NURS 2055: Nursing Management of Obstructive Pulmonary Diseases

Week 10: NURS 2055: Adult Illness Concepts I

• Focus is chapter 31: Nursing Management of Obstructive Pulmonary Diseases

Obstructive Pulmonary Disease

• Most common pulmonary disease
• Characterized by increased airway resistance due to airway narrowing or obstruction
• Airway obstructions result from accumulated secretions, edema, inflammation of the airways, bronchospasm of smooth muscle, destruction of lung tissue, or a combination of these factors

Asthma

• Chronic inflammatory disorder of the airway
• Key characteristic: episodic and reversible airway obstruction
• Hallmarks: airway inflammation and airway hyper-responsiveness
• Degree of bronchoconstriction related to airway narrowing
• Degrees of airway inflammation and hyper-responsiveness
• Exposure to triggers (infection, allergens) leads to symptoms (wheezing, coughing, shortness of breath)

Asthma - Early Phase Response

• Allergen or irritant attaches to IgE receptors on mast cells
• Mast cells release chemical inflammatory mediators (e.g., histamine)
• Intense inflammation, bronchial smooth muscle constriction, increased vasodilation and permeability
• Epithelial damage
• Peaks within 30-90 minutes after exposure
• Subsides in another 30-90 minutes

Asthma - Late Phase Response

• Inflammatory cells (eosinophils and neutrophils) infiltrate the airway
• Release mediators that induce further inflammation
• Mast cells degranulate, releasing histamine and other mediators
• Self-sustaining cycle of inflammation
• Hyper-responsiveness of airway
• Peaks 5-12 hours after exposure
• May last several hours to days
• Primary characteristic is inflammation

Asthma - Key Takeaways

• Increased airway resistance
• Reduction in airway diameter related to the inability for air to pass
• Mucosal inflammation
• Constriction of bronchial smooth muscle
• Excess production of mucous
• Hypertrophy of bronchial smooth muscle
• Thickening of basement membrane
• Hypertrophy of mucous glands
• Secretion of tenacious sputum
• Hyperinflation and air trapping of the alveoli

Asthma Triggers

• Allergens (tobacco, marijuana smoke, nose/sinus conditions, medications, food additives, GERD, genetics, air pollutants)
• Emotional stress
• Exercise-induced (high-intensity workouts)

Asthma Clinical Manifestations

• Unpredictable, episodic, variable
• Wheezing
• Breathlessness
• Dyspnea
• Sensation of chest tightness
• Coughing
• Abrupt or gradual onset
• May have no symptoms between attacks
• Prolonged expiration (1:3, 1:4 ratio)
• Sitting upright or slightly bent forward
• Anxiety
• Wheezing is variable (loud, silent) as the attack progresses
• Silent chest, severe, diminished or absent breath sounds might indicate respiratory failure

Asthma Status Asthmaticus

• Life-threatening medical emergency
• Extreme form of an acute asthma attack
• Hypoxia, hypercapnia, acute respiratory failure
• Can lead to respiratory failure and death
• Precipitated by viral illness, environmental pollutants/allergens, food allergy, poor medication adherence or stopping medications

Asthma Diagnostic Studies

• Detailed history and physical exam
• Family history of asthma, allergies, and eczema
• Pulmonary function studies (spirometry, peak expiratory flow)
• Allergy assessment
• Oximetry
• Chest x-rays (not diagnostic, rule out other conditions; may show hyperinflation)
• Blood work (sputum sample check for eosinophils)
• ABGs

Asthma Interprofessional Care

• Establishing partnerships with patients/families
• Identifying and avoiding/eliminating triggers
• Patient and family teaching
• Continuous assessment of asthma control and severity
• Appropriate medications (relievers, rescue medication, controllers, maintenance medication
• Asthma action plans
• Regular follow-up

Categories of Asthma Medications

• Reliever Medications (fast-acting): Bronchodilators (short-acting inhaled beta-adrenergic agonists), anticholinergics/short-acting muscarinic antagonists
• Controller Medications (long-term): Anti-inflammatory medications (inhaled corticosteroids, oral corticosteroids, leukotriene modifiers, anti-IgE) 
• Bronchodilators (long-acting inhaled beta2-adrenergic agonists), anticholinergics/long-acting muscarinic antagonists, medications

Asthma Patient Education

• Medication therapy involving name, dosage, administration, frequency, indications of use and consequences of improper use, importance of adherence
• Assessment of patient's ability to use inhaler accurately
• Medication typically given via inhalation
• Lower dose required
• Fewer and less intense systemic adverse events
• Quicker onset
• Use with metered-dose inhaler +/- spacer

COPD

• Chronic inflammatory response
• Preventable disease, usually progressive airflow limitation
• Chronic inflammatory response in airways and lungs
• Cigarette smoking and noxious particles/gases
• Occupational chemicals and dusts
• Infections
• Heredity
• Aging

COPD Pathophysiology

• Chronic inflammation in the airways, lung parenchyma (respiratory bronchioles and alveoli) and pulmonary blood vessels—airflow limitations during forced exhalation
• Airflow obstruction due to mucus hypersecretion, mucosal edema, and bronchospasm
• Inflammatory process that destroys tissue and disrupts normal lung defense mechanisms and repair
• Structural changes caused by inflammatory mediators (e.g., leukotrienes, interleukins)
• Chest hyper-expands leading to a barrel-shaped chest due to the inability to forcefully exhale

=== COPD Clinical Manifestations===

• Cough, sputum production, dyspnea, history of smoking
• Intermittent cough is earliest symptom
• Dyspnea interferes with daily activities
• Barrel chest
• Increased work of breathing (WOB)
• Use of intercostal and accessory muscles
• Prolonged expiratory phase
• Wheezing
• Decreased lung sounds
• Tripod positioning
• Edema in ankles (indication of right-sided heart failure)

COPD Complications

• Cor pulmonale: hypertrophy of the right side of the heart, with or without heart failure as a result of pulmonary hypertension
• Acute exacerbation: worsening COPD symptoms
• Many exacerbations due to bacterial infection
• Acute respiratory failure: overall decline in lung function, deterioration in health status, and increased risk of death
• Patients wait too long to contact healthcare providers when symptoms suggest acute exacerbation of chronic obstructive pulmonary disease
• Depression and anxiety

COPD Interprofessional Care

• Prevent disease progression (smoking cessation)
• Reduce frequency and severity of exacerbations
• Alleviate respiratory symptoms
• Improve exercise tolerance
• Treat exacerbations and complications
• Improve overall health status and quality of life
• Reduce associated morbidity and mortality

COPD Interprofessional Care (Medications)

• Bronchodilator therapy (beta2-adrenergic agonists, anticholinergic medications)
• Long-acting theophylline preparations
• Corticosteroids (oral for exacerbations)
• NSAIDs
• Antibiotics (for exacerbations with purulent sputum)
• Influenza and pneumonia vaccines

COPD Pulmonary Rehabilitation

• Optimize functional status and quality of life
• Aerobic conditioning
• Upper/lower body conditioning exercises
• Breathing and energy conservation exercises (pursed lip breathing and huff coughing)
• Optimize nutrition
• Smoking cessation
• Environmental factor management
• Health promotion strategies
• Patient education
• Psychological support and counselling

Comparison of COPD and Asthma

• Age at onset: COPD usually after 40, asthma usually before 40
• Smoking history: COPD usually has a history of smoking >10 pack years; asthma may have a causative link but not a necessary factor
• Clinical symptoms: COPD symptoms are persistent; asthma symptoms intermittent and variable
• Sputum production: COPD often has frequent sputum production; asthma sputum production is infrequent
• Allergies: Allergies present more often in asthma; less common in COPD
• Spirometry: COPD findings may not improve with therapy; asthma findings often normalize
• Disease course: COPD is progressive worsening; asthma is usually stable with exacerbations

This quiz focuses on adult illness concepts related to obstructive pulmonary diseases, specifically chapter 31 on nursing management. It covers the characteristics and management of asthma, including its early phase response and related symptoms. Test your knowledge on airway inflammation, bronchoconstriction, and the key factors contributing to airway obstruction.