Chronic Obstructive Pulmonary Disease (COPD)refers to a condition of chronic airflow restriction. COPD is actually an umbrella term for two different diseases: chronic bronchitis (disease of the airways) and emphysema (disease of the parenchyma). COPD is a leading cause of death and disability worldwide. Experts predict it will be the third leading cause of death by 2020, up from sixth in 1990.
COPD has an insidious onset, with symptoms only appearing after 50% to 70% of lung function has been lost. Changes in the lungs cause increased work of breathing. People with COPD lose lung function two to three times faster than normal. COPD also increases the risk of lung cancer.
COPD has both pulmonary and comorbid components that contribute to the severity of the disease and associated disability. Comorbid components may include cardiovascular disease, malnutrition with skeletal muscle wasting, osteoporosis, anemia, increased gastroesophageal reflux
Diseases and psychological processes such as depression and anxiety.
COPD is triggered by cigarette smoke and other harmful particles that cause pneumonia. Lung tissue is destroyed in response to an increased presence of macrophages and CD-8 T lymphocytes. As part of the pathophysiological cascade, protective antiproteinases are inactivated, reducing lung tissue repair and promoting alveolar wall destruction.
- In chronic bronchitis, the airways thicken and the mucociliary elevator is inactivated while mucus production increases. As the airway narrows in diameter, airflow decreases.
- In emphysema, the destruction of the alveolar septa reduces the surface area available for gas exchange. Elastic recoil (where the lungs return to their original size after expanding during inspiration) decreases with loss of lung tissue structure, leading to air entrapment and hyperinflation.
Cigarette smoking is the most important risk factor for the development and progression of COPD. Smoking plays a central role in the pathogenesis of the disease and promotes lifelong loss of lung function. (See smoking cessation and risk of COPD by clicking the PDF icon above.)
Other risk factors include inhaled air pollution (occupational, indoor and outdoor), impaired lung development or severe lung infection in childhood, co-existing asthma and being female. Some experts count lower socioeconomic status and diet as risk factors.
It is also believed that genetic factors influence the severity of COPD. For example, alpha1-antitrypsin (AAT) deficiency is a recessive trait that causes early COPD.
Dyspnea is the most important disabling symptom of COPD and the most common. This sustained and uncomfortable respiratory effort is a complex phenomenon that varies from person to person and is triggered by increased ventilation resulting from an increased work of breathing.
But dyspnea is more than just a physiological phenomenon. It also has psychophysiological components that are triggered by factors such as anxiety and fear. People with COPD fear the feeling of breathlessness that comes from inefficient breathing. Therefore, they avoid physical activity; As dyspnea progresses, they begin to withdraw from activities, leading to a downward spiral of disability. After all, they also suffer from increasing shortness of breath at rest.
Many COPD patients also suffer from a cough, which can be productive or non-productive. Chronic sputum production indicates chronic bronchitis.
detection and diagnosis
The US Preventive Services Task Force does not recommend COPD screening for the general population. However, he urges healthcare providers to consider screening patients with a family history of AAT deficiency to assess clinical features of COPD or other lung diseases such as asthma.
Spirometry, the diagnostic tool of choice, measures airflow obstruction. Specific spirometry tests include forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC), which reflect the change in lung volume from total lung capacity through sustained expiration to residual volume. The ratio between the expired volume and the vital capacity (FEV1/FVC) is calculated. Normal FEV1/FVC is 70% or greater; a lower ratio indicates airflow obstruction and is a sensitive indicator of COPD. Generally, in the context of a reduced FEV1/FVC ratio, absolute FEV1 expressed as a percentage of the predicted value is used to assess disease severity. (See COPD staging by clicking the PDF icon above.)
The goals of COPD treatment are to improve functioning, treat or prevent secondary complications, and improve quality of life through symptom control. Since smoking is the main risk factor for COPD, it is important to quit smoking.
Bronchodilators, corticosteroids, and pneumonia and influenza vaccines are important to control symptoms and reduce complications.
Bronchodilators include beta2-agonists, anticholinergics, and methylxanthines. These drugs are usually phased in.
- Beta2 agonists relax airway smooth muscle. They can be short-acting (e.g. albuterol) or long-acting (e.g. formoterol).
- Anticholinergics promote bronchodilation by blocking acetylcholine in postganglionic cholinergic nerves. Tiotropium (Spiriva), a long-acting anticholinergic drug, works for more than 24 hours and is the first COPD drug that only requires a daily dose.
- Methylxanthines inhibit phosphodiesterase, which increases levels of cyclic adenosine monophosphate, which in turn causes bronchodilation. But methylxanthines are metabolized to caffeine in the liver and can reach toxic levels; Therefore, inhaled bronchodilators are more commonly used instead.
Although corticosteroids are used to reduce inflammation, they are of limited value in COPD. Inhaled corticosteroids have not been shown to slow lung function decline, although they may be indicated to reduce airway inflammation in patients with COPD and chronic bronchitis. Oral corticosteroids have also not been shown to be effective in COPD, but may be indicated in exacerbations of the disease.
COPD patients should receive vaccinations against pneumonia and influenza. Annual influenza vaccinations reduce serious complications in these patients by 50%. Patients older than 65 should also receive the pneumococcal vaccine (Pneumovax). Antibiotics are only recommended for acute exacerbations of bacterial infection.
Other medications such as mucolytics, antitussives, antioxidants, immunomodulators, and opioids are not recommended in patients with stable COPD.
Oxygen therapy is reserved for patients with hypoxemia. Although it does not improve lung function, it can improve survival in hypoxemic patients. The goal is to achieve an oxygen saturation level of 90% or higher. Oxygen should be prescribed in litres/minute for rest, sleep and activity, with prescription determined by arterial blood gas values and desaturation and nocturnal desaturation studies.
Oxygen supply systems include liquid oxygen, compressed gas, and concentrators. Every system has risks and benefits. Selection depends on patient mobility and functional goals.
Portable oxygen concentrators are the latest innovation in oxygen delivery, eliminating the need for patients to carry oxygen with them. These devices have proven to be safe and effective. In 2005, the Federal Aviation Administration passed new regulations allowing patients to fly with portable concentrators. However, the rule does not require airlines to allow these systems on board; Therefore, instruct patients to check with the airline about oxygen consumption when planning a trip. The National Association of Home Oxygen Patients (http://www.oxygenconcentratorstore.com/breathe-easy/resources/nhopa/) also provides information for patients.
Although optimal medical management reduces symptoms, it cannot reverse the pathological changes that follow COPD. For patients with chronic respiratory failure, healthcare providers may prescribe pulmonary rehabilitation (PR). This multidisciplinary program is individually tailored to optimize the patient's physical and social functioning and increase autonomy. It teaches patients how to manage symptoms and achieve their maximum level of performance. The scientific basis for RP has been well established through several randomized controlled clinical trials. Improved activity tolerance reduces disabling symptoms and improves quality of life.
Patients exercise three to five times a week, with each session lasting 30 to 90 minutes. When the patient completes RP, the prescription of home (maintenance) exercise is standard care. Although patients who complete RP do not routinely experience changes in lung function, many have improved exercise capacity, reduced shortness of breath, and better quality of life.
Lung volume reduction surgery (LVRS) is an option for select patients. As COPD progresses, the lungs in the chest cavity expand too much. LVRS removes part of the lung, which reduces the tightness in the chest cavity.
The procedure involves removing lung tissue from the apices, where smoke-induced COPD is often most severe. The remaining lung tissue can then expand again and function more efficiently. A large, multi-center, national emphysema treatment study testing the effectiveness of LVRS found that patients with emphysema where the upper lobe is predominant and a low baseline exercise capacity had the greatest benefit. On the other hand, patients with emphysema distributed in the lower lobes did not benefit from surgery.
Lung transplantation is another option for selected patients. (COPD is the most common diagnosis in lung transplant candidates.) Although limited by the shortage of organ donors, transplantation has a favorable risk-benefit ratio with good 1- and 2-year survival rates. A lung transplant is not a cure for COPD. Instead, the patient swaps end-stage COPD for lifelong immunosuppressive therapy to prevent organ rejection. Candidate selection is based on disease severity, comorbid conditions, and likelihood of survival to receive transplantation and survive post-transplantation. (For more information visitwww.unos.org.)
The care of patients with COPD focuses on treating symptoms, maximizing function and teaching skills to improve self-care. Appropriate referral of patients to community resources helps ensure continuity of quality care.
Be sure to include the patient's family in your lessons as they play a crucial role in the care. Educate them about the pathophysiology of COPD, including the links between lung changes and symptoms. Instruct patients to monitor their usual symptoms and to contact their doctor if symptoms worsen. Emphasize the importance of good infection control, such as B. washing hands frequently and avoiding crowds when upper respiratory tract infections are prevalent.
Provide prescription drug education that covers the proper use of inhaled drugs (including spacers if indicated), the proper order of taking drugs to maximize their effects, and side effects. Make sure patients know how to determine the amount of medication left inhaled so they don't run out. Emphasize the importance of getting vaccinated against pneumococcus and influenza. Finally, you urge every patient who smokes to quit. (See smoking cessation recommendations by clicking the PDF icon above.)
To help patients manage shortness of breath, direct them to activities that reduce or control shortness of breath, as described below.
- breathing techniques. Techniques such as pursed-lip breathing help reduce breathing while improving the expiratory phase (by increasing the laminar flow of exhaled air). Tell the patient that the slow, controlled expiration slows the small airways.
collapse, reducing the air entrapment that occurs during forced expiration.
- Correct positioning. Explain that the tripod position, in which the patient sits or stands with the arms braced forward, pushes the diaphragm down and forward and stabilizes the chest while reducing the work of breathing. If the patient reports increased dyspnea during activities of daily living (ADLs), particularly when raising the arms overhead, it is recommended that the arms be supported during ADLs, e.g. B. by resting the elbows on a surface. Point out that this reduces the competing demands on the arm, chest, and neck muscles needed to breathe.
- Techniques for saving energy. Advise clients to speed up activities, take frequent breaks, use assistive devices, and break down activities into smaller tasks to reduce the development of shortness of breath.
Also help determine the patient's best "breathing time" of the day and recommend reserving strenuous activity for this period. Finally, emphasize the need to avoid environmental triggers for shortness of breath, including extreme temperatures and exposure to air pollution, pollen, cigarette smoke, chemical fragrances, and dust.
COPD patients often have difficulty maintaining adequate food intake. As the disease progresses, many experience cachexia. Inform patients with nutritional compromise that their hemoglobin and serum albumin levels will likely be checked by their primary care physician.
To improve her nutritional status, advise her to eat small, high-protein meals frequently and avoid gas. Instruct them to watch their weight and food intake. If recommended, advise them to use high-calorie supplements.
Advise patients who require oxygen therapy of the following:
- proper use of oxygen, including the importance of avoiding nearby open flames
- Oxygen Prescribing Instructions
- proper equipment care
- Backup oxygen system in case of power failure.
Psychosocial concerns of COPD patients include increased dependence on others, lack of control over symptoms, and decreased energy. In addition, they are at high risk for depression and anxiety due to symptom burden and functional limitations. These issues can affect their social interactions, role perception, and physical abilities.
Help them verbalize their feelings and develop healthy coping behaviors. However, be aware that conversations can become tiring as increasing shortness of breath makes speaking difficult.
If necessary, include caregivers in your discussions. If the patient has significant psychosocial problems, you should refer them to a social worker, psychologist or psychiatrist.
Sexual intimacy is an area that is often overlooked by healthcare providers. COPD can affect certain aspects of sexual function. Men can develop erectile dysfunction when lung function decreases. In addition, the physical exertion involved in sexual activity causes shortness of breath in most COPD patients. The effort required for intercourse is similar to that required to walk up a flight of stairs at a normal pace. However, do point out that sex doesn't raise your blood pressure, heart rate, or breathing rate to dangerous levels. (For patient education regarding sexual activity, see Educating Patients About Sexual Intimacy by clicking the PDF icon above.)
COPD is increasing in prevalence and burden worldwide. By understanding its pathophysiology and learning all about treatment options, you can help your patients stay independent for as long as possible.
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Gerene S. Bauldoff is Associate Professor of Clinical Nursing and Director of the Specialty Program in Adult Health and Disease Programs at The Ohio State University College of Nursing in Columbus. The planners and authors of this CNE activity have disclosed that they have no relevant financial relationships with any commercial entity related to this activity.