Transcript COPD

Interferences with Ventilation
Objectives
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Describe causes, pathophysiology, clinical
manifestations, therapeutic interventions, & nursing
management of patients with restrictive & obstructive
pulmonary disease of the upper and lower airway
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Sleep apnea, asthma in child & adult, emphysema, chronic
bronchitis, COPD
Describe the nursing process for patients who
experiences accidental interferences to ventilation
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Chest trauma
Interferences with Ventilation
Restrictive / Obstructive
Airway Disease
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Restrictive Disorders:
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Decreased compliance of the lungs or chest wall or
both
Extrapulmonary – CNS, Neuromuscular, Chest Wall
 Intrapulmonary – Pleural, Parenchymal
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Obstructive Disorders:
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Increased resistance to airflow
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Asthma, Emphysema, Chronic Bronchitis, COPD
Obstructive Sleep Apnea
(OSA)
Obstructive Sleep Apnea (OSA)
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Clinical Manifestations: insomnia, daytime sleepiness;
witnessed apneic episodes; snoring; morning
headaches; impaired concentration & memory
Dx: Polysomnography (sleep study) – multiple
episodes of apnea or hypopnea (airflow diminished 3050% with respiratory effort)
TX: Avoid sedatives & alcohol 2-4 hrs prior to sleep;
compliance with nCPAP / BiPAP
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nCPAP – continuous + airway pressure + 5-15 cm H2O pressure
BiPAP – bilevel + airway pressure – delivers higher pressure
during inspiration & lower pressure during expiration
Surgery
Pathophysiology of
Chronic Airflow Limitation
Interferences with Ventilation
Asthma
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Chronic inflammatory disorder of the airways
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Causes varying degrees of obstruction in the
airways
Recurrent episodes of wheezing, breathlessness, chest
tightness, and cough, particularly at night and in early
morning
 Associated with hyperresponsiveness to a variety of
stimuli
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Affects 1 in 20 Americans
10 millions absences per year
5,000 deaths per year
Respiratory System Drugs
Asthma
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Recurrent and reversible shortness of breath
Airways become narrow as a result of:
 Bronchospasm
 Inflammation & Edema of the bronchial mucosa
 Production of viscid mucus
Alveolar ducts/alveoli remain open, but airflow to them is
obstructed
Symptoms
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Wheezing
Difficulty breathing
Interferences with Ventilation
Asthma
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Triggers of Asthma Attacks
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Allergens
Exercise
Respiratory Infections
Nose & sinus problems
Drugs and food additives
Gastroesophageal reflux disease (GERD)
Emotional Stress
Interferences with Ventilation
Asthma - Pathophysiology
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Hallmarks of Asthma:
Airway inflammation & nonspecific
hyperirritability
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Early phase
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Characterized by bronchospasm
Induces inflammatory sequelae of the late phase response
Allergen or irritant cross-links IgE receptors on mast cells beneath
the basement membrane of the bronchial wall
OR
Hyperresponsiveness of the tracheobronchial
tree
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Caused by bronchoconstriction in response to physical,
chemical and pharmacological agents
Early & Late Responses in
Asthma
Classification of Asthma
Severity
Pathophysiology of
Acute Asthma Attack
Stepwise Approach for
Managing Asthma
Interferences with Ventilation
Asthma – Medication
Interferences with Ventilation
Asthma - Medication
Drug Therapy
Asthma & COPD
Drug Therapy – Asthma &
COPD
How to Use Metered-Dose Inhaler
Metered-Dose Inhaler
Pair Share
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When exercising, a client with asthma should be
taught to monitor for which of the following
problems?
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A. Increased peak expiratory flow rates
B. Wheezing from bronchospasm
C. Wheezing from atelectasis
D. Dyspnea from pulmonary hypertension
What would the nurse recommend to prevent future
episodes of this problem?
Pair Share
A client who has been newly diagnosed with asthma
is admitted to the acute care unit for evaluation.
The nurse provides the client with an Albuterol
(Proventil, Ventolin) metered-dose inhaler. The
nurse will plan to monitor the client very closely for
which of the following side effects of Albuterol?
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A. Tachycardia and nervousness
B. Nasal congestion and dry mouth
C. Sedation and lethargy
D. Joint pain and unstable gait
Status Asthmaticus
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Severe, life-threatening asthma attack
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Refractory to the usual treatment
“The longer it lasts, the worse it gets, and the
worse it gets, the longer it lasts”
Causes: viral illnesses, ASA or NSAID ingestion,
allergen exposure, abrupt discontinuation of
therapy, B-adrenergic blocker ingestion, poorly
controlled asthma
Results: increased airway resistance – edema,
mucous plugging, bronchospasm
Status Asthmaticus
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Clinical Manifestations:
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Wheezing, forced exhalation, neck vein
distention, HTN, sinus tachycardia, ventricular
dysrhythmias
Initial hypoxemia & hypocapnia
 Late – hypoxemia & hypercapnia
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Medical Management:
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Medications: Corticosteroids, B2-adrenergic
agonists via MDI, IV Aminophylline
Hydration
Oxygen – Humidified; Intubation/Mechanical
Ventilation 10% of the time
Chronic Obstructive Lung Disease
Chronic Bronchitis
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Presence of chronic productive cough for 3
months in 2 successive years in a patient in
whom other causes of chronic cough have been
excluded
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Frequent respiratory infections
Hx of cigarette smoking for many years
Hypoxemia & Hypercapnia result from
hypoventilation
Bluish-red color of skin
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Polycythemia – body’s attempt to compensate for chronic
hypoxemia by increasing production of red blood cells
Chronic Obstructive Lung
Disease
Chronic Bronchitis
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A client with chronic bronchitis often
shows signs of hypoxia. The nurrse would
observe for which of the following clinical
manifestations of this problem?
A. Increased capillary refill
B. Clubbing of fingers
C. Pink mucous membranes
D. Overall pale appearance
Chronic Obstructive Lung
Disease
Chronic Bronchitis
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In chronic bronchitis, impaired gas exchange occurs as a
result of which of the following?
A. Chronic inflammation, thin secretions, and chronic
infection
B. Respiratory alkalosis, decreased PaCO2, and increased
PaO2
C. Chronic inflammation and decreased surfactant in the
alveoli and atelectasis
D. Thickening of the bronchial walls, large amounts of thick
secretions, and repeated infections
Chronic Obstructive Lung Disease
Emphysema
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Abnormal permanent enlargement of the
airspaces distal to the terminal bronchioles,
accompanied by destruction of their walls and
without obvious fibrosis
Risk Factors:
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Cigarette Smoking
Irritation - > 4,000 chemicals inhaled
 Hyperplasia – reduces airway diameter
 Abnormal dilatation of distal airspaces
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Destruction of alveolar walls
Chronic Obstructive Lung Disease
Emphysema
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Risk Factors (cont’d):
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Recurring respiratory tract infections
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Heredity – alpha 1 –Antitrypsin (ATT) deficiency
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H. flu, Strep pneumoniae, Moraxella catarrhalis
Accounts for <1% of COPD in US
AAT is a serum protein produced by the liver and normally found in
the lungs
IV or nebulized AAT (Prolastin) slows COPD progression
Aging – Changes in lung structure
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Gradual loss of elastic recoil – thin alveolar wall – thoracic cage
changes from osteoporosis & calcification
Comparison of
Emphysema & Chronic Bronchitis
Alveolar Problem
Airway Problem
COPD
Pulmonary Blebs & Bullae
COPD -- Interaction of
Chronic Bronchitis &
Emphysema
Pathophysiology of Chronic
Bronchitis and Emphysema
Interferences with Ventilation
Medical Management Goals
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Improve ventilation
Promote removal of secretions
Prevent complications & progression
of symptoms
Promote patient comfort &
participation in care
Improve quality of life as much as
possible
Interferences with Ventilation
Medical Treatment
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Patients are treated primarily as
outpatients
Hospitalizations
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Acute exacerbations
Complications
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Respiratory failure, pneumonia, congestive
heart failure
Interferences with Ventilation
COPD
A high-liter flow of oxygen is contraindicated in the client with
COPD because of which of the following?
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A. The client depends often on a hypercapnic drive to
breathe
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B. The client depends on a hypoxic drive to breathe
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C. Receiving too much oxygen over a short time results in a
headache
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D. Response to high doses needed later will be ineffective
Interferences with Ventilation
COPD
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When teaching a client to use aerosol treatments, the
following is the correct sequence for administering
aerosol tx?
A. Steroid should be given immediately after the
bronchodilator
B. Steroid should be given 5 to 10 minutes after the
bronchodilator
C. Bronchodilator should be given immediately after the
steroid
D. Bronchodilator should be given 5 to 10 minutes after the
steroid
Interferences with Ventilation
Medical Management
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Smoking cessation
Treatment of respiratory infections
Bronchodilator therapy
 Beta2-adrenergic agonists
 Anticholinergic agents
 Long-acting theophylline
Corticosteroids
PEFR monitoring (peak expiratory flow rate)
Chest physiotherapy / Breathing exercises & retraining
Hydration 3L/day (unless contraindicated)
Rest - Progressive plan of exercise
Patient & family education
Influenza / Pneumovax immunization
Low flow oxygen rate (if indicated)
Pulmonary rehabilitation program
Interference with Ventilation
Oxygen Therapy
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Indications:
 Treat: Respiratory; CV; CNS disturbances
 Oxygen Administration: High or low flow systems
 High Flow — delivers fixed concentrations independent of
the patient’s respiratory pattern
 Venturi Mask – up to 50%
 Low Flow — amount delivered varies with patient’s
respiratory pattern
 Nasal cannula 2L/min = 28% oxygen
 Face tent or trach collar – Increased humidity
 Non-re-breathing mask – delivers 60-90%
 Humidity:
 1-4L low flow – use of “bubble-through”
controversial
 Nebulized
Interferences with Ventilation
Oxygen Therapy- Complications
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CO2 Narcosis –
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two chemoreceptors – O2 CO2
CO2 accumulation – major stimulus
COPD patient –
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Develops tolerance to high CO2
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Respiratory Center loses sensitivity to elevated CO2
O2 Drive “Hypoxemia”
Concern about administering O2 to COPD patients ??
Bigger Concern: not providing adequate O2
Goal: Titrate O2 to the lowest effective dose
based on arterial blood gas monitoring
Interferences with Ventilation
Oxygen Therapy- Complications
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O2 Toxicity
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Prolonged exposure to high level O2
Determined by patient tolerance, exposure time,
and effective dose
High level Manifestations –
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Initial -- Inactivate surfactant and lead to ARDS :
reduced vital capacity, cough, substernal chest pain, N&V,
paresthesia, nasal stuffiness, sore throat, malaise
Later – affects alveolar-capillary gas exchange:
pulmonary edema with copious sputum
End Stage – lung fibrosis
O2 Administration Goal: enough O2 to maintain
PaO2 within normal or acceptable limit
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O2 administration > 50% for > 24 hours potentially toxic
Chronic Obstructive Lung
Disease Complications
Pair Share
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The nurse should report what unexpected
findings in a client with emphysema?
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A. Decreased breath sounds and dyspnea on
exertion
B. Sputum with gram negative rods an
periods of apnea
C. Vesicular breath sounds and decreased
thoracic expansion
D. Increased anteroposterior chest
measurement
Nursing Care Management
Ineffective airway clearance
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Assess: Normal breath sounds; effective
coughing
Nsg Action: Elevate head of bed; sitting up;
hydration 2-3L/d; chest physiotherapy; Meds:
inhaled bronchodilators
Pt Education: Effective breathing & coughing
techniques; Medications & administration
Chest Percussion
Cupped Hand Technique
Chest Physiotherapy
Postural Drainage
Nursing Care Management
Impaired Gas Exchange
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Assess: Mental status; VS with Pulse oximetry;
ABGs
Nsg Action: Position – Tripod-supported
extremities; Administer O2 to effective level;
Pt Education: Pursed-lip breathing; signs,
symptoms & consequences of hypercapnia;
avoidance of CNS depressants; Medication
action; smoking cessation
Orthopnea Positions to
Decrease the Work of Breathing
Nursing Care Management
Imbalanced Nutrition
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Assess:
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Nsg Action:
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Weight within normal range for height and age;
appetite; caloric intact; energy level; gastric
distention; sputum production; affect; lack of
interest in foods; serum albumin level
Hi PRO, HI Calorie foods & liquid supplements;
small frequent feedings; periods of rest after
food intake; Referral—financial & nutritional
support (Meals-on-wheels; food stamps)
Pt Education:
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Referrals / Importance of rest / digestion / high
protein & calorie foods – menu planning
Nursing Care Management
Disturbed Sleep Pattern
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Assess:
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Nsg Action:
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Identify usual patterns; explore reasons for
discomfort, wakefulness, or difficulty sleeping; sleep
apnea
Identify pt-specific relaxation methods; environment
conducive to rest
Pt Education:
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Balance activity (ADL’s) / rest; avoidance of alcoholic
beverages, caffeine products, & other stimulants
before bedtime; include family; sexual activity—
positions of comfort; psychosocial issues
Nursing Care Management
Risk for Infection
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Assess:
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Nsg Action:
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Change in color, consistency, quantity, odor & viscosity of
sputum; difficulty mobilizing secretions; foul oral odor;
increased dyspnea; fever; chills; diaphoresis; changes in
respiratory rate & quality; breath sounds; hypoxemia;
hypercapnia – VS & pulse oximetry
Humidification; specimen collection; medication administration
Pt Education:
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Hand-washing; avoid contact with infected individuals; care &
cleaning of home respiratory equipment; when to seek medical
attention; steroid use; medication use
Breathing Exercises
Pair Share
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The client with chronic obstructive pulmonary
disease (COPD) has been hospitalized in the
respiratory intensive care unit due to an acute
exacerbation of COPD. The client’s arterial blood
gas analysis of 3 samples earlier in the day are
demonstrating a trending of increasing hypoxemia
and hypercapnia. The nurse will observe the client
closely for a sign which would indicate impending
respiratory failure, which would be
A. increased expectoration of sputum
B. decreased heart rate
C. increased respiratory rate
D. decreased level of consciousness
Chest Trauma
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Blunt Trauma
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Blunt steering wheel injury to chest
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Shoulder harness seat belt injury to chest
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Fractured clavicle, dislocated shoulder, rib fractures, pulmonary contusion,
cardiac contusion, cardiac tamponade
Crush injury to thorax
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Rib fractures, flail chest, pneumothorax, hemopneumothorax, pulmonary
contusion, cardiac tamponade, tear of great vessels
Pneumothorax, hemopneumothorax, great vessel tears and rupture
Penetrating Trauma
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Gunshot wound or stabbing
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Open pneumothorax, tension pneumothorax, hemopneumothorax, tear of
great vessels, damaged trachea, cardiac tamponade, esophageal damage
Chest Trauma
Emergency Treatment
Chest Trauma
Emergency Treatment
Disorders of the Pleura
Chest Tube Placement
Water Seal Drainage