COPD It Takes Your Breath Away

1. COPDIt Takes Your Breath Away Patti J. Pagel, RN, BSN Alverno College MSN Program April, 2007 patti.pagel@aurora.org

2. Self-Study Tutorial GuideInstruction Page • Click on to go back to previous slide • Click on to go to the next slide • Click on to return to objectives • Click on True/False and learn the correct answer when presented in a slide • Click on Answer for multiple choice to check for correct answer • Click here to go back to review slides • Click on website linkfor further information

3. Welcome!Main MenuClick on subject to navigate to: Or click on forward arrow to go to next slide Objectives Nursing Outcomes Pathophysiology Interventions Respiratory Review Patho Quiz Case Study Respiratory Quiz Signs & Symptoms References

4. Intended Audience • This self-study tutorial on Chronic Obstruction Pulmonary Disease is intended for the following people: • Registered Nurses • Medical Assistants • Anyone interested in learning about COPD

5. Tutorial Objectives • Review respiratory system anatomy. • Increase understanding of the pathophysiology of COPD. • Recognize signs and symptoms of COPD. • Identify treatment options: • Non-pharmaceutical nursing interventions • Pharmaceutical interventions

6. Nursing Outcomes: • Respiratory Status: Ventilation - movement of air in and out of lungs • Respiratory Status: Airway Patency - open, clear tracheobronchial passages • Knowledge: Medications - extent of understanding conveyed about the safe use of medication Source: (Moorhead et al 2004) Microsoft clipart

7. Let’s Review: Respiratory Anatomy • Upper Respiratory Tract: Mouth, nose, throat (pharynx), larynx, trachea • Lower Respiratory Tract: Lungs, bronchi, alveoli • Medulla Oblongata Controls inspiration/expiration Microsoft clipart

8. Anatomy Review Used with permission: webschoolsolutions, 2007

9. Respiratory ReviewLet’s Take a Breath Together: • Air is warmed and humidified. • Cilia filter out dust particles. • Macrophages destroy germs. • Air goes to L and R bronchi. • Then to the bronchioles. • Through to the Alveoli. • Oxygen and CO2 exchange takes place. Used with permission: Jensen M.S., Webanatomy 2007

10. Respiratory Review:Now your Breath is… • Alveoli fill with air. • Oxygen diffuses thru alveoli walls. • Oxygen diffuses to Capillaries and bloodstream. • Hemoglobin for transport of oxygen. • Oxygen to the heart and to the body. Used with permission: Jensen, M.S., Webanatomy (2007).

11. Respiratory ReviewLet your air out… • Hemoglobin frees oxygen. • O2 to cells. • CO2 is the waste product. • Veins return CO2 to heart. • Heart pumps CO2 to lungs. • CO2 passes alveoli to be exhaled Use with permission: Jensen, M.S., Webanatomy (2007)

12. Respiratory Quiz • Respiratory Assessment: Understanding the anatomy of the lungs, where does the exchange of oxygen and CO2 occur: A. Bronchioles B. Aveoli C. Bronchial Tubes Click on underlined best answer.

13. Respiratory Quiz: • Respiratory Assessment: What part of the body controls inspiration and expiration? A. Pituitary Gland B. Sympathetic Nervous System C. Medulla Oblongata Click on underlined best answer.

14. What is COPD?Chronic Obstructive Pulmonary Disease COPD is a group of respiratory disorders characterized by chronic, recurrent, irreversible obstruction of airflow in the pulmonary airways not fully reversible with inhaled bronchodilators. (Porth, 2005) (Punturieli, 2007)

15. Chronic Obstructive Pulmonary Disease (COPD) FACTS YOU SHOULD KNOW: • FOURTH leading cause of death in United States. • COPD refers to two lung diseases: Chronic Bronchitis & Emphysema. • Smoking is a primary risk factor. • Air pollution, second-hand smoke, history of childhood respiratory infections and heredity are other causes. • Female smokers are almost 13 times as likely to die from COPD than women who have never smoked. • 11.4 million U.S. adults affected. • $37.2 billion cost to nation. • Important cause of hospitalization in our aged population. Source:American Lung Association Fact Sheet August 2006

16. Chronic Obstructive Pulmonary DiseaseFact you might not know… COPD patients most likely have been smoking 20 cigarettes per day for 20 or more years before they even get symptoms (Snider, 2006). Microsoft clipart

17. What Causes COPD? What do youthink are the two causes of COPD? Find the two causes- click on word Cigarette Smoking Factory Work ObesityCancer DiabetesStroke Alcohol AbuseInactivity Coronary Heart Disease Alpha1-antitripsin Deficiency Click HERE to learn more about COPD.

18. Pathogenesis of COPD Inflammation bronchial walls Cause airway Fibrous bronchial walls obstruction & problems Hypertrophy of submucosal glands with ventilation Hypersecretion of mucus & perfusion Loss of elastic lung fibers and alveoli tissue (Porth, 2005)

19. Types of COPD: • Chronic Bronchitis ----- -Obstruction of small airway -Inflammation of major & small airways • Emphysema -Enlargement of air spaces -Destruction of tissues • Alpha1- antitrypsin deficiency -inherited disorder -protective material produced in liver and transported to lungs to help combat inflammation -leads to destruction of alveoli (Porth, 2005)

20. Characteristics of: Chronic Bronchitis • Cough with phlegm • Shortness of breath • Exercise Intolerance • Expiratory phase of respiration long • Wheezes and Crackles on auscultation • Inability to maintain stable arterial blood gases • Hypoxemia (Porth, 2005)

21. Characteristics of:Chronic Bronchitis • Doesn’t strike suddenly • Damage occurs before patients seek treatment • Pulmonary hypertension • Right heart failure with peripheral edema (Porth, 2005)

22. Chronic Bronchitis Diagnosis • Mucus producing cough most days of the month, three months of a year for two consecutive years (ALA). Microsoft Clipart

23. Characteristics: Emphysema • Dyspnea, slowly progressive • Abnormal Arterial Blood Gases • Use accessory muscles • Weight loss • Sputum production in morning, scant • Cough- minimal • Loss of lung elasticity • Destruction of alveoli walls and capillary beds (Porth, 2005)

24. Emphysema Diagnosis Careful history and physical examination Pulmonary function studies Forced Expiratory Volumes Chest radiographs Laboratory tests Microsoft clipart

25. COPD is the fourth leading cause of death in the United States. TRUE FALSE Heredity is the most common cause of COPD TRUE FALSE Click hereto proceed to next slide COPD- Let’s Review

26. Pathophysiology Autonomic Nervous System Respiratory Centers: MEDULLARY & PONS Ventilation Stretch Receptors Irritant Receptors Central Chemoreceptor Peripheral Chemoreceptor Monitor Stretch of Lungs & Chest Wall Involved With Reflexes Causing Coughing & Sneezing Respond to Arterial PCO2 Respond to Arterial PO2 & PCO2 (Freudenrich, 2007)

27. Factors that Influence the Respiratory Centers: Craig C. Freudenrich, Ph.D..  "How Your Lungs Work".  October 06, 2000  http://health.howstuffworks.com/lung.htm  (April 12, 2007) Carbon Dioxide: Central Receptor Monitors CO2 Concentration in CSF Hydrogen Ion (pH): Peripheral & Central Sensitive to pH of Blood and CSF Oxygen: Peripheral Receptor Monitors O2 concentration of blood  Hydrogen Ion=  Rate and Depth Breathing  oxygen Concentration=  Rate and Depth Breathing  CO2 =  Rate and Depth Breathing

28. The single most important driver of ventilation is CO2 But can be deadly for the COPD Patient Microsoft clipart CO2 CO2 CO2 CO2 CO2 CO2 CO2 CO2 CO2

29. Example of receptors at work: You administer high flow supplemental oxygen to a patient with COPD and the patient stops breathing. What Happened to your patient?

30. You removed his drive to breathe! Specifically, patients with COPD retain CO2 chronically. Administering oxygen removes the central chemoreceptor drive to breathe. The central chemoreceptor is not sensitive to small oxygen changes like when a person breathes deep but high flow oxygen administration extinguished the stimulus to breathe.

31. Arterial Blood Gases (ABG’s)SNAP SHOT OF YOUR PATIENT”S OXYGEN STATUS COPD PATIENT- 3L O2 Normal ABG Results Abnormal ABG Results pH 7.35-7.45 pH 7.32 PaCO2 35-45 PaCO2 69 HCO3 22-26 HCO3 32 PaO2 80-100 PaO2 86 The abnormal ABG finding indicates your patient is retaining CO2. What we don’t know just from the ABG result is if your patient is compensating or uncompensated. A complete history needs to be obtained. (Perry & Potter, 2006)

32. Pathophysiology COPD • Emphysema type of COPD: • Walls between many of the air sacs are destroyed leading to few large air sacs. • These large air sacs have less surface area for O2 and CO2 exchange. • Poor exchange of O2 and CO2 causes shortness of breath.

33. Pathophysiology COPD • Bronchitis type of COPD: • Airways inflamed and thickened • Increase number & size of mucus producing cells • Excessive mucus production • Coughing to remove mucus • Difficulty getting air in & out Used with permission: Jensen, M.S., Webanatomy (2007).

34. Pathophysiology COPD Take a look at the next slide and note where the oxygen exchange takes place in the lungs.

35. O2 and CO2 Exchange Used with permission: http://www.pbs.org/wgbh/nova/everest/exposure/body.html

36. Pathophysiology COPD Now take a look at the comparison of a healthy lung and a COPD emphysema lung.

37. With permission Copyright 2007 American Lung Association For more information about the American Lung Association or to support the work it does, call 1-800-LUNG-USA (1-800-586-4872) or log on to www.lungusa.org.

38. Pathophysiology COPD Probably a good time to share with you the… WISCONSIN TOBACCO QUIT LINE: 1-800-QUIT-NOW (1-800-784-8669) (UW WI Madison, 2005) Microsoft clipart

39. Pathophysiology QuizLet’s see how you are doing- Which type of COPD leads to destruction of the surface area of the alveoli? Chronic Bronchitis or Emphysema

40. Pathophysiology Quiz What causes the central chemoreceptor in the medulla to signal the respiratory center to increase the rate and depth of respirations? A. Low oxygen in blood B. High oxygen in blood C. High CO2 level in blood D. Gee, I need to review. CLICK HERE

41. Just checking in with you- How are you doing? Need to review more? Ready to move on? You are doing very well. We’re almost finished! Microsoft clipart

42. COPD- Signs and SymptomsReview… Chronic Cough-Major Factor in seeking care. Exercise intolerance-Fatigue Shortness of breath-At rest or activity (Kessenich & Dayer-Berenson, 2007)

43. What happens when your patient has an Exacerbation of COPD? These patients have sustained worsening of their usual state of health. They will exhibit: Worsening breathlessness Increased cough Increased sputum production (toyellow/green) (Bellamy, D. 2006)

44. What triggers a COPD Exacerbation? INFECTION AIR POLLUTION COLD WEATHER Weakened Immune System

45. COPD Patients • PINK PUFFER: early disease Emphysema • Over ventilate to maintain relatively normal ABG’s until late in disease • Red face • BLUE BLOATER: Chronic Bronchitis • Bronchial secretions and airway obstruction cause poor ventilation and perfusion; unable to compensate leading to hypoxia and cyanosis • Clubbing • Circumoral cyanosis (Porth, 2005) Microsoft Clipart

46. Barrel Chest- What’s this? COPD patients chest often looks barrel shaped. Why? These patients have a loss of lung elasticity. Airways collapse during expiration because pressure in lung tissue exceeds airway pressure. Air gets trapped causing increase in anteroposterior dimensions of the chest (Porth, 2005). Simply: Their lungs are chronically over inflated with air. Microsoft clipart

47. Pursed Lip Breathing- What’s this? COPD patients purse their lips to breath. WHY? Pursing your lips increases the resistance to the outflow of air. It helps to prevent airway collapse by increasing pressure (Porth, 2005). Simply: Pucker up. Try to blow air out. Feel the resistance? Microsoft clipart

48. Signs and Symptoms of CO2 RETAINERS Labored Breathing Feeling of Air Hunger Nausea Confusion Dizziness Headache

49. Nursing InterventionsNon Pharmaceutical SMOKING CESSATION AVOID EXPOSURE TO RESPIRATORY INFECTIONS ENCOURAGE FLU & PNEUMOCOCCAL VACCINES Microsoft clipart

50. Nursing InterventionsNon Pharmaceutical POSITIONING: Sit patient on side of bed with bed side table. BREATHING: Encourage pursed lip breathing. Incentive Spirometry DIET: Small frequent nutritious meals Easily swallowed food Microsoft clipart