Physiological basis of the care of the elderly client

1. Physiological basis of the care of the elderly client Respiratory System

2. Patient Scenario • D.A. is a 78 year old male who states he cannot get rid of his “cold” • He has a productive cough • Sputum is white to grey • He has a 31 pack year smoking history • He uses Albuterol inhaler up to 6 times per day

3. Informal evaluation What additional information do you need? • Subjective information • Objective information • Psychosocial information

4. Anatomy of the lungs

5. Performance of respiration • Controlled by respiratory muscles of the thorax • Diaphragm • Intercostal muscles • Coordinated by respiratory centers of the brain and carotid arteries • Respiratory centers respond to changes in: • Blood levels of oxygen • Carbon dioxide • Blood pH

6. Age related changes of the respiratory system • Stiffening of connective tissue of lungs • Alteration in alveolar shape → increased alveolar diameter • Decreased alveolar surface area • Increased chest wall stiffness • Stiffening of the diaphragm

7. Consequences of age-related changes • Increased residual volume • Decreased vital capacity • Premature airway closure → air trapping in lower airways

9. Abnormal breath sounds • Crackles—intermittent, nonmusical, caused by fluid filled alveoli popping open • Wheezes—high pitched, occur when air flow is blocked • Rhonchi—low pitched, snoring, rattling, occur when fluid partially blocks large airways

10. Measurement of oxygenation

11. Lung volumes and capacities

12. PFT results are based on predicted values

13. Arterial blood gases

14. Overlapping symptoms • Pulmonary embolism? • GERD? • Obstruction? • ACEi cough? • Vocal cord dysfunction?

15. Commonalities within lung diseases

16. Asthma • Airway inflammation • Increased mucous secretion production • Increased airway responsiveness/sensitivity • Reversible airflow obstruction (usually) • Eventually causes irreversible damage and scarring • Often overlooked in the older client

17. The asthmatic lung

18. Symptoms of asthma • Coughing • Wheezing • Shortness of breath • Chest tightness • Nocturnal dyspnea between 0400-0600 • CHF nocturnal dyspnea occurs 1-2 hours after retiring

19. Classifications of asthma

20. Goals of asthma therapy • Prevent symptoms that interfere with quality of life • Prevent exacerbations of asthma • Minimize need for emergency department visits • Maintain normal activity levels • Maintain (nearly) normal pulmonary function • Minimize use of “rescue” medication • Minimize adverse effects of medication

21. Stepwise approach to managing asthma Intermittent asthma • Step 1 • Preferred: short acting β-agonist (SABA) prn • Example: Albuterol Persistent asthma with daily medication • Step 2 • Preferred: low dose inhaled corticosteroids (ICS) • Example: Beclomethasone

22. Stepwise approach to managing asthma • Step 3 • Preferred: Low dose ICS + LABA or medium dose ICS • Example LABA: Advair • Step 4 • Preferred: Medium dose ICS + LABA

23. Stepwise approach to managing asthma • Step 5 • Preferred: High dose ICS + LABA • And consider Omalizumab for patients who have allergies • Step 6 • Preferred: High dose ICS + LABA + oral corticosteroid • And consider Omalizumab for patients who have allergies

24. Stepwise approach to managing asthma • At each step… • Patient education • Environmental control • Step up if needed • Step down if possible and if asthma is well controlled for at least 3 months

25. Use of inhalers • Refer to video link in syllabus • Spacers are useful for the elderly who have difficulty with coordination and timing (refer to link) • Encourage to rinse with warm water and expectorate (“swish and spit ”) to minimize candidiasis, gum disease, tooth decay

26. Use of nebulizers • Provides misted form of medication • Easy to use at home • Machine requires regular cleaning • Breathe slowly, deeply • Hold each breath 1-2 seconds before breathing out • Important to continue until dose is complete

27. Use of peak flow meter • Measures movement of air out of lungs • Helps patient antici- pate asthmatic episode • Patient finds best peak flow number • Every day for 2 weeks • On waking and between 1200-1400 • Before inhaled β-agonist

28. Potentially harmful medications for the patient with asthma • Β-blockers—can induce bronchospasm • NSAIDs—bronchospasm • Diuretics—hypokalemia • Antihistamines—prolonged QT interval • ACEi—cough • Antidepressants—symptoms of depression can be worsened by corticosteroids

29. Chronic obstructive pulmonary disease

30. Criteria for chronic bronchitis • Cough and sputum production on most days • Minimum of 3 months for at least 2 successive years, or, • For 6 months during 1 year

31. A note on acute bronchitis… • Acute inflammation of the bronchi • Usually self-limiting • Viral • Similar to pneumonia: productive cough, chills, lethargy, low grade fever • Negative chest xray • Treatment: rest, humidification, cough suppressants, acetaminophen

32. Criteria for emphysema • Permanent destruction of the alveoli • Collapse/narrowing of bronchioles • Usually in older adults with long smoking history

33. Chronic bronchitis Emphysema

34. Blue bloater • COPD with chronic bronchitis • Increased mucous production • Normal to decreased lung capacity • Increased residual lung volume with air trapping • Cyanosis and right heart failure • Body responds by decreasing ventilation and increasing cardiac output

35. Blue bloater

36. Pink puffer • COPD with severe emphysema • Pink complexion • Dyspnea • Increased residual lung capacity • Decreased elastic recoil • High tidal volume • Destruction of capillary bed • Body compensates for destruction of pulmonary capillary bed by hyperventilation • Retractions

37. Pink puffer

38. Effect of smoking and smoking cessation

39. Management of COPD • Assessment, monitoring treatment of disease • Reduce risk factors • Prevent disease progression • Assess, manage anxiety and depression • Mucolytic therapy (e.g., Mucomyst) • Rehabilitation • Manage exacerbations

40. Medications for COPD • Bronchodilators • Inhaled corticosteroids • Antibiotics • Flu vaccine annually • Pneumococcal vaccine at age 65 • Exercise training • Mucolytics and expectorants (e.g., Mucomyst, Guaifenesin)

41. Treatment of end-stage COPD • Continuous oxygen administration—low flow • Postural drainage • Chest percussion • Controlled coughing • Tracheal suctioning

42. Low flow oxygen in COPD • Normal stimulus to breathe is rise in CO2 level • In COPD, stimulus to breathe is a decrease in O2 level • Oxygen flow that is too high will minimize or eliminate the stimulus to breathe in a COPD patient

43. Tuberculosis in the elderly • Elderly the most vulnerable • Drug resistant forms prevalent • Vulnerability enhanced by multiple risk factors: • Living in an institution, homeless • Exposure to drug-resistant form • Previous infection • Diabetes • Use of immunosuppresive drugs (including corticosteroids) • Malnutrition • Renal failure

44. Treatment of tuberculosis • Isoniazid—prevent active disease once infected • Rifampin • Side effects can be significant • Interrupting treatment can create drug resistant form

45. Lung cancer in the elderly • More common in the young-old • Initial symptoms are vague and mimic other pulmonary illnesses • Chest xray initial diagnostic test • Older, debilitated patients may not be surgical candidates • Chemotherapy • Radiation • Palliative care

46. Respiratory infections: risk factors • History nosocomial pneumonia • COPD • Recent hospitalization, insitutionalization • Smoking • Hyperglycemia • Use of immunosuppressants and/or antibiotics and/or oxygen therapy • Recent antibiotic use • Eating dependency

47. Pneumonia symptoms in the elderly • Cough • Fever • Sputum production • Prodromal headache, myalgia, lethargy • Changes in behavior and mental status • New onset tachycardia and tachypnea • Change in function

48. Pneumonia

49. Pulmonary embolism risk factors • Clotting disorders • Immobility • Dehydration • Recent surgery • Atrial fibrillation • Obesity

50. Symptoms of pulmonary embolism • Sudden onset • Tachypnea • Dyspnea • Chest pain • Hypoxia • Hypotension • Possible shock