COPD: ABG, Symptoms & Treatment

Chronic Obstructive Pulmonary Disease (COPD)

• COPD is associated with ABGs, signs and symptoms, and treatments for shortness of breath

ABG

• Respiratory acidosis occurs in COPD
• Impaired CO2 elimination results in hypercapnia
• Hypercapnia results in respiratory acidosis

Signs & Symptoms

• COPD is slowly progressive, worsening over time
• Characterized by dyspnea upon exertion; chronic cough; and sputum
• Other signs and symptoms include weight loss, barrel chest (emphysema), use of accessory muscles, respiratory insufficiency and infections, and polycythemia (increased RBCs)

Treatment for Shortness of Breath

• Treatments include oxygen, breathing retraining, bronchodilators, vasodilators, nebulizer treatments and CPAP ventilator (last resort)
• Breathing retraining involves pursed lip and diaphragmatic breathing, and medicine nebulizer treatments
• CPAP ventilator keeps the airway open
• Proper administration of bronchodilators and corticosteroids is important

Patient education

• Important education includes disease process, smoking cessation, breathing exercises, and prevention of infections

Education

• Smoking cessation includes strong warnings about smoking and setting a definite "quit date"
• Breathing exercises include pursed lip and diaphragmatic breathing
• Prevention of infections includes hand washing and avoidance of irritants
• Focus on regular exercise, realistic goals, emergency management, and medication administration
• Oxygen administration at home if needed

Metered Dose Inhaler (MDI) Usage Instructions

• Shake the inhaler before use
• Sit or stand upright
• Breathe out slowly all the way
• Actuate MDI and breathe in slowly through the mouth
• Hold the breath for 10 seconds
• Repeat as directed, waiting 1 minute in between
• Rinse mouth with water after inhalation and clean MDI mouthpiece daily

Complications

• COPD complications include respiratory insufficiency and failure, pneumonia, chronic atelectasis, pneumothorax, and cor pulmonale

Respiratory Insufficiency & Failure

• Respiratory insufficiency and failure is major and life-threatening
• It may be acute or chronic

Pneumonia

• Worsening symptoms indicate pneumonia
• Symptoms include chest tightness, increased dyspnea, and fatigue
• Immunizations for influenza and pneumococcal pneumonia are needed

Chronic Atelectasis

• Complete or partial collapse of the entire lung or lobe can occur
• Alveoli become deflated or filled with fluid
• Increases risk of respiratory failure

Pneumothorax

• Air leaks into the chest wall, causing the lung to collapse
• Can be life-threatening
• Patients with severe emphysema may develop a bullae that ruptures to cause pneumothorax
• Development may be spontaneous or related to activity, such as coughing
• Rapid onset of shortness of breath
• Nurse should immediately assess symmetry of chest movement, differences in breath sounds, and pulse oximetry

Cor Pulmonale

• Right-sided heart failure is caused by long-term high blood pressure in the pulmonary arteries
• Blood backs up from pulmonary arteries and the right ventricle into the venous system
• Causes edema, distended neck veins, and pain in the liver

Alpha 1 Antitrypsin Deficiency

• Alpha 1-antitrypsin (A1AT) is produced in the liver and protects the lungs from neutrophil elastase

• A1AT protects the lung parenchyma from injury

• A1AT deficiency may lead to lung and liver disease

• A1AT deficiency is more common in European descent

• A1AT deficiency can lead to rapid development of lobular emphysema without smoking

• Genetically susceptible patients are sensitive to environmental factors such as smoking, air pollution, infectious agents, and allergens, and eventually develop COPD symptoms

• Treatment involves alpha-protease inhibitor replacement therapy, slows the progression of the disease, is only available for those with severe disease, and is costly, requiring ongoing basis

Hypoxia

• Signs and symptoms of hypoxia include low O2, tachycardia, tachypnea, clubbing of nails (chronic), fatigue, drowsiness, apathy (lack of interest), inattentiveness, and delayed reaction time

Breathing Techniques

• General breathing techniques include breathing slowly, exhaling completely, inhaling through the nose, and keeping air moist with a humidifier

Diaphragmatic Breathing

• Diaphragmatic breathing goals are to strengthen the diaphragm
• Place one hand on the abdomen and the other on the middle of the chest
• Breathe and allow the abdomen to protrude as far as possible
• Breathe out through pursed lips and contract abdominal muscles
• Repeat for 1 minute, rest for 2 minutes, and gradually increase up to 5 minutes, several times a day

Pursed Lip Breathing

• Pursed lip breathing goals are to reduce trapped air and airway resistance
• Inhale and count to 3
• Exhale slowly while tightening abdominal muscles and counting to 7
• When walking, inhale while walking 2 steps and exhale while talking 4-5 steps

Pathophysiology; Effects of Smoking

• Airflow limitation is progressive and associated with an abnormal inflammatory response to noxious particles or gasses

• Chronic inflammation damages tissues causing thickened airway walls

• Scar tissue in airways results in narrowing and decreased elastic recoil (compliance)

• Scar tissue causes thickened vessel lining and hypertrophy of smooth muscle (pulmonary hypertension)

• The body tries to self-repair, which increases the number of goblet cells and hypersecretion of mucus

• Smoking causes permanent lung damage while reducing the protective mechanisms, increasing the risk for lung cancer

• Smoking suppresses activity of scavenger cells and damages cilia

• Airflow is obstructed, and air becomes trapped

• Alveoli distend, reducing lung capacity

• Goblet cells and mucous glands become irritated

• Leads to more mucus, irritation, infections, and damage to lungs

• Carbon monoxide from smoking combines with hemoglobin to form carboxyhemoglobin

• Carboxyhemoglobin cannot carry oxygen efficiently

Risk factors

• Exposure to tobacco smoke causes 80-90% of COPD cases
• Passive smoking, increased age, occupational exposure (dust, chemicals), and air pollution are risk factors
• Genetic abnormalities: Alpha 1-antitrypsin deficiency: Enzyme inhibitor that counteracts the destruction of lung tissue, higher risk for European descent. Treatment: Alpha protease inhibitor replacement therapy

Benefits of Smoking Cessation

• Smoking cessation is the single most important therapeutic intervention for patients with COPD
• Smoking cessation improves pulmonary function and reduces dyspnea, cough, COPD exacerbations, and mortality
• Carbon monoxide levels return to normal in 1 year
• After 10 years, the risk of dying from lung cancer is about ½ that of a smoker
• After 5-15 years, the risk of stroke is the same as a non-smoker
• After 15 years, the risk of coronary heart disease is the same as a non-smoker

Two Types of COPD

• Chronic bronchitis and emphysema are the two types of COPD

Chronic Bronchitis

• Cough and sputum production for >3 months and 2 consecutive years
• Reduced ciliary function
• Thick bronchial walls become clogged with mucus and narrowed
• Increased mucus production due to irritants
• Alveoli become damaged and hardened/fibrous, with decreased alveolar macrophage function
• Increased risk for respiratory infections

Emphysema

• Gradual damage of the alveoli (tiny air sacs) develops over time
• Impairs O2 + CO2 exchange, leading to CO2 retention
• Overdistended alveoli
• Decreased recoil of the alveoli
• Increased dead space prevents gas exchange, causing Hypoxia
• CO2 elimination is impaired, resulting in hypercapnia and respiratory acidosis
• Dilated sacs trap air, increasing resistance to blood flow in lungs
• Hypoxemia causes pulmonary hypertension
• Pulmonary alveolar proteinosis (PAP) occurs where air sacs (alveoli) fill with protein, which makes breathing difficult and may cause right-sided heart failure(Cor Pulmonale)
• Hyperinflation and loss of lung elasticity lead to barrel chest

Two Types of Emphysema

• Panlobular (Panacinar) and Centrilobular (Centroacinar) are two types of Emphysema

Panlobular (Panacinar)

• Destruction of the respiratory bronchiole, alveolar duct, and alveolus
• All air spaces within the lobule are enlarged
• Signs and symptoms include hyperexpanded chest, dyspnea on exertion, and weight loss
• Exhaling is NOT passive, requiring muscular effort to move air out of lungs

Centrilobular (Centroacinar)

• Changes occur in the center of the secondary lobule only
• Signs and symptoms include chronic hypoxemia, hypercapnia, polycythemia, and episodes of right-sided heart failure, which leads to central cyanosis, resp failure, and peripheral edema

Acid/Base Balance

• Important to know how to interpret ABGs, know the effect of compensation, and be aware of what situations can cause each

How to Interpret ABGs

• Step 1: Is the pH normal?
• Step 2: Is the CO2 normal?
• Step 3: Is the HCO3 normal?
• Step 4: Match the CO2 or HCO3 with the pH
• Step 5: Does the CO2 or HCO3 go in the opposite direction?
• Step 6: Are the PO2 and O2 Sat normal?

Types of Imbalances

• The types of imbalances include respiratory acidosis, respiratory alkalosis, metabolic acidosis, and metabolic alkalosis

Respiratory Acidosis

• Occurs with hypoventilation (retain CO2)
• Caused by overdose of narcotics, COPD, and neuromuscular disorders
• Usually indicated by signs of respiratory insufficiency (SOB or Cyanosis)

Respiratory Alkalosis

• Occurs with hyperventilation (Blow off too much CO2)
• Caused by fear/pain
• Administer pain medications
• Large tidal volume & increased respiratory rate
• Bowel obstruction
• Administer stool softener

Metabolic Acidosis

• Occurs when body gains acid or loses base

• Decreasing HCO3 26

• Causes

• NG Suction/ Vomiting & Overuse of antacids

• Symptoms

• Mental confusion, Apathy, & Weakness

Lungs and kidneys play roles in acid/base balance

• Lungs control arterial CO2 concentrations through changes in depth and/or respiration rate
• Kidneys control serum bicarbonate (HCO3) through the excretion of reabsorption of filtered HCO3 and secrete H+ ions

Osteoarthritis (OA)

• Most modifiable risk factor for OA is obesity
• Diet and exercise can help minimize symptoms of OA
• Other risk factors for OA include older age, female gender, obesity, certain occupations (those requiring laborious tasks such as farming), sport activities, history of previous injuries, muscle weakness, genetic predisposition, and certain diseases
• Noninflammatory degenerative disorder of the joints
• Most common form of joint disease, sometimes called degenerative joint disease
• Articular cartilage breaks down, causing friction between bones
• Starts in 30s

Classified as OA

• Primary (idiopathic), which is not related to a prior event or disease
• It does not involve autoimmunity or inflammation but can occur as an end result of an autoimmune disorder where joint destruction occurs
• Secondary results from a previous joint injury or inflammatory disease, similar to RA
• Limited to the affected joints, with no systemic symptoms

Clinical Manifestations of OA

• Pain (worse at night), stiffness, pain aggravated by movement, relieved by rest, morning stiffness lasting usually less than 30 minutes
• Joint may be enlarged and most often occurs in weight-bearing joints

Management of OA

• Decrease pain and stiffness
• Treatment options include aerobic exercise
• Weight loss
• OT and PT (occupational therapy and physical therapy)
• Medications via mediterranean diet which includes Fish, nuts, fruits, veggies, beans, whole grains, and olive oil

Topical Medications for OA

• Analgesics: Capsaicin, Methylsalicylate & Diclofenac sodium
• How to apply:
• Apply sparingly , avoid areas of open skin, and avoid contact with eyes and mucous membranes
• The skin should be washed after application, and assess the skin for irritation

Oral Medications for OA

• These treat pain
• Initial analgesic is Acetaminophen, NSAIDs, and Cox-2, (Cardiac side effects) and Nonopioids - tramadol
• Methotrexate & colchicine:
• Treatment for RA but may be prescribed to OA pt Viscosupplementation: Injection of gel in joints

Patient Education

• Include the OA disease process
• Also pain management
• Also Joint protection through the Use of abduction pillow while avoiding dislocation
• NEVER turn to surgical side, cross legs, or bend hips at 90 degrees
• Focus on self-care with assistive devices and relaxation - promoting sleep
• Also recommend exercise

Other Recommendations

• Weight loss
• Increase in aerobic activity: strategies for remaining active
• Improving body image

Rheumatoid Arthritis (RA)

• RA is an Inflammatory degenerative disorder
• Involves autoimmunity & has systemic effects which can occur at any given time
• Pain is symmetric joints on both sides of body with unpredictable progression

Osteoarthritis (OA)

• OA is a Noninflammatory degenerative disorder that does Not involve autoimmunity
• Bone grates against bone & can be caused by wear and tear
• Tends to be one-sided on body with predictable progression
• Pain improves with rest and is at its worst at night

Medications To Treat/Side Effects Of Osteoarthritis

• Before starting meds test Liver & kidney function, also testing for Tuberculin, Hep B & Hep C
• NSAIDs are part of the Salicylates and should be taken with food For pain and inflammation
• COX-1 Causes GI ulcers and irritation
• COX-2 Causes cardiac issues
• Corticosteroids Not used for long term use, never stop abruptly & Elevate blood sugar

DMARDs

• Modifying Anti-rheumatic Drugs, is the First Choice
• Take within 3 months of diagnosis & reduce joint destruction
• Major I NON BIOLOGIC (Conventional) Target entire immune system *& Give with NSAIDs or corticosteroids Take a while to start working Methotrexate (Immunomodulator)
• Major II BIOLOGIC*
• Target specific steps in the immune process Work quickly Show greater delay in disease progression & For patients who have not responded to Major I drugs
• Monitor liver enzymes and kidney function labs before and after administering
• -Janus Kinase (JAK)* Inhibits cytokine production & Bind to JAK enzyme sites Used in combination with nonbiologic agents or as monotherapy Prevent inflammation before starting

Diagnostics

• Diagnostics tests include X-RAY,Arthrography, MRI & CT

• Rheumatoid factor is considered Not diagnostic

• +ANA: Antinuclear Antibody

• Elevated ESR & CRP Indicates inflammation

• +ACPA: Anti-Citrullinated Peptide Antibody

• CBC, Liver and Kidney Function test

• Synovial fluid

Systemic Lupus Erythematosus (SLE)

• Signs & Symptoms with Butterfly rash as well as Fever & Weight loss, Fatigue &Anemia & Hypertension Indicates renal involvement
• Also indicates Lymph node enlargement, Raynaud’s phenomenon & Sjogren’s, Rheumatoid nodules Small painless lumps under skin and Others like, arteritis, neuropathy, pericarditis, & splenomegaly

Osteoporosis (OP)

• Education Discuss the processes of treating constipation Due to decreased mobility & also medication concerns Preventing injuries and managing pain Exercise is key Intake and monitoring

Complications

• Fracture &deformities, and depression, There can be: limited mobility,,Disability, Hunched posture, Reduction in height and back pain

Medications

• Calcium supplements with 1,000 mgs daily for Men and Women

• Vitamin D -400-1000 IU daily

• Bisphosphonates: Slow bone reabsorption,

• Alendronate, Risedronate, Ibandronate, and Zoledronic acid, that should be taken first ,in the morning, taken on an empty stomach with a full glass of water

• Also - Calcitonin that inhibits bone resorption .

• It also can be and Estrogen agonist/antagonist, knowns as, SERMs that have side effects, that can induce Vaginal dryness, along with, hot flashes

• Receptors, is a receptor activator of nuclear factor Kappa-b inhibitors, that Regulates osteoclast formation, that has Side Effects of causing Muscle pain in arms and legs

Prevention

• Focus includes the use of supplements to ensure adequate calcium intake
• Take supplements in divided doses with Vitamin C and Weight training stimulates bone mineral density

Risk Factors

Nutritional deficiencies, or a carbonated Beverage heavy diet, Lack of sunlight exposure and alcohol use all contribute to Risk Factors for conditions Genetic predispositions, Low testosterone and High calcium intake can contribute to different disorders