NUR 195 Ch 11 Nursing Management:
Patients with COPD and Asthma
COPD: Pathophysiology
(Figure 11-1) - correct answer ✔✔- COPD: diseased state characterized by chronic airflow limitation that
is not fully reversible; airflow limitation in COPD is usually progressive & a/w an inflammatory response
of the lungs
- Pathologic changes that characterize COPD include an increase in mucus-producing cells, chronic
inflammation in different parts of the lung, & structural changes that result from a continuing cycle of
destruction & repair
- The inlam. response found in COPD is thought to be an amplification of the normal inflam. response;
Oxidative stress & an excess of destructive cytokines in the lungs may amplify inflam.
- Individuals may have predominantly emphysema, chronic bronchitis, or heightened airway
responsiveness
describes abnormal enlargement of the air spaces beyond the terminal bronchioles, w/ destruction of
walls of the alveoli
- Most pts will have elements of both emphysema & chronic bronchitis, & as both diseases have chronic
airflow that are not revisable, they are classified as COPD
- In later stages of COPD, gas exchange is often impaired; As alveolar walls continue to break down, the
pulmonary capillary bed is reduced in size--> resistance in pulmonary blood flow increases, forcing right
ventricle to maintain an increasingly higher pressure in the pulmonary artery
- Chronic hypoxemia increases pulmonary artery pressures-->right sided heart hypertrophy & failure (for
pulmonale) may result; decreased CO2 elimination results in hypercapnia & leads to resp. acidosis &
chronic resp. failure; worsening hypercapnia can lead to acute resp. failure
- Alveoli adjacent to bronchioles may become damaged & fibroses, resulting in altered function of the
alveolar macrophages--> making the individual more susceptible to resp. infections; Many types of
infections can produce acute episodes of bronchitis, a leading cause of exacerbations
-
COPD: Emphysema: Pathophysiology - correct answer ✔✔- The alveolar & interstitial attachments are
reduced & predisposed to collapse during exhalation; External airway compression & obstruction is
caused by hyperinflation & air trapping; this results in "less room to breathe"
,- 2 types: panacinar or panlobular (hereditary from r/t deficiency of alpha1-antitrypsin, which causes
uniform destruction of acinus [ where alveoli are located] & centrilobular (related to smoking , in which
the alveolar ducts & bronchioles in the center of lobules of the upper lobes are primarily affected)
COPD: Chronic Bronchitis: Pathophysiology
(Figure 11-2) - correct answer ✔✔- Chronic obstructive bronchitis: defined as presence of cough &
sputum production for at least 3 months in each of 2 consecutive yrs
- In simple chronic bronchitis, pulmonary function remains normal
- Chronic mucus hypersecretion causes lung function decline, exacerbations, & infections; Thickening of
epithelium, smooth muscle hypertrophy, & airway inflam. are implicated in remodeling of airways--This
remodeling causes airway lumen to be smaller
COPD: Risk Factors
(Box 11-1) - correct answer ✔✔- Tobacco smoke
- Environmental tobacco smoke
- Occupational dust & chemicals
- Indoor & outdoor air pollution
- Infection (hx of resp. infections, hx of TB in those >40yrs old)
- Most important risk factor is cigarette smoking
- A host risk factor for COPD, specifically emphysema, is deficiency of alpha1-antitrypsin, an enzyme
inhibitor that protects the lung parenchyma from injury--Genetically susceptible people are more
sensitive to environmental factors (e.g. smoking, air pollution, infectious agents, allergens)& have higher
risk of developing chronic obstructive sx's
COPD: Clinical Manifestations & Assessment
(Table 11-1) - correct answer ✔✔- Characterized by 3 primary sx's: dyspnea, chronic cough, & sputum
production
- As disease progresses, dyspnea may become severe & often interfere w/ pt's ADL's; in more severe
COPD, dyspnea can occur at rest
- Chronic cough & sputum production often preceded development of airflow limitation by many yrs-- In
early stage, pt may note early morning cough productive of a small-moderate amount of white-clear
sputum; During exacerbations, increased sputum amount & viscosity may occur, & sputum may change
color
, - Physical exam findings may be near normal in those w/ beginning & sometimes moderate disease;
Findings consistent w/ more advanced COPD may include signs of hyperinflation: increase anterior to
posterior diameter of chest, referred to as "barrel chest"; bilateral intercostal retractions at posterior
axillary libel horizontal fixation of ribs in inspiratory position; & hyper-resonance to percussion; Breath
sounds may be diminished; prolonged exhalation is usually heard throughout chest; adventitious sounds
(coarse crackles aka rhonchi & wheezes) are often heard throughout chest when pt has increased
secretions & bronchial hyper-reactivity, & during an exacerbation
- Chronic Bronchitis: Primary symptom is cough; Copious sputum production, cor pulmonale is common
(peripheral edema, elevated JDV, hepatomegaly); total lung capacity is normal or slightly increasers or
decreased; & elastic recoil is normal
- Emphysema: Primary symptom is dyspnea; Scant sputum production; cor pulmonale is rare; total lung
capacity is increased--barrel chest; elastic recoil is markedly decreased
COPD: Diagnostics - correct answer ✔✔- Pulmonary Function studies: used to help confirm dx,
determine disease severity, & monitor disease progression; Spirometry is used to evaluate airflow
obstruction; W/ obstruction, pt has difficulty exhaling or can't forcibly exhale wire from the lungs, thus
reducing the FEV1; Obstructive lung disease is defined as an FEV1 of <80% & an FEV1/FVC [forced vital
capacity] ration of <70%
- Bronchodilator Reversibility Testing: done to rule out asthma & guide initial treatment-Spirometry
obtained 1st, the pt is given an inhaled bronchodilator treatment according to protocol, & spirometry is
repeated; Pt demonstrated a degree of reversibility if pulmonary function values improve significantly
(>12%) after admin of bronchodilator--Pts who show complete reversibility usually have asthma; Pts who
show some reversibility that dent reach normal values may be dx'd w/ COPD; Pts who don't show sig.
response to bronchodilator test may still be given trial of bronchodilator tx to determine if it helps relive
sx's
- Total lung capacity & diffusion capacity may be used to dx coexisting restrictive disease & help predict
contribution of emphysema in the dx
- ABG: obtained to assess baseline oxygenation & gas exchange & are especially important in advanced
COPD
- Chest X- Ray: may establish pt;s baseline & exclude alternative dx's; seldom diagnostic in COPD unless
obvious bullous disease or severe hyperinflation are present
- High-resolution CT: may help in differential diagnosis or to evaluate pts for surgical procedures, like
bullectomy or long volume reduction surgery
- Screening for alpha1- antitrypsin deficiency is usually recommended for symptomatic pts younger than
45 & for those w/ strong family hx of COPD
- Staging of COPD is used to determine prognosis, guide therapy, & to develop research protocols--The
more severe the decline
