CHRONIC OBSTRUCTIVE PULMONARY DISEASE

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CHRONIC OBSTRUCTIVE
PULMONARY DISEASE
CHRONIC OBSTRUCTIVE
LUNG DISEASES
ASTHMA
CHRONIC
BRONCHITIS
EMPHYSEMA
FULL
ASTHMA
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REVERSIBILITY OF AIR
WAY OBSTRUTION
2
NONE
COPD
PREVALENCE of MORTALITY
(2000)
Cause
Deaths
• In 2000, the WHO estimated 2.74 million
COPD deaths worldwide.
CHD
724,269
Cancer
534,947
CVA
158,060
cause of death.
• It is expected to be the third leading
cause of death by 2020.
COPD
1,14,318
•
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
Accidents
94,828
Diabetes
64,574
*The
• In 1990, COPD was ranked 12th leading
Indian J Chest Dis & Allied
Sciences 2009; 43:139-47
3
PREVALENCE of MORBIDITY
• Cigarette smoking is the primary cause.
Year
Consultations
1980
6.1 million
1985
7.4 million
1990
10.1 million
1995
11.8 million
2000
13.9 million
2025
↑↑
1.6
billion
• WHO estimates 1.1 Billion smokers in
world.
• In India 1,49,00,000 chronic cases of
COPD in the age group of
?
4
30
4000 chemicals (more than 60 carcinogens) are
inhaled in cigarette smoke
Currently there are 94 million smokers in India
COLLEGE STUDENTS ( 2%)
TENDER AGE GROUPS
Every day 55000 Indian
youth start tobacco use
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6
THE NUMBER OF
WOMEN SMOKERS&
PASSIVE SMOKERS IS ON
RISE
Risk Factors for COPD
Nutrition
Infections
Socio-economic status
Genes (alpha1- anti-trypsin↓)
Aging Populations
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TYPES OF COPD
Simple concept…….
CHRONIC BRONCHITIS
COPD
1. Mucus gland hypertrophy
2. Smooth muscle hypertrophy
3. Goblet cell hyperplasia
4. Inflammatory infiltrate
Normal bronchial architecture
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5. Excessive mucus
10
6. Squamous metaplasia
PULMONARY VASCULAR CHANGES IN COPD
Normal Pulmonary Artery
1. THICK VESSEL WALL
2. INFALMMATORY CELLS
INFILTRATE
3. COLLAGEN DEPOSIT
4. DESTRUCTION OF CAPILLARY BED
4
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14
3
COPD
Pathophysiology
Fig. 29-7
Did you know?
• The King of Pop suffered from Alpha-1
antitrypsin deficiency,
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
Clinical Manifestations
• Develops slowly around 50 yrs of age after
20 pack years of cigarette smoking
* Packets per day x Years of smoking = Pack Years
• Diagnosis is considered with
– Cough
– Sputum production
– Dyspnea
– Exposure to risk factors
Clinical Manifestations
• Intermittent Cough with
expectoration
• Progressive Dyspnea
Described by the patient as an
“increased effort to breathe,”
“heaviness,”
“air hunger,” or “gasping.”
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 .
Clinical Manifestations
• Barrel Chest• Air gets trapped causing
increase in antero posterior
dimensions of the chest
• Characteristically underweight
with adequate caloric intake
• Chronic fatigue
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
•Poor ventilation
and perfusion;
unable to
compensate
leading to hypoxia
and cyanosis
•Clubbing
•Over ventilate to
maintain
relatively normal
ABG’s
•Red face
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.
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
• 6-Minute walk test to determine O2
desaturation in the blood with exercise
• ECG can show signs of right ventricular failure
• ABG typical findings
– Low PaO2
– ↑ PaCO2
– ↓ pH
– ↑ Bicarbonate level found in late stages COPD
Spirometry
• FEV1 – Forced expired
volume in the first
second
• FVC – Total volume of
air that can be exhaled
from maximal inhalation
to maximal exhalation
• FEV1/FVC% - The ratio
of FEV1 to FVC,
expressed as a
percentage.
SPIROMETRY
NORMAL AND COPD
0
FEV1
N o rm a l
COPD
1
L iter
2
FVC
F E V 1/ F V C
4 .1 5 0
5 .2 0 0
80 %
2 .3 5 0
3 .9 0 0
60 %
FEV1
3
COPD
FVC
4
FEV1
N o rm a l
5
1
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2
FVC
4
3
29
5
6
S e c o nd s
CHEST SKIAGRAMS
EMPHYSEMA
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30
OF
V- P MISMATCH
NUCLEOTIDE IMAGING
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31
HRCT – NORMAL CHEST
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32
HRCT – EMPHYSEMA
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33
Management based on GOLD
Post-bronchodilator
FEV1
(% predicted)
NO
TOMORROW!
1. Assess and monitor
disease
2. Reduce risk factors
3. Manage stable COPD
4. Education
5. Pharmacologic
IF ONE QUITS SMOKING
1. Studies have shown that with
smoking cessation
•
The rate of decline in lung
function slows
•
There will be definite clinical
improvement in symptoms
6. Non-pharmacologic
7. Manage
exacerbations
37
REHABILITATION
For the lungs to get more air
PURSED-LIP BREATHING
(like breathing out slowly into a straw)
INHALE
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EXHALE
38
REHABILITATION
For the lungs to get more air
DIAPHRAGMATIC BREATHING
1. Sit comfortably and
relax your shoulders.
Sit comfortably and
relax your shoulders
Note:
2. Put one hand on your 3. Then push in your
abdomen. Now inhale
abdominal muscles and
slowly through your
breathe out using the
nose. (Push your
pursed-lip technique.
abdomen out while you
(You should feel your
Putbreathe
one hand
Then pushgoindown)
your abdominal
in)on your abdomen.abdomen
Now inhale slowly through your muscles and breathe out
nose. (Push
your abdomen
therest.
pursed-lip technique
• Repeat the above maneuver
three times
and thenout
takeusing
a little
whilemany
you breathe
• This exercise can be done
times ain)
day.
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39
Positions for Postural Drainage
41
Cupped-Hand Position
42
Flutter Mucus Clearance Device
43
Methods of Oxygen Administration
C. Venturi Mask
D. Tracheostomy Mask
E. Face Tent
F. Standard Nasal
Cannulas
Fig. 29-11 C-F
44
Simple Face Mask
for Oxygen
Administration
Plastic Face Mask
with Reservoir
Bag for Oxygen
Administration
Fig. 29-1145A
You administer high flow supplemental
oxygen to a patient with COPD and the
patient stops breathing.
What Happened to your patient?
The single most important
driver of ventilation is CO2
But can be deadly for the COPD Patient
CO2
CO2
CO2
CO2
CO2
CO2
Microsoft clipart
CO2
You removed his drive to
breathe!
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
SURGERY
1. LVRS - Lung volume reduction surgery
1. Single lung transplant
1. Bullectomy
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COPD
Complications
•
•
•
•
•
Cor pulmonale
Exacerbations of COPD
Acute respiratory failure
Peptic ulcer disease
Depression/anxiety
Pathophysiology of Cor Pulmonale
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
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
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.
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.
Assessment
Nursing Objective Nursing intervention
diagnosis
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 <7.35
PaCo2>45mmHg
PaO2<60 mm Hg
SaO2<90% at rest
1. Help the patient to assume position of
Impaired Maintains comfort -tripod position or head end
gas
optimum elevation with back rest- to maximise
exchange gas
respiratory excursion and to ease work of
related to exchange
breathing
bronchial levels.
obstruction
, spasm
and
trapping
Evaluation
Improved
mental status
,eupnoea,
relaxed
PaCo2of 352.Administer appropriate bronchodilators 45 mm Hg
Pa O2as prescribed to open the airways
normal
3.Administer oxygen as ordered through
appropriate device to increase saturation
4.Plan rest and activities in such a way
(pace out nursing / club procedures) to
minimise tissue oxygen demands
5.Teach and demonstrate purse-lip
breathing to prolong expiratory phase
and to slow down the rate of respiration
6. Administer humidified oxygen and
employ room humidification to mobilize
secretions
Nursing assessment
Nursin
g
diagno
sis
Subjective data:
Ineffect
Patient verbalizes
ive
difficulty in breathing, breathi
tiredness, not able to lie ng
down flat and cough
pattern
Objective data:
related
Dyspnoeic grade –,
to
shortness of breath,
decreas
frequent sighs,
ed lung
use of accessory
expansi
muscles of breathing,
on
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
Goal Nursing interventions
Main
tain
effect
ive
breat
hing
patte
rn
1. Position patient in a semi to high Fowler’s position to
promote maximum diaphragmatic descent and lung
expansion.
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
Evaluation
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
Spo2 > 95 %
Assessment
Nursing
diagnosis
Objectiv Nursing intervention
e
Subjective
data:
Patient
verbalizes that I
am not able to
perform daily
activities
Self care
deficit
global
(Feeding,
toileting,
bathing,
grooming)
related to
lack of
coordinatio
n, muscular
weakness
Resume
s self
care
activitie
s
Objective
data:
Patient is
unable to
perform ADL
Clinical
findings:
Limited ROM
Muscle powerreduced
ADL scale-0/5
Documentary
evidence:
BP-140/90 mm
Hg
PR-90/min
RR-20/min
Evaluation
Patient will
verbalizes
that his self
care activities
are resumed.
Patient is able
2. Encourage the patient to brush his teeth, to perform
comb the hair, bathe and feed himself and activities of
to assist in toileting to promote the self care daily living.
1. Approach patient from his unaffected
side and arrange call light beside table,
helps the patient to compensate for
alteration in sensory perception.
activities.
ROM,
3. Perform back massage by following 5
Muscle
steps to prevent the occurrence of bedsore. power, ADL
scoreincreased.
4. Help the patient to resume most normal
eating position (may sit on chair with
pillow support) suited to the patient’s
disability to ease the feeding.
Assessment
Nursi
ng
diagn
osis
High
Subjective data
risk
for
Objective data
injury
Confusion,
relate
Altered gait/mobility d to
diminished cognitive altere
process,
d
Unable to carry out senso
self care activities,
ry
perce
Clinical findings
ption,
Blood pressuredimin
140/70 mm Hg
ished
Visual field deficits menta
Muscle strength
l
score- upper and
status,
lower limbs -1/5
Documented
evidence
Radioimaging
studies reveals
Consolidation of
both the lower lobes
of lung field,
Goal
Intervention
Evaluatio
n
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
Patient
regains
normal
range of
body
Temp:99°F
Pulse:98ea
ts/min
Resp:20br
eaths/min
Assessment
Nursing
diagnosis
Goal/
Objective
Nursing interventions
Evaluation
Subjective
Risk for Prevent 1.Elevate the head of bed at least 30◦ during
data:
aspiratio the risk of feedings and for one hour after feeding to Experien
ce
no
Patient
n related aspiration prevent reflux by use of reverse gravity.
verbalizes on to
aspiratio
2.Instruct individual and family on activities n
difficulty
depresse
as
swallowing a d cough/
that increase intra abdominal pressure. evidence
Objective
gag
Instruct on safety when feeding.
d
by
data:
reflexs,
3. Use appropriate measures to check the noiseless
presence
of impaired
placement of nasogastric feeding tubes. respirati
NG tube.
swallowi
Malplacement of nasogastric feeding tubes ons,
Clinical
ng
or
findings:
delayed
may result in aspiration of enteral formula. clear
breath
Decreased/
gastric
absent
gag emptying
4.Regulate gastric feedings using an sounds;
reflex,
.
intermittent schedule, allowing periods for clear,
Documentary
stomach emptying between feeding intervals. odorless
evidence:
secretion
th
SpO2 90% with
5. Aspirate the contents every 4 hourly to
s.
6L of O2.
determine the amount of the residual volume.
Assessment
Nursin
g
diagno
sis
Goal
Subjective Data Risk patient
The patient
for maintai
verbalizes itching
ns
over the site/all imp
aire intact,
over the body.
moist
Objective Data d
and
Skin-moist colour
skin wellSkin turgor
Clinical findings inte lubricat
- Presence of grity ed skin
excoriation relat
Dehydration
ed
(Stage-)
- Chronic bed to
ridden status prol
(immobility) ong
- Braden’s
ed
scale-15/25
- Documented bed
ridde
Evidence
n,
- Prolonged
use of topical
applicants
Nursing interventions
1. Inspect the skin frequently for areas of redness,
swelling . to detect early signs of infection
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 Q2hrly 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 patient’s 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.
Evaluation
The
patient
mainta
ins
intact
and
well
lubrica
ted
skin.
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
All the
best
THANK
YOU

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