Week 6

Created by Rose Kamille Colmenar

COPD, RV Failure, Pneumothorax

Interventions

• Pursed lip breathing - prolongs expiratory phase = get more CO2 out
• Tripod Position
  • clear over bed table
  • give place ot tripod
• walk
• chest pt, consult RT. available vest
• adequate fluids
• do not give a lot of oxygen

Chronic Bronchitis

Hyper secretions of mucus and chronic productive cough at least  3 months out of a year for at least 2 consecutive years

produce more mucous "cupfull of mucous

Emphysema

an abnormal enlargement of the airspaces beyond the terminal bronchioles with destruction of the walls of the alveoli (parenchymal destruction)

Exposure to irritants

• Smoking/ Second hand smoke
• Asbestos
• Airpolution
• organic and inorganic dusts, open fires from wood, animal dung, crop residue, and coal

• Biomass (open fire)cooking in poorly ventilated areas

Intervention

Quit Smoking

• Quit date
• nicotine
• 4D
  • Delay
  • Deepbreathe
  • Drink water
  • Do something else
• counseling

Assessment

an abnormal enlargement of the airspaces beyond the terminal bronchioles with destruction of the walls of the alveoli (parenchymal destruction)

Assessment/ Diagnostic

Development of cough, shortness of breath

Airway epithelium inflammation

Alpha 1 Antitrypsin Deficiency

Smoking

• cigarette, pipe, cigar, water pipe, marijuana
• Second hand smoke

Smoking history

expressed as “pack/years”: the number of packs smoked per day times the number of years of smoking. A person who has smoked an average of 2 packs per day for 20 years has a smoking history of 40 pack/years.

More sputum amount

Frank purulent sputum

Chronic mucus hypersecretion has been implicated as a cause of lung function decline, exacerbations, and infections.

Intervention

Help patient to identify irritants in the environment and together develop a plan to minimize exposure

Mucous gland hyperplasia

Bronchial muscle hyperplasia

Decreased inhibition of proteolytic enzymes

more proteolytic enzyme activity. Break downs protein in the lungs (breakdown lung tissue)

protease digest proteins

Increased neutrophils in lung parenchyma/tissue

Increase size and number of mucous glands and goblet cells

Ciliary dysfunction

cant clear out secretions. dust particles, bacteria, viruses = prone to infections

Bronchial wall narrowing

Assessment/ Diagnostic

Development of wheeze heard with auscultation

Damage to bronchioles and alveolar walls

Release of proteolytic enzymes from neutrophils

similar to genetic disease

Medications

Mucus thicker/more tenacious

great place for bacteria to grow

reduced mucus function

Airflow limitation

Intervention???

bronchodilator

tripod

putrsed lip breathing

Interventions

Alveolar septum destruction

Assessment/ Diagnostic???

Assessment

Bronchospasm, Dyspnea, Productive cough

Bronchospasm: wheezing

Elimination of portions of pulmonary capillary bed

big "sacky" alveoli = less surface area

Increase volume of air in acinus

Article Related

Intervention

• Teach patient proper cough technique
• ensure at least 200 ml fluid every 2 hours unless contraindicated
• ensure oral hygeine

Adequate hydration (2 to 3 L/day) is indicated to keep the mucous membranes moist and thereby facilitate the removal of secretions as long as not contraindicated by cardiac, liver, or kidney disease. Supplemental oxygen is administered as necessary.

Frequent infectious exacerbations

Disturbance in gas exchange

Hyperinflated Alveoli (bullae)

Bullae are enlarged airspaces that do not contribute to ventilation but occupy space in the thorax. Bullae may compress areas of healthier lung and impair gas exchange.

Assessment/ Diagnostic

Dyspnea: an awareness of uncomfortable breathing that may vary in intensity

• Early stage: mild and is noticed only with vigorous activities, such as stair-climbing and playing sports
• Late stage: severe and often interferes with the person’s activities of daily living. Even more so, it can occur at rest

Chronic cough and Sputum production: severe and often interferes with the person’s activities of daily living

• Early stage: small to moderate amount of white to clear sputum.
• Exacerbations: an increase in the amount and viscosity of sputum may occur, and the sputum may change color

Diagnosis: history, physical exam, pulmonary function test (PFT)

Spirometry

Total lung capacity

ABG

Chest xray

COPD SYMPTOMS

• Dyspnea: an awareness of uncomfortable breathing that may vary in intensity.
• Chronic Cough
• Sputum Production
• Cant get gas out
• hyperinflation dt loss o felastic recoil

In early stage disease, the person may note an early morning cough productive of a small to moderate amount of white to clear sputum. During exacerbations, an increase in the amount and viscosity of sputum may occur, and the sputum may change color.

Continued edema/narrowing of bronchial walls

Loss of elastic recoil

Continued alveolar damage and weakening of alveolar walls

Symptom of increased WOB

• Shortness of breath

• Diaphoresis

• Pursed-lip breathing

• Tachypnea or bradypnea/irregular breathing rhythm

• Use of accessory muscles

• Tachycardia

• Abdominal breathing

• Cyanosis

Assessment

• Hyperinflation: "barrel chest" 1:1 ratio of anterior to posterior diameter
• bilateral intercostal retractions at the posterior axillary line
• horizontal fixation of the ribs in the inspiratory position
• hyper resonance to percussion
• Breath sounds may be diminished
• prolonged exhalation (bronchovesicular breath sounds) is usually heard throughout the chest
• often adventitious sounds (coarse crackles and wheezes) are heard when the patient has increased secretions or bronchial hyperreactivity as well as during an exacerbation.

Intervention

Bronchodilators: relieve bronchospasm, reduce airway obstruction, and aid in secretion clearance

Corticosteroid: used for acute exacerbations with severe symptoms not affected by bronchodilator

• S/E: hyperglycemia, osteoporosis, oral thrush
  • Rinse and gargle after inhaled steroid

Mucolytics

Red Flag

• Persistent coughing is a crucial sign of COPD and should not be ignored, especially if it has been present for any length of time.
• Smaller irritating coughs are easy for patients to ignore, but should still be investigated by the community nurse
  •  questions asked about the duration of the cough
  • when it started
  • whether it is a 'dry' cough 

Difficult expiration

Airway collaps in expiration

Pickle or Chest PT

Formation of blebs

Cause bleb rupture: increase pulmonary pressure, severe coughing, ventilator use (positive pressure)

Assessment/ Diagnostic???

• Decreased breath sounds
• Tactile Fremitus - decrease (no consolidation)
• sudden chest pain that is sharp and abrupt
• a significant and sudden increase in severe shortness of breath
• asymmetry of chest movement
• unilateral retractions, hyperresonance on percussion
• crepitus (cracking sensation when touching affected area)
• bilateral differences in breath sounds, and/or oxygen desaturation

Tiotropium (LAMA)

• First-line therapy for moderate to severe disease
• Tiotropium given once a day; aclidinium given twice a day
• Tiotropium approved for reducing COPD exacerbations
• Tiotropium also available in Respimat™ device
• Each medication comes with its own delivery device

Long acting muscarinic antagonist

aka anticholinergic bronchodilator

maintenance med used on regular basis

V/Q Mismatch

With dead air space, there is ventilation without perfusion, resulting in a high ventilation–perfusion ratio

Intervention

Breathing Training

• Pursed lip breathing
• Hand fan with airflow to the cheek
• Diaphragmatic breathing
• Inspiratory muscle training
• Pacing activities
• Opioids
• Non-Invasice positive-pressure ventilation

Pursed-lip breathing helps slow exhalation and is thought to prevent the collapse of the small airways, effectively allowing more air to be exhaled and decreasing hyperinflation.

• promote relaxation and reduce feelings of panic

Fan

• cool and moving air reduces their sensation of dyspnea. Relaxation techniques such as progressive muscle relaxation may also be useful

Diaphragmatic breathing

• difficult to learn, little benefits

Inspiratory muscle training

• not standard of care

Pacing

• helping patients anticipate dyspnea-producing activities and plan how they will keep their dyspnea at a manageable level

Shunting

• perfusion without ventilation, resulting in a low ventilation-perfusion ratio
• With a tiny bit of Oxygen delivery, it reduces shunting

Risk of bleb rupture

weakness on lung wall

Intervention

Long-term oxygen therapy (worn more than 15 hours per day) was associated with increased survival, improved quality of life, a modest reduction in pulmonary arterial pressure, and decreased dyspnea.

Intervention

Careful assessment for pneumothorax including decreased lung sounds, change in oxygenation, chest pain and report variations to provider

Rapid response teams or emergency services should be initiated

bullae can be surgically removed

LVRS involves the removal of a portion of the diseased lung parenchyma. Successful LVRS results in reduced hyperinflation and improvement in the elastic recoil and diaphragmatic mechanics.

Assessment/ Diagnostic

• increased pulse and respiratory rate, mental cloudiness, dull headache, or weakness
• Cerebral vasodilation and increase cerebral bloodflow. 
  • Increased ICP = papilledema and dilated conjunctival blood vessels
• Dysrrhytmias

Pulse Ox - assess response to O2 therapy

ABG - assess PaCO2 (the breathing drive for COPD patients)

Pneumothorax

MEDICAL EMERGENCY

Hypercapnea

• Caused by inadequate ventilation, resulting in elevated plasma CO2 concentrations and, consequently, increased levels of carbonic acid
• hypoventilation - ineffective breathing measure by CO2 levels
• RESP ACIDOSIS
• body relies on levels of O2, hypoxemia = breath in

Interventions

• Bronchodilators - helps with bronchospasm
• Put patient on semifowlers
• Intermittent rest therapy: nocturnal negative pressure ventilation or continuous positive airway pressure
• Respiratory muscle training
• Ventilator

Increased Pulmonary Vascular Resistance

Resistance to pulmonary blood flow is increased, forcing the right ventricle to maintain a higher and a higher pressure in the pulmonary artery.

Hyperventilation

Polycythemia

RBC to be able to carry more oxygen.

kidney involvement

Hypoxemia stimulates erythropoeitin to produce more RBC

HIgh hematocrit

• risk of venous thrombosis
• increased clotting

Increased RV Pressure during systole

Respiratory fatigue

• Increase CO2
• considers whether the respiratory center is capable of continuing to exhale the respiratory acid

Anemia of Chronic Illness

overides polycytemia

pt are more likely to be anemic

RV Hypertrophy

???

The diagnosis of pulmonary hypertension associated with COPD is suspected in patients complaining of dyspnea and fatigue that appear to be disproportionate to pulmonary function abnormalities.

Enlargement of the central pulmonary arteries on chest radiograph, echocardiography suggestive of right ventricular enlargement and elevated plasma brain natriuretic peptide (BNP) may be present.

BNP>100 = HF/ventricular problems

Increased RA and RVEDP

Right Atrium

Right Ventricular End Diastolic Pressure

Cor Pulmonale

1. Shunts blood to parts of lung that can increase perfusion
2.  all capilaries will vasoconstrict with all tenatious secreations putting a lot of work on the right side of the heart 
3. pulmonary 
4. bronchial system - arise from aorta to deliver oxygenated blood to the lungs
5. bronchial venous drainage goes into pulmonary vein in the left atrium. The systemic blood is never 100%

Increased systemic venous pressure

dependent edema

difficult ambulation

Intervention

• Teach patient ways to reduce the risk of falls
  • remove scatter rugs at home
  • ask for help
  • get up from bed or chair slowly

• exercise training to strengthen the muscles of the upper and lower extremities and to improve exercise tolerance and endurance.
• Use of walking aids may be recommended to improve activity levels, balance, and ambulation

Exercise

• Deep breathing - every hour take 10 slow deep breaths
• moving in bed - roll side to side every hour
• leg work - ankle pumps, quad sets, buttock squeeze, leg lifts
• arm work - raise arm as you breath in; vise versa as you breath out

increased visceral edema

weight gain

Assessment/ Diagnostic

decreased activity, muscle weakness, and fatigue

Assessment/ Diagnostic

• 6 lb weight gain this week
• 3+ bilateral edema
• increased jugular venous distension

Difficult digestion, abosorption, and abdominal pain

hepatic engorgement

Intervention

Obese will continue, no weight loss

Anorexia

unable to meet normal metabolic body requirements

Hepatomegaly

RUQ pain

Intervention

High Protein

High Caloric Diet

Low/Controlled Carb - metabolize into CO2

Obese will continue, no weightloss

• Oral nutritional supplements help increase body weight and respiratory function
• timing bronchodilator therapy before meals
• assisting severely dyspneic patients during meal times to minimize energy spent eating
• teaching patients to eat small, frequent meals to help them avoid becoming too full
• encouraging choices of calorie-rich foods; and providing patients with oral supplements
• referring patients to dieticians
• encouraging progressive periods of exercise aimed at increased muscle mass

Malnutrition

Ascites

Splenomegaly

Impaired liver function

Elevated liver levels

Disruption in RBC, Platelets

thrombocytopenia

Decreased protein stores

Impaired protein synthesis

Clotting factors are proteins that are synthesized in the liver.

Coagulopathy