N24: Class #8 Obstructive and Inflammatory Lung Disease

1. N24: Class #8Obstructive and Inflammatory Lung Disease • Emphysema • Chronic Bronchitis • Asthma Christine Hooper, Ed.D., RN Spring 2006

2. Class Objectives • Differentiate among the etiology, pathophysiology, clinical manifestations, collaborative care, and appropriate nursing diagnoses of the client with emphysema and chronic bronchitis. • Describe the etiology, pathophysiology, clinical manifestations, collaborative care, and appropriate nursing diagnoses of the client with asthma.

3. Chronic Obstructive Pulmonary Disease: COPD Disease of airflow obstruction that is not totally reversible • Chronic Bronchitis • Emphysema

4. COPD: Etiology • Cigarette smoking #1 • Recurrent respiratory infection • Alpha 1-antitrypsin deficiency • Aging

5. Chronic Bronchitis • Recurrent or chronic productive cough for a minimum of 3 months for 2 consecutive years. • Risk factors • Cigarette smoke • Air pollution

6. Chronic Bronchitis Pathophysiology • Chronic inflammation • Hypertrophy & hyperplasia of bronchial glands that secrete mucus • Increase number of goblet cells • Cilia are destroyed

7. Chronic Bronchitis Pathophysiology • Narrowing of airway • Starting w/ bronchi  smaller airways • airflow resistance • work of breathing • Hypoventilation & CO2 retention  hypoxemia & hypercapnea

8. Chronic Bronchitis Pathophysiology • Bronchospasm often occurs • End result • Hypoxemia • Hypercapnea • Polycythemia (increase RBCs) • Cyanosis • Cor pulmonale (enlargement of right side of heart)

9. Chronic Bronchitis: Clinical Manifestations • In early stages • Clients may not recognize early symptoms • Symptoms progress slowly • May not be diagnosed until severe episode with a cold or flu • Productive cough • Especially in the morning • Typically referred to as “cigarette cough” • Bronchospasm • Frequent respiratory infections

10. Chronic Bronchitis: Clinical Manifestations • Advanced stages • Dyspnea on exertion Dyspnea at rest • Hypoxemia & hypercapnea • Polycythemia • Cyanosis • Bluish-red skin color • Pulmonary hypertension Cor pulmonale

11. Chronic Bronchitis: Diagnostic Tests • PFTs • FVC:  Forced vital capacity • FEV1:  Forcible exhale in 1 second • FEV1/FVC = <70% • ABGs •  PaCO2 •  PaO2 • CBC •  Hct

12. Emphysema • Abnormal distension of air spaces • Actual cause is unknown

13. Emphysema: Pathophysiology • Structural changes • Hyperinflation of alveoli • Destruction of alveolar & alveolar-capillary walls • Small airways narrow • Lung elasticity decreases

14. Emphysema: Pathophysiology • Mechanisms of structural change • Obstruction of small bronchioles • Proteolytic enzymes destroy alveolar tissue • Elastin & collagen are destroyed • Support structure is destroyed • “paper bag” lungs

15. Emphysema: Pathophysiology • The end result: • Alveoli lose elastic recoil, then distend, & eventually blow out. • Small airways collapse or narrow • Air trapping • Hyperinflation • Decreased surface area for ventilation

16. Emphysema: Clinical Manifestations • Early stages • Dyspnea • Non productive cough • Diaphragm flattens • A-P diameter increases • “Barrel chest” • Hypoxemia may occur • Increased respiratory rate • Respiratory alkalosis • Prolonged expiratory phase

17. Emphysema: Clinical Manifestations • Later stages • Hypercapnea • Purse-lip breathing • Use of accessory muscles to breathe • Underweight • No appetite & increase breathing workload • Lung sounds diminished

18. Emphysema: Clinical Manifestations

19. Emphysema: Clinical Manifestations • Pulmonary function •  residual volume,  lung capacity, DECREASED FEV1, vital capacity maybe normal • Arterial blood gases • Normal in moderate disease • May develop respiratory alkalosis • Later: hypercapnia and respiratory acidosis • Chest x-ray • Flattened diaphragm • hyperinflation

20. Goals of Treatment: Emphysema & Chronic Bronchitis • Improved ventilation • Remove secretions • Prevent complications • Slow progression of signs & symptoms • Promote patient comfort and participation in treatment

21. Collaborative Care: Emphysema & Chronic Bronchitis • Treat respiratory infection • Monitor spirometry and PEFR • Nutritional support • Fluid intake 3 lit/day • O2 as indicated

22. Collaborative Care: Medications • Anti-inflammatory • Corticosteroids • Bronchodilators • Beta-adrenergic agonist: Proventil • Methylxanthines: Theophylline • Anticholinergics: Atrovent • Mucolytics: Mucomyst • Expectorants: Guaifenisin • Antihistamines: non-drying

23. Collaborative Care: Emphysema & Chronic Bronchitis • Client teaching • Support to stop smoking • Conservation of energy • Breathing exercises • Pursed lip breathing • Diaphragm breathing • Chest physiotherapy • Percussion, vibration • Postural drainage • Self-manage medications • Inhaler & oxygen equipment

24. Asthma • Reversible inflammation & obstruction • Intermittent attacks • Sudden onset • Varies from person to person • Severity can vary from shortness of breath to death

25. Asthma • Triggers • Allergens • Exercise • Respiratory infections • Drugs and food additives • Nose and sinus problems • GERD • Emotional stress

26. Asthma: Pathophysiology • Swelling of mucus membranes (edema) • Spasm of smooth muscle in bronchioles • Increased airway resistance • Increased mucus gland secretion

27. Asthma: Pathophysiology • Early phase response: 30 – 60 minutes • Allergen or irritant activates mast cells • Inflammatory mediators are released • histamine, bradykinin, leukotrienes, prostaglandins, platelet-activating-factor, chemotactic factors, cytokines • Intense inflammation occurs • Bronchial smooth muscle constricts • Increased vasodilation and permeability • Epithelial damage • Bronchospasm • Increased mucus secretion • Edema

28. Asthma: Pathophysiology • Late phase response: 5 – 6 hours • Characterized by inflammation • Eosinophils and neutrophils infiltrate • Mediators are released mast cells release histamine and additional mediators • Self-perpetuating cycle • Lymphocytes and monocytes invade as well • Future attacks may be worse because of increased airway reactivity that results from late phase response • Individual becomes hyperresponsive to specific allergens and non-specific irritants such as cold air and dust • Specific triggers can be difficult to identify and less stimulation is required to produce a reaction

29. Asthma: Early Clinical Manifestations • Expiratory & inspiratory wheezing • Dry or moist non-productive cough • Chest tightness • Dyspnea • Anxious &Agitated • Prolonged expiratory phase • Increased respiratory & heart rate • Decreased PEFR

30. Asthma: Early Clinical Manifestations • Wheezing • Chest tightness • Dyspnea • Cough • Prolonged expiratory phase [1:3 or 1:4]

31. Asthma: Severe Clinical Manifestations • Hypoxia • Confusion • Increased heart rate & blood pressure • Respiratory rate up to 40/minute & pursed lip breathing • Use of accessory muscles • Diaphoresis & pallor • Cyanotic nail beds • Flaring nostrils

32. Endotracheal Intubation

33. Classifications of Asthma • Mild intermittent • Mild persistent • Moderate persistent • Severe persistent

34. Asthma: Diagnostic Tests • Pulmonary Function Tests • FEV1 decreased • Increase of 12% - 15% after bronchodilator indicative of asthma • PEFR decreased • Symptomatic patient • eosinophils > 5% of total WBC • Increased serum IgE • Chest x-ray shows hyperinflation • ABGs • Early: respiratory alkalosis, PaO2 normal or near-normal • severe: respiratory acidosis, increased PaCO2,

35. Asthma: Collaborative Care • Mild intermittent • Avoid triggers • Premedicate before exercising • May not need daily medication • Mild persistent asthma • Avoid triggers • Premedicate before exercising • Low-dose inhaled corticosteroids

36. Asthma: Collaborative Care • Moderate persistent asthma • Low-medium dose inhaled corticosteroids • Long-acting beta2-agonists • Can increase doses or use theophylline or leukotriene-modifier [singulair, accolate, zyflo] • Severe persistent asthma • High-dose inhaled corticosteroids • Long-acting inhaled beta2-agonists • Corticosteroids if needed

37. Asthma: Collaborative Care • Acute episode • FEV1, PEFR, pulse oximetry compared to baseline • O2 therapy • Beta2-adrenergic agonist • via MDI w/spacer or nebulizer • Q20 minutes – 4 hours prn • Corticosteroids if initial response insufficient • Severity of attack determines po or IV • If poor response, consider IV aminophylline

38. Corticosteroids Not useful for acute attack Beclomethasone: vanceril, beclovent, qvar Cromolyn & nedocromil Inhibits immediate response from exercise and allergens Prevents late-phase response Useful for premedication for exercise, seasonal asthma Intal, Tilade Leukotriene modifiers Interfere with synthesis or block action of leukotrienes Have both bronchodilation and anti-inflammatory properties Not recommended for acute asthma attacks Should not be used as only therapy for persistent asthma Accolate, Singulair, Zyflo Asthma Medications: Anti-inflammatory

39. Asthma Medications: Bronchodilators • 2-adrenergic agonists • Rapid onset: quick relief of bronchoconstriction • Treatment of choice for acute attacks • If used too much causes tremors, anxiety, tachycardia, palpitations, nausea • Too-frequent use indicates poor control of asthma • Short-acting • Albuterol[proventil]; metaproterenol [alupent]; bitolterol [tornalate]; pirbuterol [maxair] • Long-acting • Useful for nocturnal asthma • Not useful for quick relief during an acute attack • Salmeterol [serevent]

40. Methylxanthines Less effective than beta-adrenergics Useful to alleviate bronchoconstriction of early and late phase, nocturnal asthma Does not relieve hyperresponsiveness Side effects: nausea, headache, insomnia, tachycardia, arrhythmias, seizures Theophylline, aminophylline Anticholinergics Inhibit parasympathetic effects on respiratory system Increased mucus Smooth muscle contraction Useful for pts w/adverse reactions to beta-adrenergics or in combination w/beta-adrenergics Ipratropium [atrovent] Ipratropium + albuterol [Combivent] Asthma Medications: Bronchodilators con’t

41. Asthma: Client Teaching • Correct use of medications • Signs & symptoms of an attack • Dyspnea, anxiety, tight chest, wheezing, cough • Relaxation techniques • When to call for help, seek treatment • Environmental control • Cough & postural drainage techniques

42. Asthma: Nursing Diagnoses • Ineffective airway clearancer/t bronchospasm, ineffective cough, excessive mucus • Anxiety r/t difficulty breathing, fear of suffocation • Ineffective therapeutic regimen management r/t lack of information about asthma