1 Understanding COPD Carolinas Healthcare System 2013
2 This self-directed learning module contains information about the pathophysiology, diagnosis, and treatment of COPD. Target Audience: All RNs and LPNs Instructions: The material in this module is an introduction to important general information. After completing this module, contact your Manager or Clinical Nurse Educator to obtain additional information specific to your unit. Read this module. If you have any questions about the material, ask your Manager or Clinical Nurse Educator. Complete the post test at the end of this module and give it to your Manager.
3 Learning Objectives: When you finish this module, you will be able to: Define Chronic Obstructive Pulmonary Disease Identify Signs and Symptoms of COPD Identify Risk Factors Associated with COPD Describe Diagnostic Techniques Identify Treatment Modalities Identify Co-Morbidities Describe Nursing Implications in the Care of the COPD Patient
4 Definition of Chronic Obstructive Pulmonary Disease (COPD) The current definition of COPD as defined in the Global Initiative for Chronic Obstructive Lung Diseases (GOLD) Guidelines is: Chronic obstructive pulmonary diseases is a preventable and treatable disease with some significant extra pulmonary effects that may contribute to the severity in individual patients. Its pulmonary component is characterized by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases. COPD is a major cause of disability, and it's the third leading cause of death in the United States. More than 12 million people are currently diagnosed with COPD. Many more people may have the disease and not even know it.
5 Definition cont. To further clarify the definition: COPD is preventable. There are a number of risk factors to consider, with cigarette smoking being the most common. Other risk factors may include occupational exposures, air pollution, and genetic factors. COPD is treatable with specific treatment modalities. The pulmonary component of COPD is characterized by airflow limitation. This limitation is caused by small airway inflammation, leading to airway remodeling (chronic bronchitis) and the loss of alveolar attachments and alveolar elasticity (emphysema). Each person with COPD has varying degrees of each component of airflow limitation. The airflow limitation is progressive, yet treatable. Exposure to noxious articles or gases, such as cigarette smoke, leads to the inflammatory response.
6 Normal vs. COPD
7 Signs and Symptoms of COPD Symptoms of COPD often begin slowly and insidiously. A person may feel breathlessness with exercise and initially may be identified as being out of shape. Exercise may then be limited to avoid the breathlessness, which then progresses and occurs during activities of daily living. This progressing symptom is often the reason a person visits the health care provider. Other symptoms may include frequent cough (frequently referred to as smoker s cough ), wheezing, weight loss, possible mucus production. As patients may not experience all of these symptoms, use of a self-reported monthly symptoms journal may be helpful in understanding how COPD affects them.
8 Signs and Symptoms cont. Most patients with COPD have features of both chronic bronchitis and emphysema, but some present with more features of one than the other. The patient on the left has signs and symptoms of chronic bronchitis: hypoxemia, pulmonary hypertension, right-sided heart failure, and peripheral edema. The patient on the right has signs and symptoms of emphysema: pulmonary cachexia, dyspnea, and pursed-lip breathing.
9 Risk Factors There are approximately 24 million people with impaired lung function, while about half remain undiagnosed. Age-adjusted date show that COPD is the third leading cause of death in the U.S. and is the only major disease to show increasing mortality rates. Although the number of people who smoke has decreased, there is a lag time between the decrease in smoking rates and the decrease in COPD. The mortality rate for women with COPD has steadily increased since the 1970 s and has led to a rate only slightly lower than that for men, compared to a historically much lower rate for women.
10 Risk Factors cont. There are a number of risk factors for developing COPD: Tobacco smoke. A history of smoking is the most common risk factor for developing COPD. Usually the individual will have a 10 year pack history of smoking. Passive exposure to smoke is also a risk factor for developing COPD. Occupational exposures. Occupational exposure to dusts and chemicals, including hobbies, can increase the risk of COPD Indoor and outdoor pollution. Genetic factors. Alpha-1 Antitrypsin Deficiency is a hereditary deficiency. This condition increases a person s risk of developing early onset emphysema without smoking or smoking very little. Other genetic factors may exist and are being explored. Low socioeconomic status. Lower socioeconomic status is often associated with smoking, working in occupations with potential exposures, and air pollution. Other respiratory disorders. Asthma, airway hyper responsiveness, severe respiratory infections in childhood, and decreased lung growth in childhood also increase the risk of developing COPD.
11 Diagnosis There are numerous challenges to diagnosing COPD. Symptoms begin slowly and insidiously. Often, individuals do not present for treatment until they have moderate disease with enough impairment to make them short of breath with daily activities. The physician has an opportunity for early recognition at the time of history and physical examination. An individual with a history of current or past smoking, any of the previously mentioned risk factors, or any of the below listed conditions should cause the physician to suspect COPD: Chronic cough: Present intermittently or every day. Often present throughout the day; seldom only nocturnal. Chronic sputum production: Any pattern of chronic sputum production may indicate COPD. Dyspnea that is: progressive (worsens over time), persistent (present every day), described by the patient as an "increased effort to breathe," "heaviness," "air hunger," or "gasping, worse on exercise, or worse during respiratory infections. Occupational dusts and chemicals. Smoke from home cooking and heating fuels.
12 Diagnosis cont. The main test used for confirming a diagnosis of COPD is a technique that measures lung function, called spirometry. It is ordered by primary care physicians and helps to exclude other diagnoses with similar symptoms of lung obstruction, such as asthma. It is the best standardized, objective method and can be used to monitor disease progression. Doctors use spirometry results to determine appropriate treatment regimens and to evaluate their effectiveness. Sprirometry measures the amount of air that is expelled from the lungs and the time it takes to breathe it out. If the FVC (forced vital capacity) is less than 70% there is an indication of the possibility of COPD, while a value between 70% and 80% is normal.
13 The photo shows how spirometry is done. The patient takes a deep breath and then blows hard into a tube connected to a spirometer. The spirometer measures the amount of air breathed out. It also measures how fast the air was blown out.
14 Treatment Modalities Once COPD is diagnosed, The GOLD Guidelines identify specific treatment goals. These include: Relieve symptoms Prevent disease progression Improve exercise tolerance Improve health status Prevent and treat complications Prevent and treat exacerbations Reduce mortality These goals are carried out by both nonpharmacologic approaches and pharmacologic treatments.
15 Nonpharmacologic Approaches Smoking cessation counseling and therapy. Quitting smoking is the most important thing one can do to stop the disease from getting worse. Staying away from other people who smoke, or places that contain smoke is also important. Pulmonary rehabilitation helps patients improve lung function and improve quality of life and has been shown to reduce the number of hospitalizations and hospital days. Pulmonary rehabilitation includes: 1. Exercise training - Exercise training programs both improve exercise tolerance and reduce symptoms of dyspnea and fatigue in patients with COPD. The benefits of the programs will be lost without continued participation in an at-home maintenance program.
16 Nonpharmacologic Approaches cont. 2. Nutritional counseling- Good nutrition is important for people with COPD for a number of reasons. First, breathing requires more energy for them. Next, good nutrition helps the body fight infections, and chest infections could lead to hospitalization for people with COPD. Here are some guidelines to keep in mind: a. Excess weight makes the lungs and heart work harder, so it's important to achieve an ideal body weight. b. Encourage plenty of fluids to help keep mucus thin and easier to cough up. But use caution if the person with COPD retains fluid or has a medical condition for which fluids should be restricted. Check with the doctor. c. If one struggles with shortness of breath while eating, have small meals and snacks available throughout the day rather than serving three large meals.
17 Nonpharmacologic Approaches cont. 3. Patient Education- Includes such topics as pursed-lip breathing, energy conservation, sleep and rest, proper medication use, preventing flare-ups, triggers, methods to enhance sleep, and when to call the health care provider. 4. Oxygen therapy Oxygen can reduce breathlessness, increase alertness and endurance. May be prescribed at different flow rates for rest, activity, and sleep. 5. Surgical treatments Goals of surgical treatments for COPD are to extend life and to improve the quality of life. These treatments are recommended only for carefully selected patients with severe COPD. Bullectomy, lung volume reduction surgery, and lung transplantation are some examples.
18 Pharmacologic Treatments The goals of pharmacologic treatments include: 1. Prevent and control symptoms 2. Reduce the frequency and severity of exacerbations 3. Improve health status Medications include: 1. Bronchodilators 2. Steroids (including inhaled steroids) 3. Antibiotics 4. Immunizations
19 Commonly Prescribed Medications for COPD Drug Class Drug Name Comments Bronchodilators Long-Acting beta agonists: Foradil, Perforomist, Serevent, Brovana, Atrovent, Spiriva Short-Acting beta agonists : Proventil, Ventolin, Proair, Vospire, Xopenex, Alupent, Maxair, Brethine Combination Short/Long Acting: Combivent, Duoneb Bronchodilators are medications that work by opening up the airways, usually by relaxing the muscles of the airways. Combination COPD medications contain two different types of bronchodilators. Short-acting beta-agonists are often used on an as needed basis, while long-acting beta agonists are usually taken every day. Typically, an anticholinergic medication should be the first medication used for treating COPD. If necessary, a betaagonist may be added.
20 Commonly Prescribed Medications for COPD - cont. Drug Class Drug Name Comments Steroids Oral and IV : prednisone Inhaled steroids : Qvar, Pulmicort, Aerobid, Flovent, Asmanex, Azmacort Combined bronchdilator/ inhaled steroid : Advair, Symbicort Sometimes, steroids are necessary to help control a temporary worsening of COPD symptoms. They work by decreasing inflammation of the airways. Some people benefit from using an inhaled steroid on a daily basis. Inhaled steroids are not fast-acting medicines, so they must be taken on a daily basis to obtain full benefit. Antibiotics People who have COPD are prone to frequent and severe lung infections, such as bronchitis. As a result, antibiotics are often used in the treatment of COPD. In general, antibiotics are only used when an infection occurs. However, they are sometimes used on a continuous basis to help prevent infections, although this type of use is controversial.
21 Commonly Prescribed Medications for COPD - cont. Drug Class Drug Name Comments Immunizations People who have COPD are typically advised to receive a pneumococcal vaccine and a yearly flu shot, as the disease may predispose people to pneumonia or the flu. Usually, the pneumococcal vaccine is a one-time vaccine, although there are a few situations in which a booster vaccine is required.
22 Co-Morbidities COPD is commonly associated with many co-morbidities. Comorbid conditions can exponentially complicate disease management for a chronic condition. Quality of life, self-care efforts, and disease progression are adversely affected by comorbidities, such as: Lung cancer Depression Ischemic heart disease Anemia Hypertension Pneumonia Osteoporosis Diabetes Sleep disorders
23 Cigarette smoke, pollutants Muscle Muscle Wasting Pancreas Metabolic Syndrome; Type 2 Diabetes Lung Local & Systemic Inflammation? Bone Osteoporosis Heart Cardiovascular Events CRP Liver CRP Complex Chronic Comorbidities of COPD
24 Nursing Implications in the Care of COPD Patients. Monitor respiratory status, including rate and pattern of respirations, symmetry of chest wall movement, breath sounds, pulse, signs and symptoms of respiratory distress, and pulse oximetry. Administer prescribed medications, which may include antibiotics, bronchodilators, mucolytic agents and corticosteroids. Antibiotics should be administered at the first sign of infection, such as change in sputum. Opioids, sedatives and tranquilizers, which can further depress respirations, should be avoided. Clear airways with postural drainage, percussion or vibrating and suctioning as appropriate. Promote infection control. Encourage the client to obtain influenza and pneumonia vaccines at prescribed times. Improve breathing patterns. Demonstrate and encourage diaphragmatic and purse lip breathing. Have the client take a deep breath and blow out against closed lips. Administer oxygen. A low arterial oxygen level is the client s primary drive for breathing. Oxygen flow rate should be no more than 2 to 3 L per minute. Higher levels will cause the client to quit breathing. Discuss the importance of smoking cessation and avoiding second-hand smoke. Discuss ways to quit smoking and make appropriate referrals. Compromise is not acceptable; the client must stop smoking. Help patient identify/develop short- and long-term goals. Discuss the need to preserve existing lung function by adhering to prescribed program.
25 References: Aliotta, S. and Mullen, A. (2010) Case Management Adherence Guidelines for COPD. Case Management Society of America. COPD. Learn More. Breathe Better. National Heart Lung and Blood Institute. Corbridge, S. and Wilken, L., et al (2012). An Evidence-Based Approach to COPD: Part 1. American Journal of Nursing. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. Global Initiative for Chronic Obstructive Lung Disease. Spirometry for Health Care Providers. Smeltzer, S. and Bare, B. et al. Textbook of Medical-Surgical Nursing (11th Edition) Philadelphia: 2008 pp