By Emily Muchina

COPD is a broad term used to describe conditions characterized by progressive chronic obstruction to expiratory airflow. Its an irreversible condition associated with dyspnea on exertion and reduced airflow in and out the lungs

In COPD, less air flows in and out of the airways because of one or more of the following: ` The airways and air sacs lose their elastic quality. ` The walls between many of the air sacs are destroyed. ` The walls of the airways become thick and inflamed (swollen). ` The airways make more mucus than usual, which tends to clog the airways.

This results due to; ` Occlusion of the airways by mucus, ` hypertrophy of smooth muscles or bronchospasms thus loss of capillary bed. ` Shunting of pulmonary capillary blood occurs when a portion of cardiac output passes through the capillary without becoming oxygenated. ` This causes hypoxemia. ` Also there is loss of alveolar surface area in emphysema or accumulation of secretions causing impaired gas diffusion. Pulmonary abnormalities of gas exchange are related to ventilation perfusion mismatch (V/Q IS 0.8).

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Tobacco smoking Indoor air pollution (such as biomass fuel used for cooking and heating) Outdoor air pollution Occupational dusts and chemicals (vapors, irritants, and fumes Advancement in age. Familiar tendencies (For example, this may happen if a person has alpha-1 antitrypsin deficiency, a genetic condition.( this prevents destruction of lung tissues)

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Productive cough: persistent cough with large sputum production Progressive shortness of breath ( mild on extreme exertion, moderate dyspnea on exertion and severe dyspnea on mild exertion and dyspnea at rest) Easy fatigability Activity intolerance (outset of dyspnea, pallor, sweating, increased RR, HR,BP and apprehension)

On physical examination: ` Labored breathing ` Rapid shallow respirations ` Use of accessory muscles ` Anxious while in supine ` Skin color may be pale or dusky ` In severe COPD: hyperinflated chest with increase in antero-posterior diameter of chest (barrel chest), hypertrophy of accessory muscles in the upper chest and trunk, cyanosis ` On auscultation there is reduced breathe sounds and distant heart sounds; adventitious sounds on expiration ( wheeze or crackles) ` Changes in the LOC (hypoxia)

Severe cases may be complicated by weight loss, pneumothorax, right heart failure, and respiratory failure.

Lung function tests measure:

 How much air you can take into your lungs. This amount is compared to that of other people your age, height, and sex. This allows your doctor to see whether you're in the normal range.  How much air you can blow out of your lungs and how fast you can do it.  How well your lungs deliver oxygen to your blood.  How strong your breathing muscles are.

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The breathing tests most often used are: Spirometry, which measures how deeply a person can breathe and how fast air can move into and out of the lungs. It also measures how fast you can blow air out. Peak flow meter. This meter is a small, hand-held device thats sometimes used by people who have asthma. The meter helps track their breathing. Lung volume measurement. This test, in addition to spirometry, measures how much air you have left in your lungs after you breathe out completely.

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Lung diffusing capacity. This test measures how well oxygen passes from your lungs to your bloodstream. Other tests, such as a cardiopulmonary exercise test, also may be done. This test measures how well your lungs and heart work while you exercise on a treadmill or bicycle. Pulse oximetry and arterial blood gas are two tests used to measure the oxygen level in the blood. Diagnosis of COPD should be considered in any patient who has symptoms of a
chronic cough, sputum production, dyspnea (difficult or labored breathing) and a history of exposure to risk factors for the disease.

Chest x-ray; hyperinflated and flattened diaphragm

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In stable conditions the patient lives on high CO2 levels, the chemoreceptors and CNS respiratory center are adjusted to higher levels of CO2 and patients relies on hypoxic drive for the stimulus to breathe. COPD has no cure yet. However, treatments and lifestyle changes can help patients feel better, stay more active, and slow the progress of the disease. Quitting smoking is the most important step you can take to treat COPD. Monitor oxygenation ( pulse oximetry and BGAs) Breathing exercises Chest physiotherapy Bronchodilators ( anticholinergics, beta adrenergic agonists and methylxanthines) IV is used in acute cases. Bronchodilators relax the muscles around your airways. This helps open your airways and makes breathing easier/decrease air way obstruction Corticosteroids to decrease inflammation Antibiotics with infections Oxygen therapy with PO2 <55mmHg through nasal prongs or a mask. Aerosol therapy/ nebulizers with bronchodilators or mucolytic agents to liquefy and mobilize secretions

Surgeries for people who have COPD that's mainly related to emphysema include bullectomy and lung volume reduction surgery (LVRS). A lung transplant may be done for people who have very severe COPD. Bullectomy ` When the walls of the air sacs are destroyed, larger air spaces called bullae form. These air spaces can become so large that they interfere with breathing. In a bullectomy, doctors remove one or more very large bullae from the lungs. Lung Volume Reduction Surgery ` In LVRS, surgeons remove damaged tissues from the lungs. This helps the lungs work better. In carefully selected patients, LVRS can improve breathing and quality of life. Lung Transplant ` A lung transplant may benefit some people who have very severe COPD. During a lung transplant, damaged lung is removed and replaced with a healthy lung from a deceased donor. ` A lung transplant can improve your lung function and quality of life. However, lung transplants have a high risk of complications. These include infections and death due to the body rejecting the transplanted lung.
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Impaired gaseous exchange related to V/Q mismatch ` Administer and monitor bronchodilators or cortocosteroids (inhalers) ` Oxygen therapy; monitor effectiveness ` Spirometry and BGAs ` Assessment of breathing rate and depth ` Semifowlers position ` Assess & monitor mental status, such as restlessness, anxiety, confusion, & combative reactions, & respiratory status, such as cyanosis & changes in respiratory rate

Ineffective airway clearance related to bronchoconstriction, increased mucus and ineffective cough ` Encourage fluid plenty of fluid intake ` Postural drainage with chetst ohysiotherapy ` Aerosol therapy ( mucolytics and bronchodilators) ` Deep breathing and effective cough teaching ` Suction aseptically

Ineffective breathing patterns manifested by dyspnea, airway irritants ` Monitors respiratory parameters ` Observe sputum character ` Semifowlers position

Self care deficit related to fatigability secondary to hyperventilation

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In acute phase limit activities Resume activities gradually as tolerated Assist where necessary Coordinate diaphragmatic breathing with activity

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provide bed rest & limited physical activity to conserve oxygen assess response to activity to evaluate pts hypoxemia & plan changes accordingly Limit visitors & long conversations Plan nursing care in blocks to ensure periods of uninterrupted rest Place needed items e.g. tissue, call bell, within easy reach to conserve energy while facilitating independence

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A proper diet will not cure disease, but it will make one feel better; and have more energy, and the body will be able to fight infection better. Provide small meals; consider favorites; supplemental foods such as high in proteins. Assist with meals to conserve energy determine pts food preferences & provide them when possible to promote ingestion of adequate nutrients provide means of oral hygiene before meals to remove foul tastes related to sputum or medications provide frequent small meals to prevent pressure on diaphragm & minimize energy expenditure monitor pts weight & caloric intake to assess need to adjust diet

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Knowledge deficit of disease prevention., management and self care procedures Anxiety related to dyspnea Disturbance in sleep patterns Altered sexual and role-relation ship related to disease process and fatigue

Bronchitis; (also called chronic mucous hypersecretion syndrome) is defined as productive cough for at least 3 mo total duration in 2 successive years. Chronic asthmatic bronchitis is a similar, overlapping condition characterized by chronic productive cough, wheezing, and partially reversible airflow obstruction; it occurs predominantly in smokers with a history of asthma. In some cases, the distinction between chronic obstructive bronchitis and chronic asthmatic bronchitis is unclear. Emphysema is destruction of lung parenchyma leading to loss of elastic recoil and loss of alveolar septa and radial airway traction, which increases the tendency for airway collapse. Lung hyperinflation, airflow limitation, and air trapping follow. Airspaces enlarge and may eventually develop bullae.

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Bronchiectasis; Bronchiectasis is dilation and destruction of larger bronchi caused by chronic infection and inflammation. Common causes are cystic fibrosis, immune defects, and recurrent infections, though some cases appear to be idiopathic. Symptoms are chronic cough and purulent sputum expectoration; some patients may also have fever and dyspnea. Diagnosis is based on history and imaging, usually involving high-resolution CT, though standard chest x-rays may be diagnostic. Treatment and prevention of acute exacerbations are with antibiotics, drainage of secretions, and management of complications, such as superinfection and hemoptysis. Treatment of underlying disorders is important whenever possible.

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Asthma; Asthma is a disease of diffuse airway inflammation caused by a variety of triggering stimuli resulting in partially or completely reversible bronchoconstriction. Symptoms and signs include dyspnea, chest tightness, cough, and wheezing. The diagnosis is based on history, physical examination, and pulmonary function tests. Treatment involves controlling triggering factors and drug therapy, most commonly with inhaled 2-agonists and inhaled corticosteroids. Prognosis is good with treatment

Status asthmaticus occurs if bronchospasm is not controlled and symptoms are prolonged. As the patient increases the respiratory rate to compensate for narrowed airways, a lot of carbon dioxide is blown off and respiratory An acute asthma attack may be treated with an inhaled or subcutaneous adrenergic bronchodilator or, rarely, intravenous aminophylline. Intravenous or oral corticosteroids (methylprednisolone, prednisone) are potent anti-inflammatory agents that are useful in an acute episode but are avoided for long-term therapy if possible because of their cushingoid side effects. Corticosteroids must be tapered before discontinuing to prevent withdrawal symptoms

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conditions in which air has entered the pleural space outside the lungs. If the pneumothorax occurs without an associated injury, it is called a spontaneous pneumothorax. Associated with smokers, lung disease (especially emphysema) may have blisterlike defects in lung tissue, called bullae or blebs, weakened lung tissue from lung cancer can also lead to pneumothorax. A secondary spontaneous pneumothorax may occur due to underlying lung disease. Traumatic pneumothorax results from a penetrating chest injury.

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OPEN PNEUMOTHORAX. If air can enter and escape through the opening in the pleural space, it is considered an open pneumothorax. CLOSED PNEUMOTHORAX. If air collects in the space and is unable to escape, a closed pneumothorax exists. TENSION PNEUMOTHORAX. If a pneumothorax is closed, air, and therefore tension, builds up in the pleural space. As tension increases, pressure is placed on the heart and great vessels, pushing them away from the affected side of the chest. This is called a mediastinal shift. When the heart and vessels are compressed, venous return to the heart is impaired, resulting in reduced cardiac output and symptoms of shock. Tension pneumothorax is often related to the high pressures present with mechanical ventilation. It is a medical emergency. HEMOTHORAX. The term hemothorax refers to the presence of blood in the pleural space. This can occur with or without accompanying pneumothorax (hemopneumothorax) nd is often the result of traumatic injury. Other causes include lung cancer, pulmonary embolism, and anticoagulant use.

Sudden-onset dyspnea, chestpain, tachypnea Asymmetrical chest expansion Diminished or absent breath sounds on affected side Dx; Chest x-ray, ABGs, Chest tube and water seal Drainage Complications; Tension pneumothorax, Shock Nursing diagnosis; Impaired gas exchange, Acute pain

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When multiple ribs are fractured, the structural support of the chest is impaired. As a result, the affected part of the chest collapses with inspiration and bulges with expiration. This is called paradoxical respiration, which is ineffective in ventilating the lungs and results in hypoxia. Signs and Symptoms; The patient with a flail chest exhibits chest movement that is opposite to that usually seen with respiration. The patient is dyspneic, anxious, tachypneic, and tachycardic. Treatment; The patient is given supplemental oxygen. Intubation and mechanical ventilation may be necessary. If lung damage has occurred, chest tubes may be necessary for reinflation

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Impaired Gas Exchange, Ineffective Breathing Pattern, and AcutePain

A surgical incision made into the chest wall is called a thoracotomy. A thoracotomy may be performed for a number of reasons, including biopsy; removal of tumors, lesions, or foreign objects; to repair trauma following penetrating or

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Prepare the patient for waking up after surgery with an endotracheal tube connected to a ventilator, oxygen, chest tubes, intravenous fluids, cardiac monitor, Foley catheter, and possibly an epidural catheter for pain control. Let the patient know he or she will not be able to talk while the ET tube is in, and explain the use of the call light, picture board, or alternate communication techniques. Consult the surgeon for specific plans. Advise the patient that position changes and early ambulation help prevent complications following surgery. Also instruct the patient in the use of an incentive spirometer and coughing and deep breathing techniques.

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Ineffective airway clearance related to presence of ventilator, ability to cough, sedation Impaired gas exchange related to surgical intervention, opioid use, and removal of lung tissue Acute pain related to surgical procedure Impaired physical mobility related to discomfort at surgical site Risk for infection related to surgical incision and stress of major surgery

THE END