COPD and Asthma Management: Chapter 20

Chapter 20: Management of Patients with Chronic Pulmonary Disease

• The chapter focuses on managing patients with chronic pulmonary diseases, particularly asthma and COPD

Chapter Objectives

• To identify the clinical manifestations of asthma
• To describe the interprofessional & nursing management of the pt. with asthma
• To identify the clinical manifestations, interprofessional, & nursing management of chronic obstructive pulmonary disease (COPD)
• To relate the indications for O2 therapy, methods of delivery, & complications of O2 administration
• Explain the nursing management of pt. with COPD

Chronic Obstructive Lung Disease (COPD)

• COPD stands for Chronic Obstructive Pulmonary Disease
• COPD is a preventable, treatable, progressive disease with persistent airflow limitation
• COPD is a progressive lung disease that makes it hard to breathe
• COPD is characterized by airflow limitation and includes emphysema and chronic bronchitis.
• COPD is a long-term condition that worsens over time and isn't fully reversible
• COPD is a major cause of chronic morbidity and mortality throughout the world
• Many people suffer from COPD for years and die prematurely from it or its complications.
• Risk factors include smoking, chronic respiratory infections, environmental exposures, asthma, aging, and genetics
• COPD is distinct from chronic bronchitis or emphysema, though they may share features
• COPD involves abnormalities in airflow limitation, air trapping, and gas exchange
• Severe COPD can lead to pulmonary hypertension and related issues
• COPD classifications include:
• Gold 1 Mild
• Gold 2 Moderate
• Gold 3 Severe
• Gold 4 Very Severe

COPD Clinical Manifestations

• Manifestations include chronic cough, dyspnea, and sputum production
• Chronic cough is a common symptom
• Sputum production is a common symptom
• Dyspnea (shortness of breath) is a common symptom
• Prolonged expiratory phase, decreased breath sounds, and wheezing are common
• Wheezing is a common symptom
• Chest tightness is a common symptom
• Dyspnea worsens with exertion and progresses even at rest in advanced disease
• Accessory and intercostal muscles usage indicate inefficient breathing
• Wheezing, chest tightness/heaviness, and air hunger are typical
• Weight loss and anorexia
• Physical signs: barrel chest, tripod position, and pursed-lip breathing are seen
• Chronic fatigue
• Frequent respiratory infections can be a symptom
• Peripheral edema (ankles) may occur due to right-sided heart failure
• Hypoxemia and hypercapnia are common
• High hemoglobin levels related to polycythemia, bluish-red skin, and fingernail clubbing

Diagnostic Studies for COPD

• Diagnosis includes:
• History and physical exam
• Spirometry (FEV1/FVC ratio < 70%)
• Spirometry is used to assess lung function
• Post-bronchodilator FEV1/FVC < 0.70 confirms airflow limitation
• Chest x-ray
• Chest X-rays can help rule out other conditions
• Serum alpha1-antitrypsin levels
• 6-minute walk test
• SpO2 <88% at rest to qualify for supplemental O2
• COPD Assessment Test (CAT) OR Clinical COPD Questionnaire (CCQ)
• ABGs Sputum culture & sensitivity
• Arterial blood gas analysis assesses oxygen and carbon dioxide levels

COPD Complications

• Possible complications include:
• Respiratory infections, such as pneumonia and bronchitis, are common complications
• Respiratory insufficiency and Acute respiratory failure (ARF)
• Pulmonary hypertension
• Heart problems, including heart failure and pulmonary hypertension, can occur
• Cor pulmonale (right-sided heart failure)
• Lung cancer risk is increased
• Acute exacerbations, indicated by increased dyspnea, sputum volume, and sputum purulence
• Depression and anxiety can affect quality of life.
• Other symptoms of complications include malaise, insomnia, fatigue, depression, confusion, reduced exercise tolerance, wheezing, and fever

COPD Interprofessional Care

• Hospitalization may be required for complications
• Care includes evaluating exposure to environmental or occupational irritants
• Interventions include:
• Vaccines (annual influenza and pneumococcal vaccines)
• Smoking cessation
• Supplemental oxygen therapy
• Surgical therapy (for select patients)
• Pulmonary rehabilitation

COPD Oxygen Treatment

• Maintain O2 saturation > 90% during rest, sleep, and exertion
• Individualized treatment improves survival
• Humidification & Nebulization is used as O2 has a drying effect on the mucosa
• Use sterile distilled water and supply bubble-through humidifiers

Oxygen Therapy Complications

• Complications of oxygen therapy include:
• Combustion (avoid smoking or open flames)
• CO2 narcosis (hypoxic drive; administer O2 carefully)
• O2 toxicity (severe inflammation with prolonged high O2)
• Infection from humidity supporting bacterial growth (Pseudomonas aeruginosa)
• Disposable equipment is recommended

Medications to Treat COPD

• Medications used to treat COPD include:
• Bronchodilators help relax airway muscles, making breathing easier
• Bronchodilators (MDIs, beta-adrenergic agonists, muscarinic antagonists/anticholinergics, and combination agents)
• Inhaled corticosteroids reduce inflammation in the airways
• Combination inhalers contain both bronchodilators and corticosteroids
• Other medications:
• Corticosteroids
• Antibiotics
• Mucolytics
• Antitussives

Interprofessional Care for COPD

• Respiratory care includes:
• Breathing retraining (pursed lip breathing which prolongs expiration to bronchial collapse & air trapping)
• Pursed-lip breathing can help control shortness of breath
• Diaphragmatic (abd) breathing to achieve maximum inhalation & slow respiratory rate, using the diaphragm instead of accessory muscles and airway clearance techniques
• Effective coughing or huff coughing conserves energy, reduces fatigue, and facilitates removal of secretions
• Chest physiotherapy involves percussion, vibration, and postural drainage
• Airway clearance devices include positive expiratory pressure (PEP) devices like Flutter, acapella, and theraPEP

Nutrition for COPD Patients

• Malnutrition in COPD is multifactorial:
• Increased inflammatory mediators and metabolic rate
• Lack of appetite
• Indicates a poor prognosis at advanced stages
• Interventions include:
• Reducing dyspnea and conserving energy
• Providing a high-protein, moderate-carb, and moderate-fat diet
• Encouraging 5-6 small meals to avoid bloating and early satiety
• Avoiding foods difficult to chew and gas-forming foods
• Using bronchodilators before meals

Acute Exacerbations of COPD

Hospitalization is required for acute exacerbations or complications

• Monitor underlying respiratory problem and assess ABGs
• Treatments include steroids and Bi-PAP
• COPD exacerbations are acute worsenings of respiratory symptoms
• Increased dyspnea, cough, and sputum production are common
• Exacerbations may be triggered by infections or environmental factors
• Treatment includes increased bronchodilator use.
• Corticosteroids may be prescribed
• Antibiotics may be necessary for bacterial infections
• Severe exacerbations may require hospitalization
• Interprofessional care for includes pulmonary rehabilitation, exercise training, smoking cessation, nutrition counseling, & education, and modifying ADLs to conserve energy
• Exercise focuses on training upper extremities to conserve energy, improve muscle function, and reduce dyspnea
• Walking 15-20 mins./day at least 3Xs a week
• Psychosocial considerations include feelings of denial, anger, frustration, loneliness, & guilt, depression, anxiety, and sexual activity
• Encourage slow, pursed-lip breathing, refrain from eating/drinking, and use less stressful positions, O2 if prescribed
• Sleep using O2, and assess for sleep apnea

Asthma

• Asthma is characterized by bronchial hyperreactivity with reversible expiratory airflow limitation, either spontaneously or with treatment, causing cough, chest tightness, wheezing, and dyspnea.
• Clinical manifestations of asthma are unpredictable and variable
• Wheezing occurs initially during expiration, progressing to both inspiration and expiration which may not reliably indicate attack severity
• Silent breathers are life threatening
• Other symptoms include cough, dyspnea, chest tightness, tachycardia, and diaphoresis
• Air is hard to get out so one has to hyperventilate
• Sputum is generally thick, gelatinous & difficult to cough up
• Signs of hypoxemia: Anxiety, restlessness, increased pulse & increased B/P
• Use of accessory muscles and difficulty speaking in complete sentences may occur
• Asthma is classified as intermittent, mild persistent, moderate persistent, or severe persistent

Asthma - Complications and Status Asthmaticus

• Asthma attacks are variable and unpredictable
• Complications may include pneumonia, tension pneumothorax, acute respiratory failure (ARF), or status asthmaticus
• Status asthmaticus is an extreme acute attack with life-threatening hypoxia, hypercapnia, & ARF, chest tightness, severely marked SOB, sudden inability to speak, with bronchodilators & corticosteroids not effective The severity of asthma may classified as mild or life-threatening

Diagnostic Tests for Asthma

• Diagnostic tests for asthma include:
• History & physical exam- allergens
• Pulmonary function tests
• Peak Expiratory Flow Rate (PEFR) to predict attack and monitor severity of disease
• Spirometry (lung volumes & capacities)
• Chest x-ray (shows hyperinflation during exacerbation)
• Pulse oximetry & ABG's
• Allergy skin testing, sputum culture & sensitivity
• Blood levels of eosinophils & IgE

Interprofessional Care for Asthma

• The goal of treatment is to achieve and maintain control of asthma
• Medication guidelines are based on steps Symptoms dictate changes in medication
• Level of control determined by pt.'s medication use, symptoms, PEFR or FEV1
• Interprofessional Care-
• Mild to moderate attacks include no more than 2x/week symptoms
• Symptoms also include minimal interference in ADLs, Alert, oriented, speaks in sentences, some cheat tightness & dyspnea, ↑ use of asthma meds
• Interventions: O2 saturation > 90% on room air, PEFR > 50% predicted or personal best

Severe Asthma Attacks

• Symptoms of include:
• Alert & oriented but focused on breathing
• Frightened; agitated if hypoxemic
• Tachycardia, tachypnea (>30 breaths/min)
• Accessory muscle use; sits forward
• Wheezing
• PEFR < 50% predicted or personal best
• Recurring symptoms interfere w/ ADLs
• Treament involves:
• ED → hospital admission
• Supplemental O2 & oximetry
• Monitor PEFR, ABGs, VS
• Bronchodilators & oral corticosteroids
• Silent chest—immediately notify HCP

Asthma Drug Therapy

• Quick relief or rescue medications treat acute attacks
• Administer:
• Bronchodilators (inhalers!)- short-acting inhaled beta2 adrenergic agonists (albuterol onset minutes lasts 4 to 8 hrs.) , with caution w/cardiac disorders as it rises BP & HR, dysrhythmias
• Antiinflammatory drugs- IV corticosteroids

Asthma Long-term control medications

• Long-term control medications achieve & maintain control Administer Bronchodilators- long acting inhaled or oral beta2 (salmeterol, formoterol used Q 12hrs.) AntiInflammatory drugs- oral or inhaled corticosteroids, leukotriene modifiers, anti-IgE, Methylxanthines-
• Caution is needed as toxicity includes N&V, seizures, insomnia
• Administer Anticholinergics for COPD and Corticosteroids- oral 1-2 wks. maximum, inhaled- ↓ bone density
• Side effects from asthma medication can cause Oral candidiasis, hoarseness, & dry cough, gargle after each use
• Caution to use because of potentially dangerous side effects

Inhalation Devices for Asthma

• Metered dose inhalers (MDI):
• Small, hand-held, pressurized devices to delivery dose with activation; 1 to 2 puffs
• Can be used with spacer or holding chamber
• Dry powdered inhaler (DPI): Powdered medication; breath activated
• Nebulizers: Machine converts drug solutions into fine mist for inhalation via face mask or mouthpiece, easy to us

Patient Education for Asthma

• Education includes:
• Correct use of medication
• Avoid using epinephrine/ephedrine
• Avoid triggers & irritants (cigarette smoking, pet dander, cold air, aspirin, etc.)
• Avoiding lung irritants such as smoke and pollution can help prevent flare-ups
• Prompt treatment of upper respiratory infections & sinusitis
• Fluid intake of 2-3 L every day
• Staying hydrated helps thin mucus
• Good nutrition
• Uninterrupted sleep/adequate rest, and asthma support groups Asthma Action Plan

Asthma Action Plan

• Green zone = doing well, can do usual activities, peak flow =
• Yellow = worsening, symptomatic, can do some activities, peak flow = 50-79% of personal best
• Red zone = medical alert, symptomatic & meds not helping, peak flow = 50% or less, call ambulance or get to hospital asap

Acute Care for Asthma

• Monitor respiratory & cardiovascular systems, especially:
• Pulmonary function tests
• Heart rate & rhythm
• Peak Expiratory Flow Rate (PEFR) to predict attack and monitor severity of disease Give drugs as ordered and decrease pt's anxiety & sense of panic Position comfortably (semi to high-Fowler's) and stay with pt Allow rest when attack subsides

Causes and Risk Factors for COPD

• Smoking is the leading cause
• Long-term exposure to irritants such as air pollution, chemical fumes, or dusts can be a cause
• Genetic factors such as alpha-1 antitrypsin deficiency
• Alpha-1 antitrypsin deficiency is a genetic condition that can cause early-onset emphysema
• Testing is recommended for individuals with COPD diagnosed at a young age
• Augmentation therapy can help protect the lungs
• Age is a risk factor
• Respiratory infections during childhood may increase the risk

Stages of COPD

• GOLD 1: Mild; FEV1 ≥ 80% predicted
• GOLD 2: Moderate; 50% ≤ FEV1 < 80% predicted
• GOLD 3: Severe; 30% ≤ FEV1 < 50% predicted
• GOLD 4: Very Severe; FEV1 < 30% predicted
• GOLD staging helps guide treatment decisions
• FEV1 refers to Forced Expiratory Volume in 1 second

Management of COPD

• Smoking cessation is crucial
• Regular exercise improves lung function and overall health
• A healthy diet provides essential nutrients for energy and healing
• Managing stress through relaxation techniques can improve quality of life
• Proper use of inhalers and other medications is essential
• Regular monitoring by a healthcare provider is important
• Create a support network of family, friends, and healthcare professionals
• Join a support group to connect with others
• Learn about it and how to manage it effectively
• Plan ahead for travel and other activities
• Monitor symptoms and seek medical attention when needed
• Maintain a positive attitude and focus on what you can do
• Use assistive devices if needed

Prevention of COPD

• Never start smoking
• Quit smoking to reduce the risk
• Avoid exposure to secondhand smoke
• Minimize exposure to air pollution and other lung irritants
• Get vaccinated against influenza and pneumonia

Research on COPD

• Ongoing research aims to improve treatments and outcomes
• Clinical trials are testing new medications and therapies
• Studies are investigating the genetic and environmental factors
• Research is focused on developing strategies to prevent it and slow its progression

Pulmonary Rehabilitation

• Pulmonary rehabilitation is a comprehensive intervention tailored to individual patient needs
• It includes exercise training, education, and behavior change
• It is designed to improve the physical and psychological condition of people with chronic respiratory disease

End-Stage COPD

• End-stage COPD involves severe airflow limitation, frequent exacerbations, and significant impairment in quality of life
• Palliative care focuses on symptom management and comfort
• Hospice care provides support for patients and their families

Impact of COPD

• COPD is a leading cause of disability and death worldwide
• It places a significant burden on healthcare systems
• It affects millions of people worldwide

COPD and Asthma Overlap (ACOS)

• ACOS is a condition characterized by features of both COPD and asthma
• Patients with ACOS may have more frequent exacerbations and a faster decline in lung function
• Treatment strategies may differ from those used for COPD or asthma alone

This chapter discusses the management of patients with chronic pulmonary diseases, focusing on asthma and COPD. It covers clinical manifestations, interprofessional management, and nursing care. Key areas include risk factors, oxygen therapy, and complications of oxygen administration.