft, easy-to-chew foods to prevent him from becoming short of breathe while eating” (O’Neil, 2004, para. 16). Consumption of clear fluids should be encouraged to prevent dehydration and also to help thin mucous secretions.
Appropriate Medications and Diagnosis:
Although there is controversy over the amount of oxygen to give a patient with COPD, it is generally understood that the long term use of “oxygen therapy improves survival, exercise capacity, cognitive performance, and sleep” (Lewis et al., p. 640). There are various ways that oxygen therapy can be administered to a patient with COPD. In hospitals the most precise delivery of oxygen therapy is through the use of the venturi mask, however most patients prefer to use the nasal cannula. The structure of the nasal cannula allows the patient to perform daily activities such as eating and talking without interrupting oxygen delivery. When oxygen therapy is used in conjunction with smoking cessation it improves the patient’s quality of life by increasing the amount of available oxygen and increasing systemic perfusion.
Depending on the severity of COPD, “bronchodilators such as beta2-antagonist, anticholinergic, and methylxanthine” (Lewis et al., 2007, p. 639) will be given to relax the smooth muscles of the airway, and to increase gas exchange. These medications can be administered as an inhalant or by the oral route. For those experiencing moderate-to-severe COPD, glucocorticoid therapy may be combined with a bronchodilator to decrease inflammation of the airways. Inhaled glucocorticoids are preferred over oral glucocorticoids for long term treatment, because oral treatments can lead to adrenal insufficiency and Cushing’s syndrome. (See Appendix A). Patient should expect to experience improved oxygen utilization.
Diagnostic Tests and Lab Work:
Pulmonary functions test measures the intake and output of air in the lungs and is used to confirm the diagnosis of COPD. There are “four components to pulmonary function testing, [which consist of]: spirometry, postbronchodilator spirometry, lung volumes, and diffusion capacity” (Chronic Obstructive Pulmonary Disease Diagnosis, 2010, para. 3). Also, there are many diagnostic studies that support the diagnosis of COPD, such as chest x-rays, arterial blood gases, echocardiogram and electrocardiogram (ECG)” (Lewis et al., p. 638).
X-rays are not the preferred method of diagnosing COPD since it cannot pick up abnormalities until COPD is in the later stages. Arterial blood gases are performed to monitor the amount of oxygen and carbon dioxide in the blood. In individuals with COPD “typical findings are low PaCO2, elevated PaCO2, decreased or low-normal pH, and increased bicarbonate (HCO3) levels” (Lewis et al., 2007, p. 638). COPD can cause right sided heart failure related to pulmonary hypertension so patient should be monitored regularly by ECG and echocardiogram.
As discussed earlier, changes in the lungs are related to smoking, toxins in the environment or occupation. In order to identify the causative effects of these toxin, clinical trials are being conducted to development new diagnostic tests that are aimed at identify early neoplastic changes in the lung. For example, advanced imaging techniques such as the PET scan is able to reveal “metabolically active nodule [that are] highly indicative of malignancy” (Petty & Miller, n.d. p. 7), that could not be found with prior diagnostic tests. Also, a tissue autofluorescence, which is an enhanced bronchoscopy technique, “can indicate a high likelihood of malignancy” (Petty & Miller, p. 7) in the lung tissue, that cannot be seen in a CT scan or chest X-ray. Hopefully, these clinical studies as they become available to the general population, will not only identify acute changes in the lung structure in advance, but also could potentially assist in finding a cure for lung diseases.
Treatment and Treatment Options:
Medications can make COPD patients more comfortable, but there is no overall curative treatment. The disease itself “extends beyond the airways and lungs to include other body systems,” (Barnett, 2008, p. 30). The goal in treatment is aimed at the controlling the symptoms involved in these various areas of the body and to reduce the inflammatory response in the lungs. To do this, the patient will need to modify their diet and lifestyle habit to prolong the quality of their life.
As discussed earlier, emphysema and bronchitis constitute the disease known as COPD. The management and treatment of these two diseases is necessary for the patient to live a quality life. The medical treatments used to treat COPD was reviewed earlier, there are also non-pharmacological treatment options available that slow the progression of the disease and the symptoms of chronic obstructive pulmonary disease.
One non-pharmacological treatment option is pulmonary rehabilitation. The goal of this treatment is to:
“break the vicious cycle of increasing inactivity, breathlessness and physical de-condition, and improving exercise capacity and functional status as well as improving individual patient’s self-management skillsâ€¦Pulmonary rehabilitation is conducted by physiotherapist and respiratory nurses. Each session is based on the patient exercise tolerance and consists of one to two sessions a week for about an hour, for 6-8 weeksâ€¦ then followed by an educational component to enable to the patient to make lifestyle changes to help them cope better with living with COPD” (Barnett, p. 31).
There are various energy conservation techniques that a patient can use to improve the quality of available oxygen.
Often COPD patients struggle to breathe. The overall goal of the following energy conservation techniques is to help the patient breath better and to improve activities of daily living by relieving the distressing symptoms that accompany COPD. According to Barnett (2008), these techniques are:
“Exhale during strenuous part of an activity and use pursed lips to reduce to work of breathing, alter strenuous activities with easier tasks, place items within easy reach, to reduce bending and stretching for items, If needed, use aids and equipment such as electronic wheel chairs and to sit down to perform many of the daily activities” (Barnett, 2008, p. 32).
With a healthy individual, there is a low residual of air that remains in the lung. With the COPD patient, the volume of trapped air is increased and therefore decreases oxygen exchange within the lungs. Stress reducing techniques can help relax the patient. Therefore the patient can exhale the excess retained carbon dioxide and inhale even greater amounts of saturated oxygen with each new breathe. Hence, the efficiency of oxygen and carbon dioxide exchange is improved.
Individuals should be updated on immunizations, even more so if a patient has COPD. According to the CDC (2010) adult immunization schedule, patients with chronic lung disease are required to have one annual influenza and one or two pneumococcal inoculations within the patients lifetime (CDC, 2010, p. 2). If the patient becomes infected with influenza or pneumonia, damage to the lung fields can be exacerbated if not treated quickly and can possibly lead to death.
COPD: Holistic Assessment of Patient
Mr. Johnson is a 73 year old male who has presented to the Emergency Department for the third time this week with dyspnea. Patient has been smoking a minimum of one pack per day for the past 46 years. Patient is currently on two liters of supplemental oxygen at home via nasal cannula and states that he cannot seem to catch his breath. Mr. Johnson is leaning over the side of the bed in tripod position, gasping with supraclavicular retractions noted on inhalation. As a nurse, what do you think could be wrong with your patient?
Upon further evaluation, the nurse notices that Mr. Johnson also has a non-productive hacking-type cough that has persisted throughout the triage process. Mr. Johnson complains, “I just cannot seem to get this thick mucus up out of my throat and I feel like I am suffocating, like I cannot catch my breath!” Patient appears to be bracing himself over the side of the chair in a tripod position. The nurse is a waiting for the provider to place orders in the computer for the client’s chest x-ray. A venturi mask is placed on the patient and oxygen delivery is set to be administered at three liters of oxygen per minutes. This intervention successfully alleviates the patient’s rapid and shallow respirations, as well as the circumoralcyanosis. Upon auscultation the nurse notices diminished lung sounds over the left and right lower lung fields with auditory wheezing upon exhalation. The nurse also notices a barrel-like distention to the patient’s chest. The nurse begins to take the patient to radiology and abruptly stops as the patient begins to weep inconsolably. What could be the likely factor associated with the emotional reaction exhibited with the patient?
To make an accurate assessment of the patient’s psychological reaction, the nurse casually begins to inquire about the patient’s daily activities. The patient divulges to the nurse that he has lost his job, is no longer able to care for himself and feels a sense of guilt that he has become burdensome on his family members. Patient states, “I have a loving family, but feel as though they would be better off without me. I know I shouldn’t feel this way, but I have been depressed and feeling lonely for some time now.” The nurse recognizes that the patient is displaying signs of depression, low self-esteem and lack of autonomy with loss of control over his personal life. The priority nursing interventions for this patient should include a referral to a mental health agency and community outreach programs that can assist the patient to meet the psychological strains produced by his current health situation. The patient then covers his face and whispers in a soft undertone, “I cannot even afford to pay for my groceries, much less this visit! How can I afford this referral?” With this statement in mind, what priority nursing assessment should the nurse consider?
Mr. Johnson is one of many faces dealing with the strains and financial hardship associated with COPD. The overall costs of COPD are overwhelming. According to the Harvard University (2008), the “annual cost to the nation for COPD (emphysema and bronchitis) is approximately $32.1 billion, including healthcare expenditures of $18.0 billion and indirect costs of $14.1 billion” (Harvard University: Healthcare delivery- Deconstructing the costs, 2008, para 58). The global statistics are even more astounding. According to the American College of Chest Physicians (2003), “the global direct yearly costs of chronic bronchitis and COPD patient was $1876. The cost generated by the patients with COPD was $1,760.00 [per patient/year/costs], but the cost of severe cases ($2,911 per year) [per patient/year/costs] was almost double that of mild cases ($1484 per year) [per patient/year/costs]” (Miravitlles, Murio, Guerrero, & Gisbert, 2003, p.786). With these statistics in mind, what are some of the teaching points that a nurse can utilize to assist the COPD patient?
Health Teaching and Community Resources:
The nurse must take in various considerations when assisting the COPD patient. How well is the patient able to tolerate activity? Does the patient suffer from dyspnea related disturbance in their sleep pattern? What are the patient’s physical or financial resources? A patient that has a hard time meeting monthly utility bills is far less likely to be compliant with a medical regime. The nurse should focus on trying to coordinate social work service to help the patient to meet healthcare needs. If the patient has a family member, how does this affect his or her role if they are primary breed winner in the family? Interview should point out any psychological stressors that may be affecting the patient and should determine if therapy may be required.
Primary education should focus on convincing the patient to quit smoking. Inform the patient to keep up to date on immunizations such as annual flu and pneumonia vaccines. Patient should compliantly take prescribed medications and avoid second-hand smoke or exposure to other irritants such as dust, smog, extreme heat or cold and high altitudes, pollutants that can exacerbate symptoms. COPD patients must increase fluid intake to decrease viscosity of mucous secretions in addition to maintaining an adequate nutritional status to facilitate extra nutritional requirements. Diets should be low in saturated fat and should include various fruits, vegetables and whole grains. Highly emphasize to the patient that use of oxygen therapy should be only used as directed and control of respirations with pursed lip technique. Direct the patient to take frequent breaks to minimize fatigue. Pacing of activities throughout the day will minimize undue stress on the lungs. It may be necessary to coordinate follow-up appointments for the patient; however signs and symptoms such as shortness of breath, wheezing or the desire to lean forward to aid in breathing will warrant an earlier visit. A trip to the emergency room will be necessary if the patient starts to have sudden, severe shortness of breath, or if they become lightheaded, weak, faint or experience chest pain with a rapid, irregular heart rate.
Chronic Obstructive Pulmonary Disease is a progressive and debilitating disease process that wreaks havoc on the patients cardiovascular and respiratory systems. Management of COPD can be maintained and symptoms minimized through adequate diet interventions, medication regimens, completing diagnostic exams and lab tests. Though COPD is a preventable disease, the realistic nature of the disease process requires a nurse that is knowledgeable, caring and sympathetic to the patients overall needs.
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