COPD It Takes Your Breath Away Patti J. Pagel, RN, BSN Alverno College MSN Program April, 2007 [email protected].

COPDIt Takes Your Breath Away

Patti J. Pagel, RN, BSNAlverno CollegeMSN Program

April, [email protected]

Self-Study Tutorial GuideInstruction Page Click on to go back to previous slide Click on to go to the next slide Click on to return to objectives Click on True/False and learn the correct

answer when presented in a slide Click on Answer for multiple choice to check

for correct answer Click here to go back to review slides Click on website link for further information

Welcome!Main MenuClick on subject to navigate to:

Or click on forward arrow to go to next slide

ObjectivesObjectivesNursingNursing

OutcomesOutcomes

RespiratoryRespiratoryReviewReview

PathophysiologyPathophysiology

RespiratoryRespiratoryQuizQuiz

Patho QuizPatho Quiz

Signs & SymptomsSigns & Symptoms

Interventions

Case StudyCase Study

ReferencesReferences

Intended Audience

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

Review respiratory system anatomy. Increase understanding of the

pathophysiology of COPD. Recognize signs and symptoms of COPD. Identify treatment options:

Non-pharmaceutical nursing interventions

Pharmaceutical interventions

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 medicationSource: (Moorhead et al 2004)

Microsoft clipart

Let’s Review: Respiratory Anatomy

Upper Respiratory Tract:Mouth, nose, throat (pharynx),

larynx, trachea Lower Respiratory Tract:

Lungs, bronchi, alveoli Medulla Oblongata

Controls inspiration/expiration

Microsoft clipart

Anatomy Review

Respiratory ReviewLet’s Take a Breath Together: 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 CO2 exchange takes place.Used with permission: Jensen M.S., Webanatomy 2007

Respiratory Review:Now your Breath is…

Alveoli fill with air. Oxygen diffuses thru alveoli walls. Oxygen diffuses to Capillaries and bloodstream. Hemoglobin for transport of

oxygen. Oxygen to the heart and

to the body.

Used with permission: Jensen, M.S., Webanatomy (2007).

Respiratory ReviewLet your air out…

Hemoglobin frees oxygen. O2 to cells.

CO2 is the waste product.

Veins return CO2 to heart.

Heart pumps CO2 to lungs.

CO2 passes alveoli to be exhaled

Use with permission: Jensen, M.S., Webanatomy (2007)

Respiratory Quiz

Respiratory Assessment:

Understanding the anatomy of the lungs, where does the exchange of oxygen and CO2 occur:

A. Bronchioles

B. Aveoli

C. Bronchial Tubes

Click on underlined best answer.

Respiratory Quiz:

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:

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 DiseaseFact 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).

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What Causes COPD?

What do you think are the two causes of COPD?

Find the two causes- click on word

Cigarette Smoking Factory WorkObesity Cancer Diabetes Stroke Alcohol Abuse InactivityCoronary Heart DiseaseAlpha1-antitripsin DeficiencyClick HERE to learn more about COPD.

Pathogenesis of COPD

Inflammation bronchial walls Cause

airway

Fibrous bronchial walls obstruction &

problems

Hypertrophy of submucosal glands with

ventilation

Hypersecretion of mucus &

perfusion

Loss of elastic lung fibers and alveoli tissue

(Porth, 2005)

Types of COPD:

Chronic Bronchitis ----- -Obstruction of small airway-Inflammation of major & small airways

Emphysema-Enlargement of air spaces-Destruction of tissues

Alpha1- 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 Hypoxemia

(Porth, 2005)

Characteristics of:Chronic Bronchitis

Doesn’t strike suddenly Damage occurs before patients seek

treatment Pulmonary hypertension Right heart failure with peripheral edema

(Porth, 2005)

Chronic Bronchitis Diagnosis

Mucus producing cough most days of the month, three months of a year for two consecutive years (ALA).

Microsoft Clipart

Characteristics: Emphysema

Dyspnea, slowly progressive Abnormal Arterial Blood Gases Use accessory muscles Weight loss Sputum production in morning, scant Cough- minimal Loss of lung elasticity Destruction of alveoli walls and capillary beds

(Porth, 2005)

Emphysema Diagnosis

Careful history and physical examinationPulmonary function studiesForced Expiratory Volumes

Chest radiographsLaboratory tests

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COPD- Let’s Review

COPD is the fourth leading cause of death in the United States.

TRUE

FALSE

Heredity is the most common cause of COPD

TRUE

FALSE

Click here to proceed to next slide

PathophysiologyAutonomic Nervous System

Respiratory Centers:

MEDULLARY &

PONSVentilation

Central Chemoreceptor

PeripheralChemoreceptor

Respond to Arterial PCO2

Respond to Arterial

PO2 & PCO2

Stretch Receptors

IrritantReceptors

Monitor Stretch

ofLungs &

Chest Wall

InvolvedWith

ReflexesCausing

Coughing &Sneezing

(Freudenrich, 2007)

Factors that Influence the Respiratory Centers:

Craig C. Freudenrich, Ph.D.. "How Your Lungs Work". October 06, 2000 http://health.howstuffworks.com/lung.htm (April 12, 2007)

Oxygen:Peripheral Receptor

Monitors O2 concentrationof blood

Carbon Dioxide:Central Receptor

Monitors CO2

Concentration in CSF

Hydrogen Ion (pH):

Peripheral & Central

Sensitive to pH ofBlood and CSF

oxygen Concentration= Rate and Depth

Breathing

CO2 = Rate and Depth

Breathing

Hydrogen Ion= Rate and Depth

Breathing

The single most important driver of ventilation is CO2

But can be deadly for the COPD Patient

Microsoft clipart

CO2

CO2

CO2

CO2

CO2

CO2CO2

CO2

CO

2

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 CO2 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- 3L O2

Normal ABG Results Abnormal ABG ResultspH 7.35-7.45 pH 7.32PaCO2 35-45 PaCO2 69HCO3 22-26 HCO3 32PaO2 80-100 PaO2 86

The abnormal ABG finding indicates your patient is retaining CO2.What we don’t know just from the ABG result is if your patientis compensating or uncompensated. A complete history needs tobe obtained.

(Perry & Potter, 2006)

Pathophysiology COPD

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 O2 and CO2 exchange.

Poor exchange of O2 and CO2 causes

shortness of breath.


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).


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

O2 and CO2 Exchange

Used with permission: http://www.pbs.org/wgbh/nova/everest/exposure/body.html


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

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


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 QuizLet’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 CO2 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!

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COPD- Signs and SymptomsReview…

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 coughIncreased sputum production (to yellow/green)

(Bellamy, D. 2006)

What triggers a COPD Exacerbation?

INFECTION

AIR POLLUTION

COLD WEATHER

Weakened Immune System

COPD Patients PINK PUFFER: early disease Emphysema

Over ventilate to maintain relatively normal ABG’s until late in disease

Red face

BLUE BLOATER: Chronic Bronchitis 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 CO2 RETAINERS

Labored Breathing

Feeling of Air Hunger

Nausea

Confusion

Dizziness

Headache

Nursing InterventionsNon Pharmaceutical

SMOKING CESSATION

AVOID EXPOSURE TO RESPIRATORY INFECTIONS

ENCOURAGE FLU & PNEUMOCOCCAL VACCINES

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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

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PULMONARY REHABILITATION

PHYSICAL CONDITIONING

SUPPORTIN PATIENT CARE

COMMUNITY CARE

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Nursing InterventionsPharmaceutical

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

CO2 retention (Perry & Potter, 2005)

Nursing InterventionsPharmaceuticalBRONCHODILATORS

Inhaled B2-adrenergic antagonists

Anticholinergic agents- long and short acting

Inhaled corticosteroidsOral corticosteroidsIV corticosteroids

Dangerous side effects:Monitor blood sugarsCan increase heart ratePatients with fungal infections should use with caution


Nursing InterventionsPharmaceutical- In patient careGIVING SOLUMEDROL: Methylprednisolone Sodium

Succinate

INDICATION FOR COPD:

Inflammation

DOSING:

40mg-125mg q 6-8 hours IV

NURSING CONSIDERATION:

Give IV slow, over one minute

Don’t discontinue abruptly

Monitor for fungal infection

Monitor blood glucose


Nursing InterventionsPharmacologic

ANTIBIOTICSCan 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 InterventionsPharmaceutical

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 InterventionIn 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. IV Solumedrol 300mg every 2 hoursB. IV Solumedrol 60 mg every 8 hoursC. IV Solumedrol 2gm every 6 hours for 72 hoursD. IV Solumedrol 3gm every 8 hours for 48 hours

Click here to go to next slide.

Nursing InterventionIn Patient Care

Complete Respiratory AssessmentAssess Co-morbidities

Confirm allergiesReview medications

Monitor lab values: CBC, ABG’s, LytesCollaborate with physician

Educate patient and familyAdminister IV medications as ordered

EVALUATE RESPONSE TO TREATMENT

Case Study Mr. Sigh A. NosisMr. 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. TisMrs.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 American Lung Association. (2006). Chronic obstructive pulmonary

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., p1858.

Bay Area Medical Information. (2006). Overview of the respiratory system. Retrieved March 7, 2007 from http://www.bami.us/Resp/COPD2.html.

Bellamy, D., (2006). COPD exacerbations. Practice Nurse (32)6., p35-42. Retrieved February 15, 2007 from http://web.ebscohost.com/ehost/delivery?vid=4&hid=7&sid=cef94c21-be5a-4615-a3a7-33.

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

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 (3rd ed.). St Louis, MO: Mosby.

Nova. How the body uses O2. 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. (7th ed. ). Philadelphia: Lippincott, Williams & Wilkins.

Perry, A.G., & Potter, P. A., (2006). Clinical nursing skills and techniques. (6th 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:

American Lung Association website. Retrieved March 22, 2007 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 ChristineDavid(s) Elizabeth Paula Georgia KimNicholas Vicki Patti

DebbieMom Kathy(s) Susanne LindaRandyMarcia Jeanine Pat

Kris

COPD It Takes Your Breath Away Patti J. Pagel, RN, BSN Alverno College MSN Program April, 2007 [email protected].

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