Obstructive Pulmonary Diseases

Reminders:

• The course is at the halfway point of the course
• The Midterm will be during Week 8
• The Class Seminar will still take place during Week 8, though there is no lecture
• Part B of the collaborative group assignment is due at the end of Week 9

Obstructive Pulmonary Diseases

• Obstructive pulmonary diseases are common chronic lung diseases
• Conditions are characterized by a resistance increase to airflow as a result of airway obstruction or narrowing

Learning Outcomes

• Describe the etiology, pathophysiology, and clinical manifestations of COPD
• Describe nursing assessments, diagnostics, interventions, rationales, and expected outcomes related to chronic obstructive pulmonary disease
• Explain the nursing management and interprofessional care of patients with chronic obstructive pulmonary disease
• Describe the etiology, pathophysiology, and clinical manifestations of asthma
• Describe nursing assessments, diagnostics, interventions, rationales, and expected outcomes related to the care of a patient with asthma
• Explain the nursing management and interprofessional care of patients with asthma

Asthma Definition

• Asthma is a chronic inflammatory disorder of airways
• Asthma causes airway hyper-responsiveness leading to wheezing, breathlessness, chest tightness, and cough
• About 8.4% of Canadians over the age of 12 are living with asthma
• Asthma is 40% more prevalent among Indigenous populations
• About 11% of people with asthma visit an emergency department (ED) one or more times a year
• Asthma morbidity is dramatic

Triggers for Asthma

• Allergens may be seasonal or year-round, depending on allergen exposure
• Animal dander, dust mites, pollens, moulds, air pollution, and perfumes are examples of allergens
• Tobacco and Marijuana smoke are Asthma triggers
• Exercise can induce or exacerbate asthma, especially with exposure to cold air
• Respiratory infection is a precipitating factor for acute asthma attacks
• Respiratory infection can increase inflammation and hyper-responsiveness, and last 2-8 weeks
• Influenza vaccines are recommended for children 6 months and older and for adults with asthma
• Allergic rhinitis and nasal polyps are triggers for asthma
• Large polyps are removed
• Sinus conditions are usually related to inflammation of the mucous membranes
• Medications and food additives are asthma triggers
• ASA/Aspirin, NSAIDs (Ibuprophen), and Beta-blockers are triggers for asthma
• Sulphites in food and drinks can trigger asthma
• GERD is a trigger, exact mechanism is unknown, but the reflux of acid could be aspirated into lungs, causing bronchoconstriction
• Air pollutants can trigger asthma attacks, like wood smoke, vehicle exhaust, and diesel particulate
• Emotional stress: Psychological factors can worsen the disease process
• Asthma attacks can trigger panic and anxiety, but the extent of the effect is unknown
• Genetics: Inherited components; complex in nature

Pathophysiology

• An early-phase response is characterized by bronchospasm
• In the early-phase, there's an increase in mucus secretion, edema formation, increased amounts of tenacious sputum
• Peaks in 30-60 minutes after trigger exposure
• The early-phase subsides in about 30-90 minutes
• A late-phase response can be more severe than the early-phase response and is primarily inflammation
• The late-phase peaks 5-12 hours after exposure, lasting several hours to days
• Corticosteroids are effective in preventing and reversing this cycle
• Untreated airway inflammation may lead to irreversible lung damage

Pathophysiology Map Details

• Asthma Triggers: Infection, Allergens, Exercise, Irritants
• Immune Activation: IL-4, IgE production
• Mast cell degranulation
• Inflammatory mediators cause vasodilation and increased capillary permeability
• Cellular infiltration: neutrophils, lymphocytes, eosinophils
• Neuropepetides released cause autonomic nervous system effects
• Vasodilation and cellular infoiltration lead to bronchospasm, vascular hyper-congestion, edema formation, mucus secretion, impaired mucociliary function that thickens airway walls
• This causes bronchial hyper-responsiveness and airway obstruction
• Airway remodelling occurs

Clinical Manifestations

• Asthma is unpredictable, episodic & highly variable
• Recurrent episodes of wheezing, breathlessness, cough, and tight chest
• Particularly at night or early morning (0200-0500 hours)
• Manifestations may be abrupt or gradual, lasting minutes to hours
• Expiration may be prolonged
• Inspiration-expiration ratio of normal, 1:2, is prolonged to 1:3 or 1:4
• Bronchospasm, edema, and mucus in bronchioles narrow the airways and air takes longer to move out of the bronchioles
• Wheezing is unreliable to gauge severity
• Severe attacks may have no audible wheezing, usually beginning upon exhalation
• "Silent chest" can occur
• Cough variant asthma
• Cough is the only symptom, bronchospasm is not severe enough to cause airflow obstruction
• Difficulty with air movement
• Patients may feel increasing anxious
• An acute attack reveals signs of hypoxemia
• Restlessness, increasedanxiety, inappropriate behaviour
• Increased pulse and blood pressure.
• Pulsus paradoxus (drop in systolic BP during inspiratory cycle >10 mm Hg)
• Respiratory rate >30 breaths/minute

Complications

• Status asthmaticus (form of acute asthma attack)
• Common causes of severe, acute attacks include viral illnesses, ingestion of Aspirin or other NSAIDs
• Increased environmental pollutants or other allergen exposure, and discontinuation of medication therapy
• Clinical manifestations are similar to those of non-severe asthma but are serious and prolonged
• Possible complications include pneumothorax, pneumomediastinum, acute cor pulmonale with right ventricular failure, and severe respiratory muscle fatigue that leads to respiratory arrest
• Respiratory arrest can be fatal

Diagnostics

• Detailed history and physical exam is necessary
• Pulmonary function tests are different between adults and children
• Chest X-ray - not necessary to diagnose asthma; however, may be used to exclude other diagnoses
• Arterial blood gases (ABGs) and oximetry during acute episodes
• Allergy testing - helpful in determining sensitivity to specific allergens
• Eosinophil blood levels are used to measure airway inflammation
• Sputum culture and sensitivity can be performed

Interprofessional Care

• Establish partnerships between health care providers and patients and their families
• Identification and avoidance or elimination of triggers
• Patient and family teaching
• Continuous assessment of asthma control and severity
• Appropriate pharmacotherapy will be required
• Asthma action plan will be required
• Regular follow-ups
• Stepwise approach is needed:
• Confirming the diagnosis
• Monitoring level of asthma control
• Reducing exposure to environmental triggers
• Providing appropriate medications and asthma education
• Providing written action plan
• Ensuring regular follow-up
• Education is required at time of diagnosis, integrating throughout care
• Self-management needs to be tailored to the needs of the specific patient and must be culturally sensitive

Asthma Control and Severity

• "Control" and "severity" are related to each other but not correlated
• Severity is determined from symptom frequency/duration, presence of airflow limitation, and medication is required to maintain control
• Severity can change over the course of a patient's life
• Optimal asthma control: absence of both asthma symptoms, normal pulmonary function, and no need for rescue bronchodilator
• Optimal asthma control is hard to achieve in all patients, so treatment must be assessed and adjusted regularly
• Base treatment needs on the stepwise approach to treatment

Acute Asthma

• Patients often come to ED with acute asthma exacerbations and respiratory distress
• Treatment depends on the severity and response to therapy
• Measure the severity with flow rates
• Oral corticosteroids may be used
• Therapy may be started and monitored with pulse oximetry or ABGs in severe cases
• Severe attacks require same measures as acute episode
• Increase the frequency and dose of bronchodilators
• May require mechanical ventilation
• IV corticosteroids every 4-6 hours, then orally
• Continuous monitoring of patient
• Supplemental O₂ by mask or nasal cannula to achieve 90% saturation
• Use an arterial catheter to facilitate ABG monitoring if necessary
• IV fluids support for insensible losses

Medication Therapy

• Relievers treat the symptoms of asthma, through bronchodilators and anticholinergics
• Controllers achieve and maintain control of persistent asthma, through bronchodilators and anti-inflammatory medications § Corticosteroids are one type of anti-inflammatory § Antileukotrienes - adjuvant or add-on therapy for individuals experiencing symptoms (uncontrolled asthma) or significant adverse events while using Corticosteroids § Biological therapy (monoclonal antibody to IgE) is expensive and reserved for specific patients

Corticosteroid details

• Corticosteroids may be fluticasone and budesonide
• They can suppress the inflammatory response and reduce bronchial hyper-responsiveness
• The inhaled form is long-term while the systemic form controls exacerbations and manages persistent asthma
• Corticosteroids decrease mucus production, needing to be taken on a fixed schedule
• Oropharyngeal candidiasis, hoarseness, and a dry cough are local adverse effects of inhaled medication
• Reduce adverse effects by using a spacer or gargling

Bronchodilators details

• 3 Types Of Bronchodilators:
• Beta-Adrenergic agonists like salbutamol or terbutaline, which relieve acute brochospasms
• Adverse effects are mild tremor and tachycardia, with an onset in just minutes for 4–8 hours, which are not used in long-term
• Methylxanthines like Theophylline are less effective as a long-term bronchodilator
• They control after trying inhaled corticosteroid (ICS), long-acting β2 agonist (LABA), and leukotriene receptor antagonists (LTRAs) but have frequent adverse events
• Anticholinergics like ipratropium block acetylcholine and are mostly used in combination with a bronchodilator, where the most common side effect is dry mouth

Medication Therapy Continued

• Antileukotriene (e.g., zafirlukast, montelukast)
• The class of medications block the effects of leukotrienes, which are potent bronchoconstrictors, having both bronchodilator and anti-inflammatory effects in doing so
• NOT for acute attacks, they provide therapy as prophylactic and maintenance
• Biological therapy stops anti-IgE like omalizumab [Xolair]), which is subcutaneous administration every 2-4 weeks for special circumstances
• Biological stops IgE from acting to decrease level of circulating free IgE and keeps it from connecting to mast cells and the associated chemical mediators

Patient Teaching

• Correct medication administration supports success, mainly as inhalation is preferable to avoid adverse systemic events
• Inhalation occurs via devices like metered-dose inhalers (MDI) or w/o spacers, and dry powder inhalers (DPIs)
• MDIs require users to hold their breath for 10 secs, the DPI requires forceful and quicker action in comparison
• Administration of medication is easier w/ spacered-MDI combo vs other devices, withDPIs requiring the least amount of dexterity

Nursing Management: Asthma Assessment

• A health history highlights precipitating factors and medications, including current conditions, treatments and past concerns
• Note symptoms of wheezing, coughing, chest tightness, dyspnea, fatigue, fear, panic, depression, emotional distress
• Physical examination findings
  • Use of accessory muscles; positioning
  • Diaphoresis
  • Cyanosis
  • Focused respiratory assessment
  • Cardiovascular findings
• ABGs
• Lung function tests

Nursing Management: Asthma Planning

• Overall goals
  • Participate in activities of normal life (including exercise and other physical activity) with little to no interference
  • Normal or near-normal pulmonary function
  • Have the asthma under control
  • Few or no adverse effects from medication
  • Adequate knowledge and skills to participate in and carry out management of asthma

Nursing Management: Implementation

• Asthma education
  • Develop partnership with family
  • Provide information and education on: basic facts about asthma, trigger control, medications, device technique, self-monitoring and action plan, and follow-up care.
  • Collaborate with family to develop skills necessary for controlling asthma
  • Self-management education programs can reduce the number of ED visits, hospitalizations, urgent care visits, nocturnal awakening, and days of interrupted activity.
  • Asthma education programs can be cost-effective.
  • See Table 31.9 for a detailed basic education program
• Environmental Asthma trigger control
  • Reduce allergens and irritants
  • House dust mites; focus on bedroom and keeping relative humidity below 50%, laundering bed linens in hot water, and removing carpets
  • Pet dander strategies for reduction
  • Eliminate environmental tobacco smoke
  • Exercise and cold air – work within patients' limits
  • Work-related asthma
• Self-monitoring and action plans
  • Every person with asthma should have an action plan. This can involve help from patient’s loved ones.
  • Include self-monitoring, level of asthma control, treatment changes, maintaining control
  • Self-monitoring by symptoms and peak expiratory flow (PEF), regular medical review
• The Canadian Lung Association distributes resources for individuals affected by asthma

COPD description

• COPD is preventable, with limitation off airflow that isn’t fully reversible
• Usually progressive; and abnormally chronically inflames airways and lungs due to noxious particle and gas irritations
• Past COPD definitions like chronic bronchitis are just emphysema
• Cardinal symptoms include: dyspnea, difficulty breathing, shortness of breath combined with insidious to progressive limitations in activity and onset
• 9.4% of Canadians more than 35 y.o, gender prevalence is high with both groups, first nations even more so

COPD Etiology

• Tobacco smoke primarily drives COPD from tobacco smoke's stimulants increaseing the sympathetic nervous system and all things related while decreasing oxygen
• Occupational chemicals, dust from a variety of different ways, and infection from recurring infection can increase lung tissue damage
• Heredity factors depend on alpha-antitypsin and aging is caused by changing long structure

COPD Pathophysiology

• Defining features of COPD, are airflow limitations that occur while enforcing exhalation due to loss of elastic recoil which isn’t fully reversible
• Airflow obstruction due to mucus hypersecretion, mucosal edema, and bronchospasm
• Can be identified from primary inflammatory processes in a non-reversible way, damaging all components

COPD Pathology continued

• Supporting structures of lungs are destroyed Air goes inside easily but does not leave and stays to collapse
• Mucus is hypersecreted, causing dysfunction of cilia with exchange abnormalities and hyperinflation of lungs
• Characterizing symptoms needs consideration if having comorbidities

COPD Manifestations

• Manifestations will show symptoms of cough, sputum production, risk factors, and even dyspnea
• Dyspnea is present even without exertion and during rest, with blue-red skin and adequate caloric intake
• Prolonged expiratory phase is often apparent and weight loss is not uncommon as well

Classifying COPD

• Classified as mild, moderate, severe, and very severe
• Table 31.12 of the Canadian Thoracic society details specifics regarding symptoms, function limitation, and impairment

Classsifications of Acute COPD Complications

• Right Heart Failure is pulmonary hypertension on right of the heart
• Signals an increasing change, dyspnea. cough, and sputum which is known to be potentially with poorer outcomes
• The causes result from air pollutants and infections
• Acute respiratory failure:
  • Occurs because of Exacerbations, cor pulmonale, medication discontinuation and painful feelings
• Mental symptoms from anxiety and depression can impact the experience

COPD Diagnostic Testing Steps

• History and physical is noted
• Pulmonary function tests assist
• Serum, chest, and sputum are samples needed combined with exercise and heart checkups

Clinical Assessment

• Begins with both thorough history and physical is relevant and important
• Spirometry typical findings need reduce FEV and increase volume alongside ABGs
• ABGs must have reduced O2 levels that can be tested by walking for desaturation

Interprofessional

• First, manage and prevent by smoking cessation. Alongside treatment in a daily functional and excercising
• A breathing-easy and manageable exacerbation improves quality of life, which in turn reduces chances of mortality
• B2 increases heart effectiveness with antibiotics

COPD Oxygen

• O2 can reduce heart needs while maintaining levels
• Oxygen can be supplied even at home to allow mental clarity, excercise
• Humidification can assist 02 flow

Copd surgery

• Surgically, a person may enhance lung ability and oxygen performance
• This would provide easier breathing and quality

Lifestyle changes

• Lifestyle changes will need optimizal levels for the patient
• The patient will need to excercise, breathe properly plus eat to enhance their mental capacity and support

Age-related COPD

• Age effects body and oxygen to reduce function
• Comobidities assist such changes

COPD Assessment

• Look at the hx and note any weightloss
• Note the ADL impact based by the patient’s symptoms and assess physical impact
• Asses cyanosis for breathing patterns
• Note bowel symptoms for heart impact
• Anteroskeletal levels could demonstrate chest impact

COPD planning

• Prevent as primary, performing ADLS with easier
• Improved excercise, to allow more days with a higher quality

COPD implementing

• Promote a healthier habit of not smoking, and note any family hx
• Encourage the patient to exercise and take air carefully
• The patient should excercise, sleep properly and ask for help if needed.