Download - respiratory system and copd
RESPIRATORY SYSTEM
MS SEENA RACHEL GEORGE
IMSC NURSING
BHCON
THE HUMAN RESPIRATORY SYSTEM
It is the system consisting of tubes and is responsible for the exchange of gases in Humans by filtering incoming air and transporting it into the microscopic alveoli where gases are exchanged
Your respiratory system provides the energy needed by cells of the body to funtion according to their designated tasks
The organs of the ldquoRespiratory Tractrdquo
can be divided into two groupsldquoSTRUCTURALLYrdquo
The Upper Respiratory Tract
Nose
Nasal cavity
Sinuses
Pharynx
The Lower Respiratory Tract
Larynx
Trachea
Bronchial Tree
Lungs
CONDUCTING PASSAGES
bull NOSE - NASAL CAVITY amp
PARANASAL SINUSES
bull PHARYNX
bull LARYNX ndash EPIGLOTTIS amp VOCAL CORDS
bull TRACHEA
bull BRONCHI ndash BRONCHIAL TREE
bull LUNGS ndashLOBES OF THE LUNGS
PLUERAL CAVITIES AND ALVEOLI
Nose (nasal cavity)
bull Both olfactory and respiratory functions
bull Inspired air is warmed or cooled
bull Brought close to body temperature
bull Also moistened by fluid derived from
transudation through epithelium and
secretions of glands and goblet cells
Warming and
humidification of inspired air
bull Moist air is necessary
for integrity and proper
functioning of
ciliated epithelium
bull Secretions have
bactericidal actions
bull Stiff hairs trap dust and
foreign particles
bull Resonator in voice and speech
Pharynxbull Nasal cavity opens posteriorly into
nasopharynx
bull During swallowing respiration is
Temporarily inhibited permitting
food to enter oropharynx
bull Elevation of larynx and
closure of vocal cords
prevents entry of food into larynx
Larynx
bull Lower part of pharynx and at upper end of
trachea
bull Cartilagenous cartilages being held
together ligaments
bull Production of voice
bull Achieved by forcible expulsion of air from
lungs causing production of sound
bull Contraction of adductor muscles and glottis
It is an enlargement in the airway
superior to the trachea and inferior to the pharynx
bull It helps keep particles from entering the
trachea and also houses the vocal cords
It is composed of a framework of muscles
and cartilage bound by elastic tissue
The Epiglottis
It is a large leaf-shaped piece of cartilage
A flap of cartilage that prevents food from
entering the trachea (or windpipe)
During swallowing there is elevation of the larynx
The Vocal Cords Inside the larynx 2 pairs of folds of muscle and
connective tissues covered with mucous membrane make up the vocal cords
a The upper pair is the false vocal cords
b The lower pair is the true vocal cords
c Changing tension on the vocal cords controls pitch while increasing the loudness depends upon increasing the force of air vibrating the vocal cords
During normal breathing the vocal cords are relaxed and the
glottis is a triangular slit
bull During swallowing the false vocal cords and epiglottis close off the glottis
THE TRACHEA
bull It is a tubular passage way for airlocated anterior to the esophagus
bull It extends from the larynx to the 5th thoracic vertebra where it divides into the
right and left bronchi
bull The inner wall of the trachea is lined with
ciliated mucous membrane
with many goblet cells
that serve to trap incoming
particles
bull The tracheal wall is
supported by 20 incomplete
cartilaginous rings
BRONCHI The Bronchi are the two main air passages
into the lungs
They are composed of the
ldquoRight Primary Bronchusrdquo- leading to the right lung
ldquoLeft Primary Bronchusrdquo - leading to the left lung
The Bronchial Tree
The bronchial tree consists of branched tubes leading from the trachea to the alveoli
The bronchial tree begins with the two primary bronchi each leading to a lung
The branches of the bronchial tree from the trachea are right and left primary bronchi
these further subdivide until bronchioles give rise to alveolar ducts which terminate in alveoli
LUNGS
bull One on either side
bull Large cone-shaped spongy structures
which occupy most of thoracic cavity
bull Left lung is divided into 2 lobes and right
into 3
bull Lined by pleura (visceral and parietal)
Terminal branches
bull Bronchioles branch further
and the smallest
subdivisions being terminal
bronchiole
bull It is estimated no of
divisions from tracheal
bifurcation to terminal
bronchiole is 16
bull Total no of divisions till
alveoli is 23
The right lung has three lobes
The left lung has two lobes
Each lobe is composed of lobules
that contain air passages alveoli nerves
blood vessels lymphatic vessels
and connective tissues
Pulmonary alveolibull Alveoli are lined by a single layer of flat epithelialcellsbull Alveolar type I cells are principal liningbull Type II are cuboidal cells secrete surfactantbull Average width is 03 mmbull 300 million alveoli in human lung
Surfactantbull Formed from fatty acids by alveolar type II cellsbull Complex mixture of several phospholipidsproteins and ionsbull Most important components are phospholipiddipalmitoyl phosphatidyl choline (DDPC)surfactant appoproteins and calcium ions
The Pleural Cavities
A layer of serous membrane between the visceral pleura and the parietal pleura
bull It contains a lubricating fluid secretedby the membranes that preventsfriction between the membranes and allows their easy movement on one another during breathing
The Alveoli
They are cup-shaped out pouching lined by epithelium and supported by a thin elastic basement membrane
bull With that you can imagine having bunch of grapeswith each grape indicating and alveolus
Alveolar sacs are 2 or more alveoli that share a common opening
This is where the primary exchange of gases occur
STRUCTURE
nose nasal cavity
pharynx (throat)
larynx
trachea (windpipe)
bronchi
bronchioles
alveoli
FUNCTION
warms moistens amp filters air as it is inhaled
passageway for air leads to trachea
the voice box where vocal chords are located
tube from pharynx to bronchi
rings of cartilage provide structure keeps the
windpipe open
trachea is lined with fine hairs called cilia which
filter air before it reaches the lungs
two branches at the end of the trachea each
lead to a lung
a network of smaller branches leading from the
bronchi into the lung tissue amp ultimately to air
sacs
the functional respiratory units in the lung
where gases (oxygen amp carbon dioxide) are
exchanged (enter amp exit the blood stream)
Summary of FUNCTIONS
LIST OF RESPIRATORY AND LUNG DISEASES
bull Upper respiratory tract infections
bull Lower respiratory tract infections
bull Asthma
bull Copd
bull Inflammatory lung diseases
bull Obstructive lung diseases
bull Restrictive lung diseases
bull Respiratory tumors
bull Pleural cavity diseases
bull Pulmonary vascular diseases
Diagnostic Test
bull CHEST XRAY
bull ABG ANALYSIS
bull EXERCISE TESTING
bull MEDIASTINOSCOPY amp MEDIASTINOTOMY
bull BRONCHOSCOPY
bull CHEST IMAGING
bull CHEST TUBE INSERTION
bull NEEDLE BIOPSY OF THE PLEURA OR LUNG
bull PULMONARY FUNCTION TEST (PFT)
bull SUCTIONING
bull THORACOCENTESIS
bull THORACOSCOPY
bull THORACOTOMY
COPD
bull Also known as
COLD (Chronic Obstructive Lung Disease )
COAD (Chronic Obstructive Airway Disease)
Smokerrsquos lung
CAL (Chronic Airflow Limitation)
CORD (Chronic Obstructive Respiratory Disease)
DEFINITION
Chronic obstructive pulmonary disease (COPD) is
a preventable and treatable disease characterized
by airflow limitation that is progressive not fully
reversible and associated with an abnormal
inflammatory response of the lungs
Chronic Bronchitis
bull Chronic bronchitis is a chronic inflammatory
condition in the lungs
bull It causes a cough that often brings up mucus as well as shortness of
breathwheezing and
chest tightness
Emphysema
bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs
EPIDEMIOLOGYbull More common in older people especially those
gt65 years
bull Fifth leading cause of death and disabilityworldwide
bull Death rates for males and females are roughlyequivalent
bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod
Risk Factors
Exposures Host Factors
Environmental tobacco smoke
Genetic predisposition (AAT deficiency)
Occupational dusts and chemicals
Airway hyperresponsiveness
Air pollution Impaired lung growth
Risk Factors
bull Exposures
ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD
ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD
Host Factors
bull Host factor refers to the traits of an individual person that affect susceptibility to disease
ndash AAT deficiency accounts for less than 1 of COPD cases
ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function
ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses
Pathophysiology of COPD
1 Airway inflammation
2 Structural changes
3 Mucociliary dysfunction
- Chronic inflammatory cascade for COPD
ASSESSMENT
1 Clinical presentation
ndash History
ndash Physical examination
2 Diagnostic testing
ndash Pulmonary function testing
ndash Laboratories
ndash Imaging
Clinical Presentation
HistoryPhysical
Examination
- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors
- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles
ASSESSMENT
bull General appearance
bull Vital signs Heart rhythm
bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
bull ABGs SaO2 CBC WBC and chest x-ray results
bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea
bull Nutrition and weight loss
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
THE HUMAN RESPIRATORY SYSTEM
It is the system consisting of tubes and is responsible for the exchange of gases in Humans by filtering incoming air and transporting it into the microscopic alveoli where gases are exchanged
Your respiratory system provides the energy needed by cells of the body to funtion according to their designated tasks
The organs of the ldquoRespiratory Tractrdquo
can be divided into two groupsldquoSTRUCTURALLYrdquo
The Upper Respiratory Tract
Nose
Nasal cavity
Sinuses
Pharynx
The Lower Respiratory Tract
Larynx
Trachea
Bronchial Tree
Lungs
CONDUCTING PASSAGES
bull NOSE - NASAL CAVITY amp
PARANASAL SINUSES
bull PHARYNX
bull LARYNX ndash EPIGLOTTIS amp VOCAL CORDS
bull TRACHEA
bull BRONCHI ndash BRONCHIAL TREE
bull LUNGS ndashLOBES OF THE LUNGS
PLUERAL CAVITIES AND ALVEOLI
Nose (nasal cavity)
bull Both olfactory and respiratory functions
bull Inspired air is warmed or cooled
bull Brought close to body temperature
bull Also moistened by fluid derived from
transudation through epithelium and
secretions of glands and goblet cells
Warming and
humidification of inspired air
bull Moist air is necessary
for integrity and proper
functioning of
ciliated epithelium
bull Secretions have
bactericidal actions
bull Stiff hairs trap dust and
foreign particles
bull Resonator in voice and speech
Pharynxbull Nasal cavity opens posteriorly into
nasopharynx
bull During swallowing respiration is
Temporarily inhibited permitting
food to enter oropharynx
bull Elevation of larynx and
closure of vocal cords
prevents entry of food into larynx
Larynx
bull Lower part of pharynx and at upper end of
trachea
bull Cartilagenous cartilages being held
together ligaments
bull Production of voice
bull Achieved by forcible expulsion of air from
lungs causing production of sound
bull Contraction of adductor muscles and glottis
It is an enlargement in the airway
superior to the trachea and inferior to the pharynx
bull It helps keep particles from entering the
trachea and also houses the vocal cords
It is composed of a framework of muscles
and cartilage bound by elastic tissue
The Epiglottis
It is a large leaf-shaped piece of cartilage
A flap of cartilage that prevents food from
entering the trachea (or windpipe)
During swallowing there is elevation of the larynx
The Vocal Cords Inside the larynx 2 pairs of folds of muscle and
connective tissues covered with mucous membrane make up the vocal cords
a The upper pair is the false vocal cords
b The lower pair is the true vocal cords
c Changing tension on the vocal cords controls pitch while increasing the loudness depends upon increasing the force of air vibrating the vocal cords
During normal breathing the vocal cords are relaxed and the
glottis is a triangular slit
bull During swallowing the false vocal cords and epiglottis close off the glottis
THE TRACHEA
bull It is a tubular passage way for airlocated anterior to the esophagus
bull It extends from the larynx to the 5th thoracic vertebra where it divides into the
right and left bronchi
bull The inner wall of the trachea is lined with
ciliated mucous membrane
with many goblet cells
that serve to trap incoming
particles
bull The tracheal wall is
supported by 20 incomplete
cartilaginous rings
BRONCHI The Bronchi are the two main air passages
into the lungs
They are composed of the
ldquoRight Primary Bronchusrdquo- leading to the right lung
ldquoLeft Primary Bronchusrdquo - leading to the left lung
The Bronchial Tree
The bronchial tree consists of branched tubes leading from the trachea to the alveoli
The bronchial tree begins with the two primary bronchi each leading to a lung
The branches of the bronchial tree from the trachea are right and left primary bronchi
these further subdivide until bronchioles give rise to alveolar ducts which terminate in alveoli
LUNGS
bull One on either side
bull Large cone-shaped spongy structures
which occupy most of thoracic cavity
bull Left lung is divided into 2 lobes and right
into 3
bull Lined by pleura (visceral and parietal)
Terminal branches
bull Bronchioles branch further
and the smallest
subdivisions being terminal
bronchiole
bull It is estimated no of
divisions from tracheal
bifurcation to terminal
bronchiole is 16
bull Total no of divisions till
alveoli is 23
The right lung has three lobes
The left lung has two lobes
Each lobe is composed of lobules
that contain air passages alveoli nerves
blood vessels lymphatic vessels
and connective tissues
Pulmonary alveolibull Alveoli are lined by a single layer of flat epithelialcellsbull Alveolar type I cells are principal liningbull Type II are cuboidal cells secrete surfactantbull Average width is 03 mmbull 300 million alveoli in human lung
Surfactantbull Formed from fatty acids by alveolar type II cellsbull Complex mixture of several phospholipidsproteins and ionsbull Most important components are phospholipiddipalmitoyl phosphatidyl choline (DDPC)surfactant appoproteins and calcium ions
The Pleural Cavities
A layer of serous membrane between the visceral pleura and the parietal pleura
bull It contains a lubricating fluid secretedby the membranes that preventsfriction between the membranes and allows their easy movement on one another during breathing
The Alveoli
They are cup-shaped out pouching lined by epithelium and supported by a thin elastic basement membrane
bull With that you can imagine having bunch of grapeswith each grape indicating and alveolus
Alveolar sacs are 2 or more alveoli that share a common opening
This is where the primary exchange of gases occur
STRUCTURE
nose nasal cavity
pharynx (throat)
larynx
trachea (windpipe)
bronchi
bronchioles
alveoli
FUNCTION
warms moistens amp filters air as it is inhaled
passageway for air leads to trachea
the voice box where vocal chords are located
tube from pharynx to bronchi
rings of cartilage provide structure keeps the
windpipe open
trachea is lined with fine hairs called cilia which
filter air before it reaches the lungs
two branches at the end of the trachea each
lead to a lung
a network of smaller branches leading from the
bronchi into the lung tissue amp ultimately to air
sacs
the functional respiratory units in the lung
where gases (oxygen amp carbon dioxide) are
exchanged (enter amp exit the blood stream)
Summary of FUNCTIONS
LIST OF RESPIRATORY AND LUNG DISEASES
bull Upper respiratory tract infections
bull Lower respiratory tract infections
bull Asthma
bull Copd
bull Inflammatory lung diseases
bull Obstructive lung diseases
bull Restrictive lung diseases
bull Respiratory tumors
bull Pleural cavity diseases
bull Pulmonary vascular diseases
Diagnostic Test
bull CHEST XRAY
bull ABG ANALYSIS
bull EXERCISE TESTING
bull MEDIASTINOSCOPY amp MEDIASTINOTOMY
bull BRONCHOSCOPY
bull CHEST IMAGING
bull CHEST TUBE INSERTION
bull NEEDLE BIOPSY OF THE PLEURA OR LUNG
bull PULMONARY FUNCTION TEST (PFT)
bull SUCTIONING
bull THORACOCENTESIS
bull THORACOSCOPY
bull THORACOTOMY
COPD
bull Also known as
COLD (Chronic Obstructive Lung Disease )
COAD (Chronic Obstructive Airway Disease)
Smokerrsquos lung
CAL (Chronic Airflow Limitation)
CORD (Chronic Obstructive Respiratory Disease)
DEFINITION
Chronic obstructive pulmonary disease (COPD) is
a preventable and treatable disease characterized
by airflow limitation that is progressive not fully
reversible and associated with an abnormal
inflammatory response of the lungs
Chronic Bronchitis
bull Chronic bronchitis is a chronic inflammatory
condition in the lungs
bull It causes a cough that often brings up mucus as well as shortness of
breathwheezing and
chest tightness
Emphysema
bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs
EPIDEMIOLOGYbull More common in older people especially those
gt65 years
bull Fifth leading cause of death and disabilityworldwide
bull Death rates for males and females are roughlyequivalent
bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod
Risk Factors
Exposures Host Factors
Environmental tobacco smoke
Genetic predisposition (AAT deficiency)
Occupational dusts and chemicals
Airway hyperresponsiveness
Air pollution Impaired lung growth
Risk Factors
bull Exposures
ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD
ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD
Host Factors
bull Host factor refers to the traits of an individual person that affect susceptibility to disease
ndash AAT deficiency accounts for less than 1 of COPD cases
ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function
ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses
Pathophysiology of COPD
1 Airway inflammation
2 Structural changes
3 Mucociliary dysfunction
- Chronic inflammatory cascade for COPD
ASSESSMENT
1 Clinical presentation
ndash History
ndash Physical examination
2 Diagnostic testing
ndash Pulmonary function testing
ndash Laboratories
ndash Imaging
Clinical Presentation
HistoryPhysical
Examination
- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors
- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles
ASSESSMENT
bull General appearance
bull Vital signs Heart rhythm
bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
bull ABGs SaO2 CBC WBC and chest x-ray results
bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea
bull Nutrition and weight loss
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
The organs of the ldquoRespiratory Tractrdquo
can be divided into two groupsldquoSTRUCTURALLYrdquo
The Upper Respiratory Tract
Nose
Nasal cavity
Sinuses
Pharynx
The Lower Respiratory Tract
Larynx
Trachea
Bronchial Tree
Lungs
CONDUCTING PASSAGES
bull NOSE - NASAL CAVITY amp
PARANASAL SINUSES
bull PHARYNX
bull LARYNX ndash EPIGLOTTIS amp VOCAL CORDS
bull TRACHEA
bull BRONCHI ndash BRONCHIAL TREE
bull LUNGS ndashLOBES OF THE LUNGS
PLUERAL CAVITIES AND ALVEOLI
Nose (nasal cavity)
bull Both olfactory and respiratory functions
bull Inspired air is warmed or cooled
bull Brought close to body temperature
bull Also moistened by fluid derived from
transudation through epithelium and
secretions of glands and goblet cells
Warming and
humidification of inspired air
bull Moist air is necessary
for integrity and proper
functioning of
ciliated epithelium
bull Secretions have
bactericidal actions
bull Stiff hairs trap dust and
foreign particles
bull Resonator in voice and speech
Pharynxbull Nasal cavity opens posteriorly into
nasopharynx
bull During swallowing respiration is
Temporarily inhibited permitting
food to enter oropharynx
bull Elevation of larynx and
closure of vocal cords
prevents entry of food into larynx
Larynx
bull Lower part of pharynx and at upper end of
trachea
bull Cartilagenous cartilages being held
together ligaments
bull Production of voice
bull Achieved by forcible expulsion of air from
lungs causing production of sound
bull Contraction of adductor muscles and glottis
It is an enlargement in the airway
superior to the trachea and inferior to the pharynx
bull It helps keep particles from entering the
trachea and also houses the vocal cords
It is composed of a framework of muscles
and cartilage bound by elastic tissue
The Epiglottis
It is a large leaf-shaped piece of cartilage
A flap of cartilage that prevents food from
entering the trachea (or windpipe)
During swallowing there is elevation of the larynx
The Vocal Cords Inside the larynx 2 pairs of folds of muscle and
connective tissues covered with mucous membrane make up the vocal cords
a The upper pair is the false vocal cords
b The lower pair is the true vocal cords
c Changing tension on the vocal cords controls pitch while increasing the loudness depends upon increasing the force of air vibrating the vocal cords
During normal breathing the vocal cords are relaxed and the
glottis is a triangular slit
bull During swallowing the false vocal cords and epiglottis close off the glottis
THE TRACHEA
bull It is a tubular passage way for airlocated anterior to the esophagus
bull It extends from the larynx to the 5th thoracic vertebra where it divides into the
right and left bronchi
bull The inner wall of the trachea is lined with
ciliated mucous membrane
with many goblet cells
that serve to trap incoming
particles
bull The tracheal wall is
supported by 20 incomplete
cartilaginous rings
BRONCHI The Bronchi are the two main air passages
into the lungs
They are composed of the
ldquoRight Primary Bronchusrdquo- leading to the right lung
ldquoLeft Primary Bronchusrdquo - leading to the left lung
The Bronchial Tree
The bronchial tree consists of branched tubes leading from the trachea to the alveoli
The bronchial tree begins with the two primary bronchi each leading to a lung
The branches of the bronchial tree from the trachea are right and left primary bronchi
these further subdivide until bronchioles give rise to alveolar ducts which terminate in alveoli
LUNGS
bull One on either side
bull Large cone-shaped spongy structures
which occupy most of thoracic cavity
bull Left lung is divided into 2 lobes and right
into 3
bull Lined by pleura (visceral and parietal)
Terminal branches
bull Bronchioles branch further
and the smallest
subdivisions being terminal
bronchiole
bull It is estimated no of
divisions from tracheal
bifurcation to terminal
bronchiole is 16
bull Total no of divisions till
alveoli is 23
The right lung has three lobes
The left lung has two lobes
Each lobe is composed of lobules
that contain air passages alveoli nerves
blood vessels lymphatic vessels
and connective tissues
Pulmonary alveolibull Alveoli are lined by a single layer of flat epithelialcellsbull Alveolar type I cells are principal liningbull Type II are cuboidal cells secrete surfactantbull Average width is 03 mmbull 300 million alveoli in human lung
Surfactantbull Formed from fatty acids by alveolar type II cellsbull Complex mixture of several phospholipidsproteins and ionsbull Most important components are phospholipiddipalmitoyl phosphatidyl choline (DDPC)surfactant appoproteins and calcium ions
The Pleural Cavities
A layer of serous membrane between the visceral pleura and the parietal pleura
bull It contains a lubricating fluid secretedby the membranes that preventsfriction between the membranes and allows their easy movement on one another during breathing
The Alveoli
They are cup-shaped out pouching lined by epithelium and supported by a thin elastic basement membrane
bull With that you can imagine having bunch of grapeswith each grape indicating and alveolus
Alveolar sacs are 2 or more alveoli that share a common opening
This is where the primary exchange of gases occur
STRUCTURE
nose nasal cavity
pharynx (throat)
larynx
trachea (windpipe)
bronchi
bronchioles
alveoli
FUNCTION
warms moistens amp filters air as it is inhaled
passageway for air leads to trachea
the voice box where vocal chords are located
tube from pharynx to bronchi
rings of cartilage provide structure keeps the
windpipe open
trachea is lined with fine hairs called cilia which
filter air before it reaches the lungs
two branches at the end of the trachea each
lead to a lung
a network of smaller branches leading from the
bronchi into the lung tissue amp ultimately to air
sacs
the functional respiratory units in the lung
where gases (oxygen amp carbon dioxide) are
exchanged (enter amp exit the blood stream)
Summary of FUNCTIONS
LIST OF RESPIRATORY AND LUNG DISEASES
bull Upper respiratory tract infections
bull Lower respiratory tract infections
bull Asthma
bull Copd
bull Inflammatory lung diseases
bull Obstructive lung diseases
bull Restrictive lung diseases
bull Respiratory tumors
bull Pleural cavity diseases
bull Pulmonary vascular diseases
Diagnostic Test
bull CHEST XRAY
bull ABG ANALYSIS
bull EXERCISE TESTING
bull MEDIASTINOSCOPY amp MEDIASTINOTOMY
bull BRONCHOSCOPY
bull CHEST IMAGING
bull CHEST TUBE INSERTION
bull NEEDLE BIOPSY OF THE PLEURA OR LUNG
bull PULMONARY FUNCTION TEST (PFT)
bull SUCTIONING
bull THORACOCENTESIS
bull THORACOSCOPY
bull THORACOTOMY
COPD
bull Also known as
COLD (Chronic Obstructive Lung Disease )
COAD (Chronic Obstructive Airway Disease)
Smokerrsquos lung
CAL (Chronic Airflow Limitation)
CORD (Chronic Obstructive Respiratory Disease)
DEFINITION
Chronic obstructive pulmonary disease (COPD) is
a preventable and treatable disease characterized
by airflow limitation that is progressive not fully
reversible and associated with an abnormal
inflammatory response of the lungs
Chronic Bronchitis
bull Chronic bronchitis is a chronic inflammatory
condition in the lungs
bull It causes a cough that often brings up mucus as well as shortness of
breathwheezing and
chest tightness
Emphysema
bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs
EPIDEMIOLOGYbull More common in older people especially those
gt65 years
bull Fifth leading cause of death and disabilityworldwide
bull Death rates for males and females are roughlyequivalent
bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod
Risk Factors
Exposures Host Factors
Environmental tobacco smoke
Genetic predisposition (AAT deficiency)
Occupational dusts and chemicals
Airway hyperresponsiveness
Air pollution Impaired lung growth
Risk Factors
bull Exposures
ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD
ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD
Host Factors
bull Host factor refers to the traits of an individual person that affect susceptibility to disease
ndash AAT deficiency accounts for less than 1 of COPD cases
ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function
ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses
Pathophysiology of COPD
1 Airway inflammation
2 Structural changes
3 Mucociliary dysfunction
- Chronic inflammatory cascade for COPD
ASSESSMENT
1 Clinical presentation
ndash History
ndash Physical examination
2 Diagnostic testing
ndash Pulmonary function testing
ndash Laboratories
ndash Imaging
Clinical Presentation
HistoryPhysical
Examination
- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors
- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles
ASSESSMENT
bull General appearance
bull Vital signs Heart rhythm
bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
bull ABGs SaO2 CBC WBC and chest x-ray results
bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea
bull Nutrition and weight loss
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
CONDUCTING PASSAGES
bull NOSE - NASAL CAVITY amp
PARANASAL SINUSES
bull PHARYNX
bull LARYNX ndash EPIGLOTTIS amp VOCAL CORDS
bull TRACHEA
bull BRONCHI ndash BRONCHIAL TREE
bull LUNGS ndashLOBES OF THE LUNGS
PLUERAL CAVITIES AND ALVEOLI
Nose (nasal cavity)
bull Both olfactory and respiratory functions
bull Inspired air is warmed or cooled
bull Brought close to body temperature
bull Also moistened by fluid derived from
transudation through epithelium and
secretions of glands and goblet cells
Warming and
humidification of inspired air
bull Moist air is necessary
for integrity and proper
functioning of
ciliated epithelium
bull Secretions have
bactericidal actions
bull Stiff hairs trap dust and
foreign particles
bull Resonator in voice and speech
Pharynxbull Nasal cavity opens posteriorly into
nasopharynx
bull During swallowing respiration is
Temporarily inhibited permitting
food to enter oropharynx
bull Elevation of larynx and
closure of vocal cords
prevents entry of food into larynx
Larynx
bull Lower part of pharynx and at upper end of
trachea
bull Cartilagenous cartilages being held
together ligaments
bull Production of voice
bull Achieved by forcible expulsion of air from
lungs causing production of sound
bull Contraction of adductor muscles and glottis
It is an enlargement in the airway
superior to the trachea and inferior to the pharynx
bull It helps keep particles from entering the
trachea and also houses the vocal cords
It is composed of a framework of muscles
and cartilage bound by elastic tissue
The Epiglottis
It is a large leaf-shaped piece of cartilage
A flap of cartilage that prevents food from
entering the trachea (or windpipe)
During swallowing there is elevation of the larynx
The Vocal Cords Inside the larynx 2 pairs of folds of muscle and
connective tissues covered with mucous membrane make up the vocal cords
a The upper pair is the false vocal cords
b The lower pair is the true vocal cords
c Changing tension on the vocal cords controls pitch while increasing the loudness depends upon increasing the force of air vibrating the vocal cords
During normal breathing the vocal cords are relaxed and the
glottis is a triangular slit
bull During swallowing the false vocal cords and epiglottis close off the glottis
THE TRACHEA
bull It is a tubular passage way for airlocated anterior to the esophagus
bull It extends from the larynx to the 5th thoracic vertebra where it divides into the
right and left bronchi
bull The inner wall of the trachea is lined with
ciliated mucous membrane
with many goblet cells
that serve to trap incoming
particles
bull The tracheal wall is
supported by 20 incomplete
cartilaginous rings
BRONCHI The Bronchi are the two main air passages
into the lungs
They are composed of the
ldquoRight Primary Bronchusrdquo- leading to the right lung
ldquoLeft Primary Bronchusrdquo - leading to the left lung
The Bronchial Tree
The bronchial tree consists of branched tubes leading from the trachea to the alveoli
The bronchial tree begins with the two primary bronchi each leading to a lung
The branches of the bronchial tree from the trachea are right and left primary bronchi
these further subdivide until bronchioles give rise to alveolar ducts which terminate in alveoli
LUNGS
bull One on either side
bull Large cone-shaped spongy structures
which occupy most of thoracic cavity
bull Left lung is divided into 2 lobes and right
into 3
bull Lined by pleura (visceral and parietal)
Terminal branches
bull Bronchioles branch further
and the smallest
subdivisions being terminal
bronchiole
bull It is estimated no of
divisions from tracheal
bifurcation to terminal
bronchiole is 16
bull Total no of divisions till
alveoli is 23
The right lung has three lobes
The left lung has two lobes
Each lobe is composed of lobules
that contain air passages alveoli nerves
blood vessels lymphatic vessels
and connective tissues
Pulmonary alveolibull Alveoli are lined by a single layer of flat epithelialcellsbull Alveolar type I cells are principal liningbull Type II are cuboidal cells secrete surfactantbull Average width is 03 mmbull 300 million alveoli in human lung
Surfactantbull Formed from fatty acids by alveolar type II cellsbull Complex mixture of several phospholipidsproteins and ionsbull Most important components are phospholipiddipalmitoyl phosphatidyl choline (DDPC)surfactant appoproteins and calcium ions
The Pleural Cavities
A layer of serous membrane between the visceral pleura and the parietal pleura
bull It contains a lubricating fluid secretedby the membranes that preventsfriction between the membranes and allows their easy movement on one another during breathing
The Alveoli
They are cup-shaped out pouching lined by epithelium and supported by a thin elastic basement membrane
bull With that you can imagine having bunch of grapeswith each grape indicating and alveolus
Alveolar sacs are 2 or more alveoli that share a common opening
This is where the primary exchange of gases occur
STRUCTURE
nose nasal cavity
pharynx (throat)
larynx
trachea (windpipe)
bronchi
bronchioles
alveoli
FUNCTION
warms moistens amp filters air as it is inhaled
passageway for air leads to trachea
the voice box where vocal chords are located
tube from pharynx to bronchi
rings of cartilage provide structure keeps the
windpipe open
trachea is lined with fine hairs called cilia which
filter air before it reaches the lungs
two branches at the end of the trachea each
lead to a lung
a network of smaller branches leading from the
bronchi into the lung tissue amp ultimately to air
sacs
the functional respiratory units in the lung
where gases (oxygen amp carbon dioxide) are
exchanged (enter amp exit the blood stream)
Summary of FUNCTIONS
LIST OF RESPIRATORY AND LUNG DISEASES
bull Upper respiratory tract infections
bull Lower respiratory tract infections
bull Asthma
bull Copd
bull Inflammatory lung diseases
bull Obstructive lung diseases
bull Restrictive lung diseases
bull Respiratory tumors
bull Pleural cavity diseases
bull Pulmonary vascular diseases
Diagnostic Test
bull CHEST XRAY
bull ABG ANALYSIS
bull EXERCISE TESTING
bull MEDIASTINOSCOPY amp MEDIASTINOTOMY
bull BRONCHOSCOPY
bull CHEST IMAGING
bull CHEST TUBE INSERTION
bull NEEDLE BIOPSY OF THE PLEURA OR LUNG
bull PULMONARY FUNCTION TEST (PFT)
bull SUCTIONING
bull THORACOCENTESIS
bull THORACOSCOPY
bull THORACOTOMY
COPD
bull Also known as
COLD (Chronic Obstructive Lung Disease )
COAD (Chronic Obstructive Airway Disease)
Smokerrsquos lung
CAL (Chronic Airflow Limitation)
CORD (Chronic Obstructive Respiratory Disease)
DEFINITION
Chronic obstructive pulmonary disease (COPD) is
a preventable and treatable disease characterized
by airflow limitation that is progressive not fully
reversible and associated with an abnormal
inflammatory response of the lungs
Chronic Bronchitis
bull Chronic bronchitis is a chronic inflammatory
condition in the lungs
bull It causes a cough that often brings up mucus as well as shortness of
breathwheezing and
chest tightness
Emphysema
bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs
EPIDEMIOLOGYbull More common in older people especially those
gt65 years
bull Fifth leading cause of death and disabilityworldwide
bull Death rates for males and females are roughlyequivalent
bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod
Risk Factors
Exposures Host Factors
Environmental tobacco smoke
Genetic predisposition (AAT deficiency)
Occupational dusts and chemicals
Airway hyperresponsiveness
Air pollution Impaired lung growth
Risk Factors
bull Exposures
ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD
ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD
Host Factors
bull Host factor refers to the traits of an individual person that affect susceptibility to disease
ndash AAT deficiency accounts for less than 1 of COPD cases
ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function
ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses
Pathophysiology of COPD
1 Airway inflammation
2 Structural changes
3 Mucociliary dysfunction
- Chronic inflammatory cascade for COPD
ASSESSMENT
1 Clinical presentation
ndash History
ndash Physical examination
2 Diagnostic testing
ndash Pulmonary function testing
ndash Laboratories
ndash Imaging
Clinical Presentation
HistoryPhysical
Examination
- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors
- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles
ASSESSMENT
bull General appearance
bull Vital signs Heart rhythm
bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
bull ABGs SaO2 CBC WBC and chest x-ray results
bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea
bull Nutrition and weight loss
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Nose (nasal cavity)
bull Both olfactory and respiratory functions
bull Inspired air is warmed or cooled
bull Brought close to body temperature
bull Also moistened by fluid derived from
transudation through epithelium and
secretions of glands and goblet cells
Warming and
humidification of inspired air
bull Moist air is necessary
for integrity and proper
functioning of
ciliated epithelium
bull Secretions have
bactericidal actions
bull Stiff hairs trap dust and
foreign particles
bull Resonator in voice and speech
Pharynxbull Nasal cavity opens posteriorly into
nasopharynx
bull During swallowing respiration is
Temporarily inhibited permitting
food to enter oropharynx
bull Elevation of larynx and
closure of vocal cords
prevents entry of food into larynx
Larynx
bull Lower part of pharynx and at upper end of
trachea
bull Cartilagenous cartilages being held
together ligaments
bull Production of voice
bull Achieved by forcible expulsion of air from
lungs causing production of sound
bull Contraction of adductor muscles and glottis
It is an enlargement in the airway
superior to the trachea and inferior to the pharynx
bull It helps keep particles from entering the
trachea and also houses the vocal cords
It is composed of a framework of muscles
and cartilage bound by elastic tissue
The Epiglottis
It is a large leaf-shaped piece of cartilage
A flap of cartilage that prevents food from
entering the trachea (or windpipe)
During swallowing there is elevation of the larynx
The Vocal Cords Inside the larynx 2 pairs of folds of muscle and
connective tissues covered with mucous membrane make up the vocal cords
a The upper pair is the false vocal cords
b The lower pair is the true vocal cords
c Changing tension on the vocal cords controls pitch while increasing the loudness depends upon increasing the force of air vibrating the vocal cords
During normal breathing the vocal cords are relaxed and the
glottis is a triangular slit
bull During swallowing the false vocal cords and epiglottis close off the glottis
THE TRACHEA
bull It is a tubular passage way for airlocated anterior to the esophagus
bull It extends from the larynx to the 5th thoracic vertebra where it divides into the
right and left bronchi
bull The inner wall of the trachea is lined with
ciliated mucous membrane
with many goblet cells
that serve to trap incoming
particles
bull The tracheal wall is
supported by 20 incomplete
cartilaginous rings
BRONCHI The Bronchi are the two main air passages
into the lungs
They are composed of the
ldquoRight Primary Bronchusrdquo- leading to the right lung
ldquoLeft Primary Bronchusrdquo - leading to the left lung
The Bronchial Tree
The bronchial tree consists of branched tubes leading from the trachea to the alveoli
The bronchial tree begins with the two primary bronchi each leading to a lung
The branches of the bronchial tree from the trachea are right and left primary bronchi
these further subdivide until bronchioles give rise to alveolar ducts which terminate in alveoli
LUNGS
bull One on either side
bull Large cone-shaped spongy structures
which occupy most of thoracic cavity
bull Left lung is divided into 2 lobes and right
into 3
bull Lined by pleura (visceral and parietal)
Terminal branches
bull Bronchioles branch further
and the smallest
subdivisions being terminal
bronchiole
bull It is estimated no of
divisions from tracheal
bifurcation to terminal
bronchiole is 16
bull Total no of divisions till
alveoli is 23
The right lung has three lobes
The left lung has two lobes
Each lobe is composed of lobules
that contain air passages alveoli nerves
blood vessels lymphatic vessels
and connective tissues
Pulmonary alveolibull Alveoli are lined by a single layer of flat epithelialcellsbull Alveolar type I cells are principal liningbull Type II are cuboidal cells secrete surfactantbull Average width is 03 mmbull 300 million alveoli in human lung
Surfactantbull Formed from fatty acids by alveolar type II cellsbull Complex mixture of several phospholipidsproteins and ionsbull Most important components are phospholipiddipalmitoyl phosphatidyl choline (DDPC)surfactant appoproteins and calcium ions
The Pleural Cavities
A layer of serous membrane between the visceral pleura and the parietal pleura
bull It contains a lubricating fluid secretedby the membranes that preventsfriction between the membranes and allows their easy movement on one another during breathing
The Alveoli
They are cup-shaped out pouching lined by epithelium and supported by a thin elastic basement membrane
bull With that you can imagine having bunch of grapeswith each grape indicating and alveolus
Alveolar sacs are 2 or more alveoli that share a common opening
This is where the primary exchange of gases occur
STRUCTURE
nose nasal cavity
pharynx (throat)
larynx
trachea (windpipe)
bronchi
bronchioles
alveoli
FUNCTION
warms moistens amp filters air as it is inhaled
passageway for air leads to trachea
the voice box where vocal chords are located
tube from pharynx to bronchi
rings of cartilage provide structure keeps the
windpipe open
trachea is lined with fine hairs called cilia which
filter air before it reaches the lungs
two branches at the end of the trachea each
lead to a lung
a network of smaller branches leading from the
bronchi into the lung tissue amp ultimately to air
sacs
the functional respiratory units in the lung
where gases (oxygen amp carbon dioxide) are
exchanged (enter amp exit the blood stream)
Summary of FUNCTIONS
LIST OF RESPIRATORY AND LUNG DISEASES
bull Upper respiratory tract infections
bull Lower respiratory tract infections
bull Asthma
bull Copd
bull Inflammatory lung diseases
bull Obstructive lung diseases
bull Restrictive lung diseases
bull Respiratory tumors
bull Pleural cavity diseases
bull Pulmonary vascular diseases
Diagnostic Test
bull CHEST XRAY
bull ABG ANALYSIS
bull EXERCISE TESTING
bull MEDIASTINOSCOPY amp MEDIASTINOTOMY
bull BRONCHOSCOPY
bull CHEST IMAGING
bull CHEST TUBE INSERTION
bull NEEDLE BIOPSY OF THE PLEURA OR LUNG
bull PULMONARY FUNCTION TEST (PFT)
bull SUCTIONING
bull THORACOCENTESIS
bull THORACOSCOPY
bull THORACOTOMY
COPD
bull Also known as
COLD (Chronic Obstructive Lung Disease )
COAD (Chronic Obstructive Airway Disease)
Smokerrsquos lung
CAL (Chronic Airflow Limitation)
CORD (Chronic Obstructive Respiratory Disease)
DEFINITION
Chronic obstructive pulmonary disease (COPD) is
a preventable and treatable disease characterized
by airflow limitation that is progressive not fully
reversible and associated with an abnormal
inflammatory response of the lungs
Chronic Bronchitis
bull Chronic bronchitis is a chronic inflammatory
condition in the lungs
bull It causes a cough that often brings up mucus as well as shortness of
breathwheezing and
chest tightness
Emphysema
bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs
EPIDEMIOLOGYbull More common in older people especially those
gt65 years
bull Fifth leading cause of death and disabilityworldwide
bull Death rates for males and females are roughlyequivalent
bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod
Risk Factors
Exposures Host Factors
Environmental tobacco smoke
Genetic predisposition (AAT deficiency)
Occupational dusts and chemicals
Airway hyperresponsiveness
Air pollution Impaired lung growth
Risk Factors
bull Exposures
ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD
ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD
Host Factors
bull Host factor refers to the traits of an individual person that affect susceptibility to disease
ndash AAT deficiency accounts for less than 1 of COPD cases
ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function
ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses
Pathophysiology of COPD
1 Airway inflammation
2 Structural changes
3 Mucociliary dysfunction
- Chronic inflammatory cascade for COPD
ASSESSMENT
1 Clinical presentation
ndash History
ndash Physical examination
2 Diagnostic testing
ndash Pulmonary function testing
ndash Laboratories
ndash Imaging
Clinical Presentation
HistoryPhysical
Examination
- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors
- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles
ASSESSMENT
bull General appearance
bull Vital signs Heart rhythm
bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
bull ABGs SaO2 CBC WBC and chest x-ray results
bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea
bull Nutrition and weight loss
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Warming and
humidification of inspired air
bull Moist air is necessary
for integrity and proper
functioning of
ciliated epithelium
bull Secretions have
bactericidal actions
bull Stiff hairs trap dust and
foreign particles
bull Resonator in voice and speech
Pharynxbull Nasal cavity opens posteriorly into
nasopharynx
bull During swallowing respiration is
Temporarily inhibited permitting
food to enter oropharynx
bull Elevation of larynx and
closure of vocal cords
prevents entry of food into larynx
Larynx
bull Lower part of pharynx and at upper end of
trachea
bull Cartilagenous cartilages being held
together ligaments
bull Production of voice
bull Achieved by forcible expulsion of air from
lungs causing production of sound
bull Contraction of adductor muscles and glottis
It is an enlargement in the airway
superior to the trachea and inferior to the pharynx
bull It helps keep particles from entering the
trachea and also houses the vocal cords
It is composed of a framework of muscles
and cartilage bound by elastic tissue
The Epiglottis
It is a large leaf-shaped piece of cartilage
A flap of cartilage that prevents food from
entering the trachea (or windpipe)
During swallowing there is elevation of the larynx
The Vocal Cords Inside the larynx 2 pairs of folds of muscle and
connective tissues covered with mucous membrane make up the vocal cords
a The upper pair is the false vocal cords
b The lower pair is the true vocal cords
c Changing tension on the vocal cords controls pitch while increasing the loudness depends upon increasing the force of air vibrating the vocal cords
During normal breathing the vocal cords are relaxed and the
glottis is a triangular slit
bull During swallowing the false vocal cords and epiglottis close off the glottis
THE TRACHEA
bull It is a tubular passage way for airlocated anterior to the esophagus
bull It extends from the larynx to the 5th thoracic vertebra where it divides into the
right and left bronchi
bull The inner wall of the trachea is lined with
ciliated mucous membrane
with many goblet cells
that serve to trap incoming
particles
bull The tracheal wall is
supported by 20 incomplete
cartilaginous rings
BRONCHI The Bronchi are the two main air passages
into the lungs
They are composed of the
ldquoRight Primary Bronchusrdquo- leading to the right lung
ldquoLeft Primary Bronchusrdquo - leading to the left lung
The Bronchial Tree
The bronchial tree consists of branched tubes leading from the trachea to the alveoli
The bronchial tree begins with the two primary bronchi each leading to a lung
The branches of the bronchial tree from the trachea are right and left primary bronchi
these further subdivide until bronchioles give rise to alveolar ducts which terminate in alveoli
LUNGS
bull One on either side
bull Large cone-shaped spongy structures
which occupy most of thoracic cavity
bull Left lung is divided into 2 lobes and right
into 3
bull Lined by pleura (visceral and parietal)
Terminal branches
bull Bronchioles branch further
and the smallest
subdivisions being terminal
bronchiole
bull It is estimated no of
divisions from tracheal
bifurcation to terminal
bronchiole is 16
bull Total no of divisions till
alveoli is 23
The right lung has three lobes
The left lung has two lobes
Each lobe is composed of lobules
that contain air passages alveoli nerves
blood vessels lymphatic vessels
and connective tissues
Pulmonary alveolibull Alveoli are lined by a single layer of flat epithelialcellsbull Alveolar type I cells are principal liningbull Type II are cuboidal cells secrete surfactantbull Average width is 03 mmbull 300 million alveoli in human lung
Surfactantbull Formed from fatty acids by alveolar type II cellsbull Complex mixture of several phospholipidsproteins and ionsbull Most important components are phospholipiddipalmitoyl phosphatidyl choline (DDPC)surfactant appoproteins and calcium ions
The Pleural Cavities
A layer of serous membrane between the visceral pleura and the parietal pleura
bull It contains a lubricating fluid secretedby the membranes that preventsfriction between the membranes and allows their easy movement on one another during breathing
The Alveoli
They are cup-shaped out pouching lined by epithelium and supported by a thin elastic basement membrane
bull With that you can imagine having bunch of grapeswith each grape indicating and alveolus
Alveolar sacs are 2 or more alveoli that share a common opening
This is where the primary exchange of gases occur
STRUCTURE
nose nasal cavity
pharynx (throat)
larynx
trachea (windpipe)
bronchi
bronchioles
alveoli
FUNCTION
warms moistens amp filters air as it is inhaled
passageway for air leads to trachea
the voice box where vocal chords are located
tube from pharynx to bronchi
rings of cartilage provide structure keeps the
windpipe open
trachea is lined with fine hairs called cilia which
filter air before it reaches the lungs
two branches at the end of the trachea each
lead to a lung
a network of smaller branches leading from the
bronchi into the lung tissue amp ultimately to air
sacs
the functional respiratory units in the lung
where gases (oxygen amp carbon dioxide) are
exchanged (enter amp exit the blood stream)
Summary of FUNCTIONS
LIST OF RESPIRATORY AND LUNG DISEASES
bull Upper respiratory tract infections
bull Lower respiratory tract infections
bull Asthma
bull Copd
bull Inflammatory lung diseases
bull Obstructive lung diseases
bull Restrictive lung diseases
bull Respiratory tumors
bull Pleural cavity diseases
bull Pulmonary vascular diseases
Diagnostic Test
bull CHEST XRAY
bull ABG ANALYSIS
bull EXERCISE TESTING
bull MEDIASTINOSCOPY amp MEDIASTINOTOMY
bull BRONCHOSCOPY
bull CHEST IMAGING
bull CHEST TUBE INSERTION
bull NEEDLE BIOPSY OF THE PLEURA OR LUNG
bull PULMONARY FUNCTION TEST (PFT)
bull SUCTIONING
bull THORACOCENTESIS
bull THORACOSCOPY
bull THORACOTOMY
COPD
bull Also known as
COLD (Chronic Obstructive Lung Disease )
COAD (Chronic Obstructive Airway Disease)
Smokerrsquos lung
CAL (Chronic Airflow Limitation)
CORD (Chronic Obstructive Respiratory Disease)
DEFINITION
Chronic obstructive pulmonary disease (COPD) is
a preventable and treatable disease characterized
by airflow limitation that is progressive not fully
reversible and associated with an abnormal
inflammatory response of the lungs
Chronic Bronchitis
bull Chronic bronchitis is a chronic inflammatory
condition in the lungs
bull It causes a cough that often brings up mucus as well as shortness of
breathwheezing and
chest tightness
Emphysema
bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs
EPIDEMIOLOGYbull More common in older people especially those
gt65 years
bull Fifth leading cause of death and disabilityworldwide
bull Death rates for males and females are roughlyequivalent
bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod
Risk Factors
Exposures Host Factors
Environmental tobacco smoke
Genetic predisposition (AAT deficiency)
Occupational dusts and chemicals
Airway hyperresponsiveness
Air pollution Impaired lung growth
Risk Factors
bull Exposures
ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD
ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD
Host Factors
bull Host factor refers to the traits of an individual person that affect susceptibility to disease
ndash AAT deficiency accounts for less than 1 of COPD cases
ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function
ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses
Pathophysiology of COPD
1 Airway inflammation
2 Structural changes
3 Mucociliary dysfunction
- Chronic inflammatory cascade for COPD
ASSESSMENT
1 Clinical presentation
ndash History
ndash Physical examination
2 Diagnostic testing
ndash Pulmonary function testing
ndash Laboratories
ndash Imaging
Clinical Presentation
HistoryPhysical
Examination
- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors
- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles
ASSESSMENT
bull General appearance
bull Vital signs Heart rhythm
bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
bull ABGs SaO2 CBC WBC and chest x-ray results
bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea
bull Nutrition and weight loss
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Pharynxbull Nasal cavity opens posteriorly into
nasopharynx
bull During swallowing respiration is
Temporarily inhibited permitting
food to enter oropharynx
bull Elevation of larynx and
closure of vocal cords
prevents entry of food into larynx
Larynx
bull Lower part of pharynx and at upper end of
trachea
bull Cartilagenous cartilages being held
together ligaments
bull Production of voice
bull Achieved by forcible expulsion of air from
lungs causing production of sound
bull Contraction of adductor muscles and glottis
It is an enlargement in the airway
superior to the trachea and inferior to the pharynx
bull It helps keep particles from entering the
trachea and also houses the vocal cords
It is composed of a framework of muscles
and cartilage bound by elastic tissue
The Epiglottis
It is a large leaf-shaped piece of cartilage
A flap of cartilage that prevents food from
entering the trachea (or windpipe)
During swallowing there is elevation of the larynx
The Vocal Cords Inside the larynx 2 pairs of folds of muscle and
connective tissues covered with mucous membrane make up the vocal cords
a The upper pair is the false vocal cords
b The lower pair is the true vocal cords
c Changing tension on the vocal cords controls pitch while increasing the loudness depends upon increasing the force of air vibrating the vocal cords
During normal breathing the vocal cords are relaxed and the
glottis is a triangular slit
bull During swallowing the false vocal cords and epiglottis close off the glottis
THE TRACHEA
bull It is a tubular passage way for airlocated anterior to the esophagus
bull It extends from the larynx to the 5th thoracic vertebra where it divides into the
right and left bronchi
bull The inner wall of the trachea is lined with
ciliated mucous membrane
with many goblet cells
that serve to trap incoming
particles
bull The tracheal wall is
supported by 20 incomplete
cartilaginous rings
BRONCHI The Bronchi are the two main air passages
into the lungs
They are composed of the
ldquoRight Primary Bronchusrdquo- leading to the right lung
ldquoLeft Primary Bronchusrdquo - leading to the left lung
The Bronchial Tree
The bronchial tree consists of branched tubes leading from the trachea to the alveoli
The bronchial tree begins with the two primary bronchi each leading to a lung
The branches of the bronchial tree from the trachea are right and left primary bronchi
these further subdivide until bronchioles give rise to alveolar ducts which terminate in alveoli
LUNGS
bull One on either side
bull Large cone-shaped spongy structures
which occupy most of thoracic cavity
bull Left lung is divided into 2 lobes and right
into 3
bull Lined by pleura (visceral and parietal)
Terminal branches
bull Bronchioles branch further
and the smallest
subdivisions being terminal
bronchiole
bull It is estimated no of
divisions from tracheal
bifurcation to terminal
bronchiole is 16
bull Total no of divisions till
alveoli is 23
The right lung has three lobes
The left lung has two lobes
Each lobe is composed of lobules
that contain air passages alveoli nerves
blood vessels lymphatic vessels
and connective tissues
Pulmonary alveolibull Alveoli are lined by a single layer of flat epithelialcellsbull Alveolar type I cells are principal liningbull Type II are cuboidal cells secrete surfactantbull Average width is 03 mmbull 300 million alveoli in human lung
Surfactantbull Formed from fatty acids by alveolar type II cellsbull Complex mixture of several phospholipidsproteins and ionsbull Most important components are phospholipiddipalmitoyl phosphatidyl choline (DDPC)surfactant appoproteins and calcium ions
The Pleural Cavities
A layer of serous membrane between the visceral pleura and the parietal pleura
bull It contains a lubricating fluid secretedby the membranes that preventsfriction between the membranes and allows their easy movement on one another during breathing
The Alveoli
They are cup-shaped out pouching lined by epithelium and supported by a thin elastic basement membrane
bull With that you can imagine having bunch of grapeswith each grape indicating and alveolus
Alveolar sacs are 2 or more alveoli that share a common opening
This is where the primary exchange of gases occur
STRUCTURE
nose nasal cavity
pharynx (throat)
larynx
trachea (windpipe)
bronchi
bronchioles
alveoli
FUNCTION
warms moistens amp filters air as it is inhaled
passageway for air leads to trachea
the voice box where vocal chords are located
tube from pharynx to bronchi
rings of cartilage provide structure keeps the
windpipe open
trachea is lined with fine hairs called cilia which
filter air before it reaches the lungs
two branches at the end of the trachea each
lead to a lung
a network of smaller branches leading from the
bronchi into the lung tissue amp ultimately to air
sacs
the functional respiratory units in the lung
where gases (oxygen amp carbon dioxide) are
exchanged (enter amp exit the blood stream)
Summary of FUNCTIONS
LIST OF RESPIRATORY AND LUNG DISEASES
bull Upper respiratory tract infections
bull Lower respiratory tract infections
bull Asthma
bull Copd
bull Inflammatory lung diseases
bull Obstructive lung diseases
bull Restrictive lung diseases
bull Respiratory tumors
bull Pleural cavity diseases
bull Pulmonary vascular diseases
Diagnostic Test
bull CHEST XRAY
bull ABG ANALYSIS
bull EXERCISE TESTING
bull MEDIASTINOSCOPY amp MEDIASTINOTOMY
bull BRONCHOSCOPY
bull CHEST IMAGING
bull CHEST TUBE INSERTION
bull NEEDLE BIOPSY OF THE PLEURA OR LUNG
bull PULMONARY FUNCTION TEST (PFT)
bull SUCTIONING
bull THORACOCENTESIS
bull THORACOSCOPY
bull THORACOTOMY
COPD
bull Also known as
COLD (Chronic Obstructive Lung Disease )
COAD (Chronic Obstructive Airway Disease)
Smokerrsquos lung
CAL (Chronic Airflow Limitation)
CORD (Chronic Obstructive Respiratory Disease)
DEFINITION
Chronic obstructive pulmonary disease (COPD) is
a preventable and treatable disease characterized
by airflow limitation that is progressive not fully
reversible and associated with an abnormal
inflammatory response of the lungs
Chronic Bronchitis
bull Chronic bronchitis is a chronic inflammatory
condition in the lungs
bull It causes a cough that often brings up mucus as well as shortness of
breathwheezing and
chest tightness
Emphysema
bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs
EPIDEMIOLOGYbull More common in older people especially those
gt65 years
bull Fifth leading cause of death and disabilityworldwide
bull Death rates for males and females are roughlyequivalent
bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod
Risk Factors
Exposures Host Factors
Environmental tobacco smoke
Genetic predisposition (AAT deficiency)
Occupational dusts and chemicals
Airway hyperresponsiveness
Air pollution Impaired lung growth
Risk Factors
bull Exposures
ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD
ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD
Host Factors
bull Host factor refers to the traits of an individual person that affect susceptibility to disease
ndash AAT deficiency accounts for less than 1 of COPD cases
ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function
ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses
Pathophysiology of COPD
1 Airway inflammation
2 Structural changes
3 Mucociliary dysfunction
- Chronic inflammatory cascade for COPD
ASSESSMENT
1 Clinical presentation
ndash History
ndash Physical examination
2 Diagnostic testing
ndash Pulmonary function testing
ndash Laboratories
ndash Imaging
Clinical Presentation
HistoryPhysical
Examination
- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors
- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles
ASSESSMENT
bull General appearance
bull Vital signs Heart rhythm
bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
bull ABGs SaO2 CBC WBC and chest x-ray results
bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea
bull Nutrition and weight loss
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Larynx
bull Lower part of pharynx and at upper end of
trachea
bull Cartilagenous cartilages being held
together ligaments
bull Production of voice
bull Achieved by forcible expulsion of air from
lungs causing production of sound
bull Contraction of adductor muscles and glottis
It is an enlargement in the airway
superior to the trachea and inferior to the pharynx
bull It helps keep particles from entering the
trachea and also houses the vocal cords
It is composed of a framework of muscles
and cartilage bound by elastic tissue
The Epiglottis
It is a large leaf-shaped piece of cartilage
A flap of cartilage that prevents food from
entering the trachea (or windpipe)
During swallowing there is elevation of the larynx
The Vocal Cords Inside the larynx 2 pairs of folds of muscle and
connective tissues covered with mucous membrane make up the vocal cords
a The upper pair is the false vocal cords
b The lower pair is the true vocal cords
c Changing tension on the vocal cords controls pitch while increasing the loudness depends upon increasing the force of air vibrating the vocal cords
During normal breathing the vocal cords are relaxed and the
glottis is a triangular slit
bull During swallowing the false vocal cords and epiglottis close off the glottis
THE TRACHEA
bull It is a tubular passage way for airlocated anterior to the esophagus
bull It extends from the larynx to the 5th thoracic vertebra where it divides into the
right and left bronchi
bull The inner wall of the trachea is lined with
ciliated mucous membrane
with many goblet cells
that serve to trap incoming
particles
bull The tracheal wall is
supported by 20 incomplete
cartilaginous rings
BRONCHI The Bronchi are the two main air passages
into the lungs
They are composed of the
ldquoRight Primary Bronchusrdquo- leading to the right lung
ldquoLeft Primary Bronchusrdquo - leading to the left lung
The Bronchial Tree
The bronchial tree consists of branched tubes leading from the trachea to the alveoli
The bronchial tree begins with the two primary bronchi each leading to a lung
The branches of the bronchial tree from the trachea are right and left primary bronchi
these further subdivide until bronchioles give rise to alveolar ducts which terminate in alveoli
LUNGS
bull One on either side
bull Large cone-shaped spongy structures
which occupy most of thoracic cavity
bull Left lung is divided into 2 lobes and right
into 3
bull Lined by pleura (visceral and parietal)
Terminal branches
bull Bronchioles branch further
and the smallest
subdivisions being terminal
bronchiole
bull It is estimated no of
divisions from tracheal
bifurcation to terminal
bronchiole is 16
bull Total no of divisions till
alveoli is 23
The right lung has three lobes
The left lung has two lobes
Each lobe is composed of lobules
that contain air passages alveoli nerves
blood vessels lymphatic vessels
and connective tissues
Pulmonary alveolibull Alveoli are lined by a single layer of flat epithelialcellsbull Alveolar type I cells are principal liningbull Type II are cuboidal cells secrete surfactantbull Average width is 03 mmbull 300 million alveoli in human lung
Surfactantbull Formed from fatty acids by alveolar type II cellsbull Complex mixture of several phospholipidsproteins and ionsbull Most important components are phospholipiddipalmitoyl phosphatidyl choline (DDPC)surfactant appoproteins and calcium ions
The Pleural Cavities
A layer of serous membrane between the visceral pleura and the parietal pleura
bull It contains a lubricating fluid secretedby the membranes that preventsfriction between the membranes and allows their easy movement on one another during breathing
The Alveoli
They are cup-shaped out pouching lined by epithelium and supported by a thin elastic basement membrane
bull With that you can imagine having bunch of grapeswith each grape indicating and alveolus
Alveolar sacs are 2 or more alveoli that share a common opening
This is where the primary exchange of gases occur
STRUCTURE
nose nasal cavity
pharynx (throat)
larynx
trachea (windpipe)
bronchi
bronchioles
alveoli
FUNCTION
warms moistens amp filters air as it is inhaled
passageway for air leads to trachea
the voice box where vocal chords are located
tube from pharynx to bronchi
rings of cartilage provide structure keeps the
windpipe open
trachea is lined with fine hairs called cilia which
filter air before it reaches the lungs
two branches at the end of the trachea each
lead to a lung
a network of smaller branches leading from the
bronchi into the lung tissue amp ultimately to air
sacs
the functional respiratory units in the lung
where gases (oxygen amp carbon dioxide) are
exchanged (enter amp exit the blood stream)
Summary of FUNCTIONS
LIST OF RESPIRATORY AND LUNG DISEASES
bull Upper respiratory tract infections
bull Lower respiratory tract infections
bull Asthma
bull Copd
bull Inflammatory lung diseases
bull Obstructive lung diseases
bull Restrictive lung diseases
bull Respiratory tumors
bull Pleural cavity diseases
bull Pulmonary vascular diseases
Diagnostic Test
bull CHEST XRAY
bull ABG ANALYSIS
bull EXERCISE TESTING
bull MEDIASTINOSCOPY amp MEDIASTINOTOMY
bull BRONCHOSCOPY
bull CHEST IMAGING
bull CHEST TUBE INSERTION
bull NEEDLE BIOPSY OF THE PLEURA OR LUNG
bull PULMONARY FUNCTION TEST (PFT)
bull SUCTIONING
bull THORACOCENTESIS
bull THORACOSCOPY
bull THORACOTOMY
COPD
bull Also known as
COLD (Chronic Obstructive Lung Disease )
COAD (Chronic Obstructive Airway Disease)
Smokerrsquos lung
CAL (Chronic Airflow Limitation)
CORD (Chronic Obstructive Respiratory Disease)
DEFINITION
Chronic obstructive pulmonary disease (COPD) is
a preventable and treatable disease characterized
by airflow limitation that is progressive not fully
reversible and associated with an abnormal
inflammatory response of the lungs
Chronic Bronchitis
bull Chronic bronchitis is a chronic inflammatory
condition in the lungs
bull It causes a cough that often brings up mucus as well as shortness of
breathwheezing and
chest tightness
Emphysema
bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs
EPIDEMIOLOGYbull More common in older people especially those
gt65 years
bull Fifth leading cause of death and disabilityworldwide
bull Death rates for males and females are roughlyequivalent
bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod
Risk Factors
Exposures Host Factors
Environmental tobacco smoke
Genetic predisposition (AAT deficiency)
Occupational dusts and chemicals
Airway hyperresponsiveness
Air pollution Impaired lung growth
Risk Factors
bull Exposures
ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD
ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD
Host Factors
bull Host factor refers to the traits of an individual person that affect susceptibility to disease
ndash AAT deficiency accounts for less than 1 of COPD cases
ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function
ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses
Pathophysiology of COPD
1 Airway inflammation
2 Structural changes
3 Mucociliary dysfunction
- Chronic inflammatory cascade for COPD
ASSESSMENT
1 Clinical presentation
ndash History
ndash Physical examination
2 Diagnostic testing
ndash Pulmonary function testing
ndash Laboratories
ndash Imaging
Clinical Presentation
HistoryPhysical
Examination
- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors
- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles
ASSESSMENT
bull General appearance
bull Vital signs Heart rhythm
bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
bull ABGs SaO2 CBC WBC and chest x-ray results
bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea
bull Nutrition and weight loss
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
It is an enlargement in the airway
superior to the trachea and inferior to the pharynx
bull It helps keep particles from entering the
trachea and also houses the vocal cords
It is composed of a framework of muscles
and cartilage bound by elastic tissue
The Epiglottis
It is a large leaf-shaped piece of cartilage
A flap of cartilage that prevents food from
entering the trachea (or windpipe)
During swallowing there is elevation of the larynx
The Vocal Cords Inside the larynx 2 pairs of folds of muscle and
connective tissues covered with mucous membrane make up the vocal cords
a The upper pair is the false vocal cords
b The lower pair is the true vocal cords
c Changing tension on the vocal cords controls pitch while increasing the loudness depends upon increasing the force of air vibrating the vocal cords
During normal breathing the vocal cords are relaxed and the
glottis is a triangular slit
bull During swallowing the false vocal cords and epiglottis close off the glottis
THE TRACHEA
bull It is a tubular passage way for airlocated anterior to the esophagus
bull It extends from the larynx to the 5th thoracic vertebra where it divides into the
right and left bronchi
bull The inner wall of the trachea is lined with
ciliated mucous membrane
with many goblet cells
that serve to trap incoming
particles
bull The tracheal wall is
supported by 20 incomplete
cartilaginous rings
BRONCHI The Bronchi are the two main air passages
into the lungs
They are composed of the
ldquoRight Primary Bronchusrdquo- leading to the right lung
ldquoLeft Primary Bronchusrdquo - leading to the left lung
The Bronchial Tree
The bronchial tree consists of branched tubes leading from the trachea to the alveoli
The bronchial tree begins with the two primary bronchi each leading to a lung
The branches of the bronchial tree from the trachea are right and left primary bronchi
these further subdivide until bronchioles give rise to alveolar ducts which terminate in alveoli
LUNGS
bull One on either side
bull Large cone-shaped spongy structures
which occupy most of thoracic cavity
bull Left lung is divided into 2 lobes and right
into 3
bull Lined by pleura (visceral and parietal)
Terminal branches
bull Bronchioles branch further
and the smallest
subdivisions being terminal
bronchiole
bull It is estimated no of
divisions from tracheal
bifurcation to terminal
bronchiole is 16
bull Total no of divisions till
alveoli is 23
The right lung has three lobes
The left lung has two lobes
Each lobe is composed of lobules
that contain air passages alveoli nerves
blood vessels lymphatic vessels
and connective tissues
Pulmonary alveolibull Alveoli are lined by a single layer of flat epithelialcellsbull Alveolar type I cells are principal liningbull Type II are cuboidal cells secrete surfactantbull Average width is 03 mmbull 300 million alveoli in human lung
Surfactantbull Formed from fatty acids by alveolar type II cellsbull Complex mixture of several phospholipidsproteins and ionsbull Most important components are phospholipiddipalmitoyl phosphatidyl choline (DDPC)surfactant appoproteins and calcium ions
The Pleural Cavities
A layer of serous membrane between the visceral pleura and the parietal pleura
bull It contains a lubricating fluid secretedby the membranes that preventsfriction between the membranes and allows their easy movement on one another during breathing
The Alveoli
They are cup-shaped out pouching lined by epithelium and supported by a thin elastic basement membrane
bull With that you can imagine having bunch of grapeswith each grape indicating and alveolus
Alveolar sacs are 2 or more alveoli that share a common opening
This is where the primary exchange of gases occur
STRUCTURE
nose nasal cavity
pharynx (throat)
larynx
trachea (windpipe)
bronchi
bronchioles
alveoli
FUNCTION
warms moistens amp filters air as it is inhaled
passageway for air leads to trachea
the voice box where vocal chords are located
tube from pharynx to bronchi
rings of cartilage provide structure keeps the
windpipe open
trachea is lined with fine hairs called cilia which
filter air before it reaches the lungs
two branches at the end of the trachea each
lead to a lung
a network of smaller branches leading from the
bronchi into the lung tissue amp ultimately to air
sacs
the functional respiratory units in the lung
where gases (oxygen amp carbon dioxide) are
exchanged (enter amp exit the blood stream)
Summary of FUNCTIONS
LIST OF RESPIRATORY AND LUNG DISEASES
bull Upper respiratory tract infections
bull Lower respiratory tract infections
bull Asthma
bull Copd
bull Inflammatory lung diseases
bull Obstructive lung diseases
bull Restrictive lung diseases
bull Respiratory tumors
bull Pleural cavity diseases
bull Pulmonary vascular diseases
Diagnostic Test
bull CHEST XRAY
bull ABG ANALYSIS
bull EXERCISE TESTING
bull MEDIASTINOSCOPY amp MEDIASTINOTOMY
bull BRONCHOSCOPY
bull CHEST IMAGING
bull CHEST TUBE INSERTION
bull NEEDLE BIOPSY OF THE PLEURA OR LUNG
bull PULMONARY FUNCTION TEST (PFT)
bull SUCTIONING
bull THORACOCENTESIS
bull THORACOSCOPY
bull THORACOTOMY
COPD
bull Also known as
COLD (Chronic Obstructive Lung Disease )
COAD (Chronic Obstructive Airway Disease)
Smokerrsquos lung
CAL (Chronic Airflow Limitation)
CORD (Chronic Obstructive Respiratory Disease)
DEFINITION
Chronic obstructive pulmonary disease (COPD) is
a preventable and treatable disease characterized
by airflow limitation that is progressive not fully
reversible and associated with an abnormal
inflammatory response of the lungs
Chronic Bronchitis
bull Chronic bronchitis is a chronic inflammatory
condition in the lungs
bull It causes a cough that often brings up mucus as well as shortness of
breathwheezing and
chest tightness
Emphysema
bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs
EPIDEMIOLOGYbull More common in older people especially those
gt65 years
bull Fifth leading cause of death and disabilityworldwide
bull Death rates for males and females are roughlyequivalent
bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod
Risk Factors
Exposures Host Factors
Environmental tobacco smoke
Genetic predisposition (AAT deficiency)
Occupational dusts and chemicals
Airway hyperresponsiveness
Air pollution Impaired lung growth
Risk Factors
bull Exposures
ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD
ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD
Host Factors
bull Host factor refers to the traits of an individual person that affect susceptibility to disease
ndash AAT deficiency accounts for less than 1 of COPD cases
ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function
ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses
Pathophysiology of COPD
1 Airway inflammation
2 Structural changes
3 Mucociliary dysfunction
- Chronic inflammatory cascade for COPD
ASSESSMENT
1 Clinical presentation
ndash History
ndash Physical examination
2 Diagnostic testing
ndash Pulmonary function testing
ndash Laboratories
ndash Imaging
Clinical Presentation
HistoryPhysical
Examination
- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors
- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles
ASSESSMENT
bull General appearance
bull Vital signs Heart rhythm
bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
bull ABGs SaO2 CBC WBC and chest x-ray results
bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea
bull Nutrition and weight loss
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
The Epiglottis
It is a large leaf-shaped piece of cartilage
A flap of cartilage that prevents food from
entering the trachea (or windpipe)
During swallowing there is elevation of the larynx
The Vocal Cords Inside the larynx 2 pairs of folds of muscle and
connective tissues covered with mucous membrane make up the vocal cords
a The upper pair is the false vocal cords
b The lower pair is the true vocal cords
c Changing tension on the vocal cords controls pitch while increasing the loudness depends upon increasing the force of air vibrating the vocal cords
During normal breathing the vocal cords are relaxed and the
glottis is a triangular slit
bull During swallowing the false vocal cords and epiglottis close off the glottis
THE TRACHEA
bull It is a tubular passage way for airlocated anterior to the esophagus
bull It extends from the larynx to the 5th thoracic vertebra where it divides into the
right and left bronchi
bull The inner wall of the trachea is lined with
ciliated mucous membrane
with many goblet cells
that serve to trap incoming
particles
bull The tracheal wall is
supported by 20 incomplete
cartilaginous rings
BRONCHI The Bronchi are the two main air passages
into the lungs
They are composed of the
ldquoRight Primary Bronchusrdquo- leading to the right lung
ldquoLeft Primary Bronchusrdquo - leading to the left lung
The Bronchial Tree
The bronchial tree consists of branched tubes leading from the trachea to the alveoli
The bronchial tree begins with the two primary bronchi each leading to a lung
The branches of the bronchial tree from the trachea are right and left primary bronchi
these further subdivide until bronchioles give rise to alveolar ducts which terminate in alveoli
LUNGS
bull One on either side
bull Large cone-shaped spongy structures
which occupy most of thoracic cavity
bull Left lung is divided into 2 lobes and right
into 3
bull Lined by pleura (visceral and parietal)
Terminal branches
bull Bronchioles branch further
and the smallest
subdivisions being terminal
bronchiole
bull It is estimated no of
divisions from tracheal
bifurcation to terminal
bronchiole is 16
bull Total no of divisions till
alveoli is 23
The right lung has three lobes
The left lung has two lobes
Each lobe is composed of lobules
that contain air passages alveoli nerves
blood vessels lymphatic vessels
and connective tissues
Pulmonary alveolibull Alveoli are lined by a single layer of flat epithelialcellsbull Alveolar type I cells are principal liningbull Type II are cuboidal cells secrete surfactantbull Average width is 03 mmbull 300 million alveoli in human lung
Surfactantbull Formed from fatty acids by alveolar type II cellsbull Complex mixture of several phospholipidsproteins and ionsbull Most important components are phospholipiddipalmitoyl phosphatidyl choline (DDPC)surfactant appoproteins and calcium ions
The Pleural Cavities
A layer of serous membrane between the visceral pleura and the parietal pleura
bull It contains a lubricating fluid secretedby the membranes that preventsfriction between the membranes and allows their easy movement on one another during breathing
The Alveoli
They are cup-shaped out pouching lined by epithelium and supported by a thin elastic basement membrane
bull With that you can imagine having bunch of grapeswith each grape indicating and alveolus
Alveolar sacs are 2 or more alveoli that share a common opening
This is where the primary exchange of gases occur
STRUCTURE
nose nasal cavity
pharynx (throat)
larynx
trachea (windpipe)
bronchi
bronchioles
alveoli
FUNCTION
warms moistens amp filters air as it is inhaled
passageway for air leads to trachea
the voice box where vocal chords are located
tube from pharynx to bronchi
rings of cartilage provide structure keeps the
windpipe open
trachea is lined with fine hairs called cilia which
filter air before it reaches the lungs
two branches at the end of the trachea each
lead to a lung
a network of smaller branches leading from the
bronchi into the lung tissue amp ultimately to air
sacs
the functional respiratory units in the lung
where gases (oxygen amp carbon dioxide) are
exchanged (enter amp exit the blood stream)
Summary of FUNCTIONS
LIST OF RESPIRATORY AND LUNG DISEASES
bull Upper respiratory tract infections
bull Lower respiratory tract infections
bull Asthma
bull Copd
bull Inflammatory lung diseases
bull Obstructive lung diseases
bull Restrictive lung diseases
bull Respiratory tumors
bull Pleural cavity diseases
bull Pulmonary vascular diseases
Diagnostic Test
bull CHEST XRAY
bull ABG ANALYSIS
bull EXERCISE TESTING
bull MEDIASTINOSCOPY amp MEDIASTINOTOMY
bull BRONCHOSCOPY
bull CHEST IMAGING
bull CHEST TUBE INSERTION
bull NEEDLE BIOPSY OF THE PLEURA OR LUNG
bull PULMONARY FUNCTION TEST (PFT)
bull SUCTIONING
bull THORACOCENTESIS
bull THORACOSCOPY
bull THORACOTOMY
COPD
bull Also known as
COLD (Chronic Obstructive Lung Disease )
COAD (Chronic Obstructive Airway Disease)
Smokerrsquos lung
CAL (Chronic Airflow Limitation)
CORD (Chronic Obstructive Respiratory Disease)
DEFINITION
Chronic obstructive pulmonary disease (COPD) is
a preventable and treatable disease characterized
by airflow limitation that is progressive not fully
reversible and associated with an abnormal
inflammatory response of the lungs
Chronic Bronchitis
bull Chronic bronchitis is a chronic inflammatory
condition in the lungs
bull It causes a cough that often brings up mucus as well as shortness of
breathwheezing and
chest tightness
Emphysema
bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs
EPIDEMIOLOGYbull More common in older people especially those
gt65 years
bull Fifth leading cause of death and disabilityworldwide
bull Death rates for males and females are roughlyequivalent
bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod
Risk Factors
Exposures Host Factors
Environmental tobacco smoke
Genetic predisposition (AAT deficiency)
Occupational dusts and chemicals
Airway hyperresponsiveness
Air pollution Impaired lung growth
Risk Factors
bull Exposures
ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD
ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD
Host Factors
bull Host factor refers to the traits of an individual person that affect susceptibility to disease
ndash AAT deficiency accounts for less than 1 of COPD cases
ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function
ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses
Pathophysiology of COPD
1 Airway inflammation
2 Structural changes
3 Mucociliary dysfunction
- Chronic inflammatory cascade for COPD
ASSESSMENT
1 Clinical presentation
ndash History
ndash Physical examination
2 Diagnostic testing
ndash Pulmonary function testing
ndash Laboratories
ndash Imaging
Clinical Presentation
HistoryPhysical
Examination
- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors
- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles
ASSESSMENT
bull General appearance
bull Vital signs Heart rhythm
bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
bull ABGs SaO2 CBC WBC and chest x-ray results
bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea
bull Nutrition and weight loss
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
The Vocal Cords Inside the larynx 2 pairs of folds of muscle and
connective tissues covered with mucous membrane make up the vocal cords
a The upper pair is the false vocal cords
b The lower pair is the true vocal cords
c Changing tension on the vocal cords controls pitch while increasing the loudness depends upon increasing the force of air vibrating the vocal cords
During normal breathing the vocal cords are relaxed and the
glottis is a triangular slit
bull During swallowing the false vocal cords and epiglottis close off the glottis
THE TRACHEA
bull It is a tubular passage way for airlocated anterior to the esophagus
bull It extends from the larynx to the 5th thoracic vertebra where it divides into the
right and left bronchi
bull The inner wall of the trachea is lined with
ciliated mucous membrane
with many goblet cells
that serve to trap incoming
particles
bull The tracheal wall is
supported by 20 incomplete
cartilaginous rings
BRONCHI The Bronchi are the two main air passages
into the lungs
They are composed of the
ldquoRight Primary Bronchusrdquo- leading to the right lung
ldquoLeft Primary Bronchusrdquo - leading to the left lung
The Bronchial Tree
The bronchial tree consists of branched tubes leading from the trachea to the alveoli
The bronchial tree begins with the two primary bronchi each leading to a lung
The branches of the bronchial tree from the trachea are right and left primary bronchi
these further subdivide until bronchioles give rise to alveolar ducts which terminate in alveoli
LUNGS
bull One on either side
bull Large cone-shaped spongy structures
which occupy most of thoracic cavity
bull Left lung is divided into 2 lobes and right
into 3
bull Lined by pleura (visceral and parietal)
Terminal branches
bull Bronchioles branch further
and the smallest
subdivisions being terminal
bronchiole
bull It is estimated no of
divisions from tracheal
bifurcation to terminal
bronchiole is 16
bull Total no of divisions till
alveoli is 23
The right lung has three lobes
The left lung has two lobes
Each lobe is composed of lobules
that contain air passages alveoli nerves
blood vessels lymphatic vessels
and connective tissues
Pulmonary alveolibull Alveoli are lined by a single layer of flat epithelialcellsbull Alveolar type I cells are principal liningbull Type II are cuboidal cells secrete surfactantbull Average width is 03 mmbull 300 million alveoli in human lung
Surfactantbull Formed from fatty acids by alveolar type II cellsbull Complex mixture of several phospholipidsproteins and ionsbull Most important components are phospholipiddipalmitoyl phosphatidyl choline (DDPC)surfactant appoproteins and calcium ions
The Pleural Cavities
A layer of serous membrane between the visceral pleura and the parietal pleura
bull It contains a lubricating fluid secretedby the membranes that preventsfriction between the membranes and allows their easy movement on one another during breathing
The Alveoli
They are cup-shaped out pouching lined by epithelium and supported by a thin elastic basement membrane
bull With that you can imagine having bunch of grapeswith each grape indicating and alveolus
Alveolar sacs are 2 or more alveoli that share a common opening
This is where the primary exchange of gases occur
STRUCTURE
nose nasal cavity
pharynx (throat)
larynx
trachea (windpipe)
bronchi
bronchioles
alveoli
FUNCTION
warms moistens amp filters air as it is inhaled
passageway for air leads to trachea
the voice box where vocal chords are located
tube from pharynx to bronchi
rings of cartilage provide structure keeps the
windpipe open
trachea is lined with fine hairs called cilia which
filter air before it reaches the lungs
two branches at the end of the trachea each
lead to a lung
a network of smaller branches leading from the
bronchi into the lung tissue amp ultimately to air
sacs
the functional respiratory units in the lung
where gases (oxygen amp carbon dioxide) are
exchanged (enter amp exit the blood stream)
Summary of FUNCTIONS
LIST OF RESPIRATORY AND LUNG DISEASES
bull Upper respiratory tract infections
bull Lower respiratory tract infections
bull Asthma
bull Copd
bull Inflammatory lung diseases
bull Obstructive lung diseases
bull Restrictive lung diseases
bull Respiratory tumors
bull Pleural cavity diseases
bull Pulmonary vascular diseases
Diagnostic Test
bull CHEST XRAY
bull ABG ANALYSIS
bull EXERCISE TESTING
bull MEDIASTINOSCOPY amp MEDIASTINOTOMY
bull BRONCHOSCOPY
bull CHEST IMAGING
bull CHEST TUBE INSERTION
bull NEEDLE BIOPSY OF THE PLEURA OR LUNG
bull PULMONARY FUNCTION TEST (PFT)
bull SUCTIONING
bull THORACOCENTESIS
bull THORACOSCOPY
bull THORACOTOMY
COPD
bull Also known as
COLD (Chronic Obstructive Lung Disease )
COAD (Chronic Obstructive Airway Disease)
Smokerrsquos lung
CAL (Chronic Airflow Limitation)
CORD (Chronic Obstructive Respiratory Disease)
DEFINITION
Chronic obstructive pulmonary disease (COPD) is
a preventable and treatable disease characterized
by airflow limitation that is progressive not fully
reversible and associated with an abnormal
inflammatory response of the lungs
Chronic Bronchitis
bull Chronic bronchitis is a chronic inflammatory
condition in the lungs
bull It causes a cough that often brings up mucus as well as shortness of
breathwheezing and
chest tightness
Emphysema
bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs
EPIDEMIOLOGYbull More common in older people especially those
gt65 years
bull Fifth leading cause of death and disabilityworldwide
bull Death rates for males and females are roughlyequivalent
bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod
Risk Factors
Exposures Host Factors
Environmental tobacco smoke
Genetic predisposition (AAT deficiency)
Occupational dusts and chemicals
Airway hyperresponsiveness
Air pollution Impaired lung growth
Risk Factors
bull Exposures
ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD
ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD
Host Factors
bull Host factor refers to the traits of an individual person that affect susceptibility to disease
ndash AAT deficiency accounts for less than 1 of COPD cases
ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function
ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses
Pathophysiology of COPD
1 Airway inflammation
2 Structural changes
3 Mucociliary dysfunction
- Chronic inflammatory cascade for COPD
ASSESSMENT
1 Clinical presentation
ndash History
ndash Physical examination
2 Diagnostic testing
ndash Pulmonary function testing
ndash Laboratories
ndash Imaging
Clinical Presentation
HistoryPhysical
Examination
- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors
- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles
ASSESSMENT
bull General appearance
bull Vital signs Heart rhythm
bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
bull ABGs SaO2 CBC WBC and chest x-ray results
bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea
bull Nutrition and weight loss
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
During normal breathing the vocal cords are relaxed and the
glottis is a triangular slit
bull During swallowing the false vocal cords and epiglottis close off the glottis
THE TRACHEA
bull It is a tubular passage way for airlocated anterior to the esophagus
bull It extends from the larynx to the 5th thoracic vertebra where it divides into the
right and left bronchi
bull The inner wall of the trachea is lined with
ciliated mucous membrane
with many goblet cells
that serve to trap incoming
particles
bull The tracheal wall is
supported by 20 incomplete
cartilaginous rings
BRONCHI The Bronchi are the two main air passages
into the lungs
They are composed of the
ldquoRight Primary Bronchusrdquo- leading to the right lung
ldquoLeft Primary Bronchusrdquo - leading to the left lung
The Bronchial Tree
The bronchial tree consists of branched tubes leading from the trachea to the alveoli
The bronchial tree begins with the two primary bronchi each leading to a lung
The branches of the bronchial tree from the trachea are right and left primary bronchi
these further subdivide until bronchioles give rise to alveolar ducts which terminate in alveoli
LUNGS
bull One on either side
bull Large cone-shaped spongy structures
which occupy most of thoracic cavity
bull Left lung is divided into 2 lobes and right
into 3
bull Lined by pleura (visceral and parietal)
Terminal branches
bull Bronchioles branch further
and the smallest
subdivisions being terminal
bronchiole
bull It is estimated no of
divisions from tracheal
bifurcation to terminal
bronchiole is 16
bull Total no of divisions till
alveoli is 23
The right lung has three lobes
The left lung has two lobes
Each lobe is composed of lobules
that contain air passages alveoli nerves
blood vessels lymphatic vessels
and connective tissues
Pulmonary alveolibull Alveoli are lined by a single layer of flat epithelialcellsbull Alveolar type I cells are principal liningbull Type II are cuboidal cells secrete surfactantbull Average width is 03 mmbull 300 million alveoli in human lung
Surfactantbull Formed from fatty acids by alveolar type II cellsbull Complex mixture of several phospholipidsproteins and ionsbull Most important components are phospholipiddipalmitoyl phosphatidyl choline (DDPC)surfactant appoproteins and calcium ions
The Pleural Cavities
A layer of serous membrane between the visceral pleura and the parietal pleura
bull It contains a lubricating fluid secretedby the membranes that preventsfriction between the membranes and allows their easy movement on one another during breathing
The Alveoli
They are cup-shaped out pouching lined by epithelium and supported by a thin elastic basement membrane
bull With that you can imagine having bunch of grapeswith each grape indicating and alveolus
Alveolar sacs are 2 or more alveoli that share a common opening
This is where the primary exchange of gases occur
STRUCTURE
nose nasal cavity
pharynx (throat)
larynx
trachea (windpipe)
bronchi
bronchioles
alveoli
FUNCTION
warms moistens amp filters air as it is inhaled
passageway for air leads to trachea
the voice box where vocal chords are located
tube from pharynx to bronchi
rings of cartilage provide structure keeps the
windpipe open
trachea is lined with fine hairs called cilia which
filter air before it reaches the lungs
two branches at the end of the trachea each
lead to a lung
a network of smaller branches leading from the
bronchi into the lung tissue amp ultimately to air
sacs
the functional respiratory units in the lung
where gases (oxygen amp carbon dioxide) are
exchanged (enter amp exit the blood stream)
Summary of FUNCTIONS
LIST OF RESPIRATORY AND LUNG DISEASES
bull Upper respiratory tract infections
bull Lower respiratory tract infections
bull Asthma
bull Copd
bull Inflammatory lung diseases
bull Obstructive lung diseases
bull Restrictive lung diseases
bull Respiratory tumors
bull Pleural cavity diseases
bull Pulmonary vascular diseases
Diagnostic Test
bull CHEST XRAY
bull ABG ANALYSIS
bull EXERCISE TESTING
bull MEDIASTINOSCOPY amp MEDIASTINOTOMY
bull BRONCHOSCOPY
bull CHEST IMAGING
bull CHEST TUBE INSERTION
bull NEEDLE BIOPSY OF THE PLEURA OR LUNG
bull PULMONARY FUNCTION TEST (PFT)
bull SUCTIONING
bull THORACOCENTESIS
bull THORACOSCOPY
bull THORACOTOMY
COPD
bull Also known as
COLD (Chronic Obstructive Lung Disease )
COAD (Chronic Obstructive Airway Disease)
Smokerrsquos lung
CAL (Chronic Airflow Limitation)
CORD (Chronic Obstructive Respiratory Disease)
DEFINITION
Chronic obstructive pulmonary disease (COPD) is
a preventable and treatable disease characterized
by airflow limitation that is progressive not fully
reversible and associated with an abnormal
inflammatory response of the lungs
Chronic Bronchitis
bull Chronic bronchitis is a chronic inflammatory
condition in the lungs
bull It causes a cough that often brings up mucus as well as shortness of
breathwheezing and
chest tightness
Emphysema
bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs
EPIDEMIOLOGYbull More common in older people especially those
gt65 years
bull Fifth leading cause of death and disabilityworldwide
bull Death rates for males and females are roughlyequivalent
bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod
Risk Factors
Exposures Host Factors
Environmental tobacco smoke
Genetic predisposition (AAT deficiency)
Occupational dusts and chemicals
Airway hyperresponsiveness
Air pollution Impaired lung growth
Risk Factors
bull Exposures
ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD
ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD
Host Factors
bull Host factor refers to the traits of an individual person that affect susceptibility to disease
ndash AAT deficiency accounts for less than 1 of COPD cases
ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function
ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses
Pathophysiology of COPD
1 Airway inflammation
2 Structural changes
3 Mucociliary dysfunction
- Chronic inflammatory cascade for COPD
ASSESSMENT
1 Clinical presentation
ndash History
ndash Physical examination
2 Diagnostic testing
ndash Pulmonary function testing
ndash Laboratories
ndash Imaging
Clinical Presentation
HistoryPhysical
Examination
- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors
- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles
ASSESSMENT
bull General appearance
bull Vital signs Heart rhythm
bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
bull ABGs SaO2 CBC WBC and chest x-ray results
bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea
bull Nutrition and weight loss
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
THE TRACHEA
bull It is a tubular passage way for airlocated anterior to the esophagus
bull It extends from the larynx to the 5th thoracic vertebra where it divides into the
right and left bronchi
bull The inner wall of the trachea is lined with
ciliated mucous membrane
with many goblet cells
that serve to trap incoming
particles
bull The tracheal wall is
supported by 20 incomplete
cartilaginous rings
BRONCHI The Bronchi are the two main air passages
into the lungs
They are composed of the
ldquoRight Primary Bronchusrdquo- leading to the right lung
ldquoLeft Primary Bronchusrdquo - leading to the left lung
The Bronchial Tree
The bronchial tree consists of branched tubes leading from the trachea to the alveoli
The bronchial tree begins with the two primary bronchi each leading to a lung
The branches of the bronchial tree from the trachea are right and left primary bronchi
these further subdivide until bronchioles give rise to alveolar ducts which terminate in alveoli
LUNGS
bull One on either side
bull Large cone-shaped spongy structures
which occupy most of thoracic cavity
bull Left lung is divided into 2 lobes and right
into 3
bull Lined by pleura (visceral and parietal)
Terminal branches
bull Bronchioles branch further
and the smallest
subdivisions being terminal
bronchiole
bull It is estimated no of
divisions from tracheal
bifurcation to terminal
bronchiole is 16
bull Total no of divisions till
alveoli is 23
The right lung has three lobes
The left lung has two lobes
Each lobe is composed of lobules
that contain air passages alveoli nerves
blood vessels lymphatic vessels
and connective tissues
Pulmonary alveolibull Alveoli are lined by a single layer of flat epithelialcellsbull Alveolar type I cells are principal liningbull Type II are cuboidal cells secrete surfactantbull Average width is 03 mmbull 300 million alveoli in human lung
Surfactantbull Formed from fatty acids by alveolar type II cellsbull Complex mixture of several phospholipidsproteins and ionsbull Most important components are phospholipiddipalmitoyl phosphatidyl choline (DDPC)surfactant appoproteins and calcium ions
The Pleural Cavities
A layer of serous membrane between the visceral pleura and the parietal pleura
bull It contains a lubricating fluid secretedby the membranes that preventsfriction between the membranes and allows their easy movement on one another during breathing
The Alveoli
They are cup-shaped out pouching lined by epithelium and supported by a thin elastic basement membrane
bull With that you can imagine having bunch of grapeswith each grape indicating and alveolus
Alveolar sacs are 2 or more alveoli that share a common opening
This is where the primary exchange of gases occur
STRUCTURE
nose nasal cavity
pharynx (throat)
larynx
trachea (windpipe)
bronchi
bronchioles
alveoli
FUNCTION
warms moistens amp filters air as it is inhaled
passageway for air leads to trachea
the voice box where vocal chords are located
tube from pharynx to bronchi
rings of cartilage provide structure keeps the
windpipe open
trachea is lined with fine hairs called cilia which
filter air before it reaches the lungs
two branches at the end of the trachea each
lead to a lung
a network of smaller branches leading from the
bronchi into the lung tissue amp ultimately to air
sacs
the functional respiratory units in the lung
where gases (oxygen amp carbon dioxide) are
exchanged (enter amp exit the blood stream)
Summary of FUNCTIONS
LIST OF RESPIRATORY AND LUNG DISEASES
bull Upper respiratory tract infections
bull Lower respiratory tract infections
bull Asthma
bull Copd
bull Inflammatory lung diseases
bull Obstructive lung diseases
bull Restrictive lung diseases
bull Respiratory tumors
bull Pleural cavity diseases
bull Pulmonary vascular diseases
Diagnostic Test
bull CHEST XRAY
bull ABG ANALYSIS
bull EXERCISE TESTING
bull MEDIASTINOSCOPY amp MEDIASTINOTOMY
bull BRONCHOSCOPY
bull CHEST IMAGING
bull CHEST TUBE INSERTION
bull NEEDLE BIOPSY OF THE PLEURA OR LUNG
bull PULMONARY FUNCTION TEST (PFT)
bull SUCTIONING
bull THORACOCENTESIS
bull THORACOSCOPY
bull THORACOTOMY
COPD
bull Also known as
COLD (Chronic Obstructive Lung Disease )
COAD (Chronic Obstructive Airway Disease)
Smokerrsquos lung
CAL (Chronic Airflow Limitation)
CORD (Chronic Obstructive Respiratory Disease)
DEFINITION
Chronic obstructive pulmonary disease (COPD) is
a preventable and treatable disease characterized
by airflow limitation that is progressive not fully
reversible and associated with an abnormal
inflammatory response of the lungs
Chronic Bronchitis
bull Chronic bronchitis is a chronic inflammatory
condition in the lungs
bull It causes a cough that often brings up mucus as well as shortness of
breathwheezing and
chest tightness
Emphysema
bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs
EPIDEMIOLOGYbull More common in older people especially those
gt65 years
bull Fifth leading cause of death and disabilityworldwide
bull Death rates for males and females are roughlyequivalent
bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod
Risk Factors
Exposures Host Factors
Environmental tobacco smoke
Genetic predisposition (AAT deficiency)
Occupational dusts and chemicals
Airway hyperresponsiveness
Air pollution Impaired lung growth
Risk Factors
bull Exposures
ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD
ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD
Host Factors
bull Host factor refers to the traits of an individual person that affect susceptibility to disease
ndash AAT deficiency accounts for less than 1 of COPD cases
ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function
ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses
Pathophysiology of COPD
1 Airway inflammation
2 Structural changes
3 Mucociliary dysfunction
- Chronic inflammatory cascade for COPD
ASSESSMENT
1 Clinical presentation
ndash History
ndash Physical examination
2 Diagnostic testing
ndash Pulmonary function testing
ndash Laboratories
ndash Imaging
Clinical Presentation
HistoryPhysical
Examination
- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors
- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles
ASSESSMENT
bull General appearance
bull Vital signs Heart rhythm
bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
bull ABGs SaO2 CBC WBC and chest x-ray results
bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea
bull Nutrition and weight loss
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
bull The inner wall of the trachea is lined with
ciliated mucous membrane
with many goblet cells
that serve to trap incoming
particles
bull The tracheal wall is
supported by 20 incomplete
cartilaginous rings
BRONCHI The Bronchi are the two main air passages
into the lungs
They are composed of the
ldquoRight Primary Bronchusrdquo- leading to the right lung
ldquoLeft Primary Bronchusrdquo - leading to the left lung
The Bronchial Tree
The bronchial tree consists of branched tubes leading from the trachea to the alveoli
The bronchial tree begins with the two primary bronchi each leading to a lung
The branches of the bronchial tree from the trachea are right and left primary bronchi
these further subdivide until bronchioles give rise to alveolar ducts which terminate in alveoli
LUNGS
bull One on either side
bull Large cone-shaped spongy structures
which occupy most of thoracic cavity
bull Left lung is divided into 2 lobes and right
into 3
bull Lined by pleura (visceral and parietal)
Terminal branches
bull Bronchioles branch further
and the smallest
subdivisions being terminal
bronchiole
bull It is estimated no of
divisions from tracheal
bifurcation to terminal
bronchiole is 16
bull Total no of divisions till
alveoli is 23
The right lung has three lobes
The left lung has two lobes
Each lobe is composed of lobules
that contain air passages alveoli nerves
blood vessels lymphatic vessels
and connective tissues
Pulmonary alveolibull Alveoli are lined by a single layer of flat epithelialcellsbull Alveolar type I cells are principal liningbull Type II are cuboidal cells secrete surfactantbull Average width is 03 mmbull 300 million alveoli in human lung
Surfactantbull Formed from fatty acids by alveolar type II cellsbull Complex mixture of several phospholipidsproteins and ionsbull Most important components are phospholipiddipalmitoyl phosphatidyl choline (DDPC)surfactant appoproteins and calcium ions
The Pleural Cavities
A layer of serous membrane between the visceral pleura and the parietal pleura
bull It contains a lubricating fluid secretedby the membranes that preventsfriction between the membranes and allows their easy movement on one another during breathing
The Alveoli
They are cup-shaped out pouching lined by epithelium and supported by a thin elastic basement membrane
bull With that you can imagine having bunch of grapeswith each grape indicating and alveolus
Alveolar sacs are 2 or more alveoli that share a common opening
This is where the primary exchange of gases occur
STRUCTURE
nose nasal cavity
pharynx (throat)
larynx
trachea (windpipe)
bronchi
bronchioles
alveoli
FUNCTION
warms moistens amp filters air as it is inhaled
passageway for air leads to trachea
the voice box where vocal chords are located
tube from pharynx to bronchi
rings of cartilage provide structure keeps the
windpipe open
trachea is lined with fine hairs called cilia which
filter air before it reaches the lungs
two branches at the end of the trachea each
lead to a lung
a network of smaller branches leading from the
bronchi into the lung tissue amp ultimately to air
sacs
the functional respiratory units in the lung
where gases (oxygen amp carbon dioxide) are
exchanged (enter amp exit the blood stream)
Summary of FUNCTIONS
LIST OF RESPIRATORY AND LUNG DISEASES
bull Upper respiratory tract infections
bull Lower respiratory tract infections
bull Asthma
bull Copd
bull Inflammatory lung diseases
bull Obstructive lung diseases
bull Restrictive lung diseases
bull Respiratory tumors
bull Pleural cavity diseases
bull Pulmonary vascular diseases
Diagnostic Test
bull CHEST XRAY
bull ABG ANALYSIS
bull EXERCISE TESTING
bull MEDIASTINOSCOPY amp MEDIASTINOTOMY
bull BRONCHOSCOPY
bull CHEST IMAGING
bull CHEST TUBE INSERTION
bull NEEDLE BIOPSY OF THE PLEURA OR LUNG
bull PULMONARY FUNCTION TEST (PFT)
bull SUCTIONING
bull THORACOCENTESIS
bull THORACOSCOPY
bull THORACOTOMY
COPD
bull Also known as
COLD (Chronic Obstructive Lung Disease )
COAD (Chronic Obstructive Airway Disease)
Smokerrsquos lung
CAL (Chronic Airflow Limitation)
CORD (Chronic Obstructive Respiratory Disease)
DEFINITION
Chronic obstructive pulmonary disease (COPD) is
a preventable and treatable disease characterized
by airflow limitation that is progressive not fully
reversible and associated with an abnormal
inflammatory response of the lungs
Chronic Bronchitis
bull Chronic bronchitis is a chronic inflammatory
condition in the lungs
bull It causes a cough that often brings up mucus as well as shortness of
breathwheezing and
chest tightness
Emphysema
bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs
EPIDEMIOLOGYbull More common in older people especially those
gt65 years
bull Fifth leading cause of death and disabilityworldwide
bull Death rates for males and females are roughlyequivalent
bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod
Risk Factors
Exposures Host Factors
Environmental tobacco smoke
Genetic predisposition (AAT deficiency)
Occupational dusts and chemicals
Airway hyperresponsiveness
Air pollution Impaired lung growth
Risk Factors
bull Exposures
ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD
ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD
Host Factors
bull Host factor refers to the traits of an individual person that affect susceptibility to disease
ndash AAT deficiency accounts for less than 1 of COPD cases
ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function
ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses
Pathophysiology of COPD
1 Airway inflammation
2 Structural changes
3 Mucociliary dysfunction
- Chronic inflammatory cascade for COPD
ASSESSMENT
1 Clinical presentation
ndash History
ndash Physical examination
2 Diagnostic testing
ndash Pulmonary function testing
ndash Laboratories
ndash Imaging
Clinical Presentation
HistoryPhysical
Examination
- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors
- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles
ASSESSMENT
bull General appearance
bull Vital signs Heart rhythm
bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
bull ABGs SaO2 CBC WBC and chest x-ray results
bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea
bull Nutrition and weight loss
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
BRONCHI The Bronchi are the two main air passages
into the lungs
They are composed of the
ldquoRight Primary Bronchusrdquo- leading to the right lung
ldquoLeft Primary Bronchusrdquo - leading to the left lung
The Bronchial Tree
The bronchial tree consists of branched tubes leading from the trachea to the alveoli
The bronchial tree begins with the two primary bronchi each leading to a lung
The branches of the bronchial tree from the trachea are right and left primary bronchi
these further subdivide until bronchioles give rise to alveolar ducts which terminate in alveoli
LUNGS
bull One on either side
bull Large cone-shaped spongy structures
which occupy most of thoracic cavity
bull Left lung is divided into 2 lobes and right
into 3
bull Lined by pleura (visceral and parietal)
Terminal branches
bull Bronchioles branch further
and the smallest
subdivisions being terminal
bronchiole
bull It is estimated no of
divisions from tracheal
bifurcation to terminal
bronchiole is 16
bull Total no of divisions till
alveoli is 23
The right lung has three lobes
The left lung has two lobes
Each lobe is composed of lobules
that contain air passages alveoli nerves
blood vessels lymphatic vessels
and connective tissues
Pulmonary alveolibull Alveoli are lined by a single layer of flat epithelialcellsbull Alveolar type I cells are principal liningbull Type II are cuboidal cells secrete surfactantbull Average width is 03 mmbull 300 million alveoli in human lung
Surfactantbull Formed from fatty acids by alveolar type II cellsbull Complex mixture of several phospholipidsproteins and ionsbull Most important components are phospholipiddipalmitoyl phosphatidyl choline (DDPC)surfactant appoproteins and calcium ions
The Pleural Cavities
A layer of serous membrane between the visceral pleura and the parietal pleura
bull It contains a lubricating fluid secretedby the membranes that preventsfriction between the membranes and allows their easy movement on one another during breathing
The Alveoli
They are cup-shaped out pouching lined by epithelium and supported by a thin elastic basement membrane
bull With that you can imagine having bunch of grapeswith each grape indicating and alveolus
Alveolar sacs are 2 or more alveoli that share a common opening
This is where the primary exchange of gases occur
STRUCTURE
nose nasal cavity
pharynx (throat)
larynx
trachea (windpipe)
bronchi
bronchioles
alveoli
FUNCTION
warms moistens amp filters air as it is inhaled
passageway for air leads to trachea
the voice box where vocal chords are located
tube from pharynx to bronchi
rings of cartilage provide structure keeps the
windpipe open
trachea is lined with fine hairs called cilia which
filter air before it reaches the lungs
two branches at the end of the trachea each
lead to a lung
a network of smaller branches leading from the
bronchi into the lung tissue amp ultimately to air
sacs
the functional respiratory units in the lung
where gases (oxygen amp carbon dioxide) are
exchanged (enter amp exit the blood stream)
Summary of FUNCTIONS
LIST OF RESPIRATORY AND LUNG DISEASES
bull Upper respiratory tract infections
bull Lower respiratory tract infections
bull Asthma
bull Copd
bull Inflammatory lung diseases
bull Obstructive lung diseases
bull Restrictive lung diseases
bull Respiratory tumors
bull Pleural cavity diseases
bull Pulmonary vascular diseases
Diagnostic Test
bull CHEST XRAY
bull ABG ANALYSIS
bull EXERCISE TESTING
bull MEDIASTINOSCOPY amp MEDIASTINOTOMY
bull BRONCHOSCOPY
bull CHEST IMAGING
bull CHEST TUBE INSERTION
bull NEEDLE BIOPSY OF THE PLEURA OR LUNG
bull PULMONARY FUNCTION TEST (PFT)
bull SUCTIONING
bull THORACOCENTESIS
bull THORACOSCOPY
bull THORACOTOMY
COPD
bull Also known as
COLD (Chronic Obstructive Lung Disease )
COAD (Chronic Obstructive Airway Disease)
Smokerrsquos lung
CAL (Chronic Airflow Limitation)
CORD (Chronic Obstructive Respiratory Disease)
DEFINITION
Chronic obstructive pulmonary disease (COPD) is
a preventable and treatable disease characterized
by airflow limitation that is progressive not fully
reversible and associated with an abnormal
inflammatory response of the lungs
Chronic Bronchitis
bull Chronic bronchitis is a chronic inflammatory
condition in the lungs
bull It causes a cough that often brings up mucus as well as shortness of
breathwheezing and
chest tightness
Emphysema
bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs
EPIDEMIOLOGYbull More common in older people especially those
gt65 years
bull Fifth leading cause of death and disabilityworldwide
bull Death rates for males and females are roughlyequivalent
bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod
Risk Factors
Exposures Host Factors
Environmental tobacco smoke
Genetic predisposition (AAT deficiency)
Occupational dusts and chemicals
Airway hyperresponsiveness
Air pollution Impaired lung growth
Risk Factors
bull Exposures
ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD
ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD
Host Factors
bull Host factor refers to the traits of an individual person that affect susceptibility to disease
ndash AAT deficiency accounts for less than 1 of COPD cases
ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function
ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses
Pathophysiology of COPD
1 Airway inflammation
2 Structural changes
3 Mucociliary dysfunction
- Chronic inflammatory cascade for COPD
ASSESSMENT
1 Clinical presentation
ndash History
ndash Physical examination
2 Diagnostic testing
ndash Pulmonary function testing
ndash Laboratories
ndash Imaging
Clinical Presentation
HistoryPhysical
Examination
- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors
- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles
ASSESSMENT
bull General appearance
bull Vital signs Heart rhythm
bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
bull ABGs SaO2 CBC WBC and chest x-ray results
bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea
bull Nutrition and weight loss
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
The Bronchial Tree
The bronchial tree consists of branched tubes leading from the trachea to the alveoli
The bronchial tree begins with the two primary bronchi each leading to a lung
The branches of the bronchial tree from the trachea are right and left primary bronchi
these further subdivide until bronchioles give rise to alveolar ducts which terminate in alveoli
LUNGS
bull One on either side
bull Large cone-shaped spongy structures
which occupy most of thoracic cavity
bull Left lung is divided into 2 lobes and right
into 3
bull Lined by pleura (visceral and parietal)
Terminal branches
bull Bronchioles branch further
and the smallest
subdivisions being terminal
bronchiole
bull It is estimated no of
divisions from tracheal
bifurcation to terminal
bronchiole is 16
bull Total no of divisions till
alveoli is 23
The right lung has three lobes
The left lung has two lobes
Each lobe is composed of lobules
that contain air passages alveoli nerves
blood vessels lymphatic vessels
and connective tissues
Pulmonary alveolibull Alveoli are lined by a single layer of flat epithelialcellsbull Alveolar type I cells are principal liningbull Type II are cuboidal cells secrete surfactantbull Average width is 03 mmbull 300 million alveoli in human lung
Surfactantbull Formed from fatty acids by alveolar type II cellsbull Complex mixture of several phospholipidsproteins and ionsbull Most important components are phospholipiddipalmitoyl phosphatidyl choline (DDPC)surfactant appoproteins and calcium ions
The Pleural Cavities
A layer of serous membrane between the visceral pleura and the parietal pleura
bull It contains a lubricating fluid secretedby the membranes that preventsfriction between the membranes and allows their easy movement on one another during breathing
The Alveoli
They are cup-shaped out pouching lined by epithelium and supported by a thin elastic basement membrane
bull With that you can imagine having bunch of grapeswith each grape indicating and alveolus
Alveolar sacs are 2 or more alveoli that share a common opening
This is where the primary exchange of gases occur
STRUCTURE
nose nasal cavity
pharynx (throat)
larynx
trachea (windpipe)
bronchi
bronchioles
alveoli
FUNCTION
warms moistens amp filters air as it is inhaled
passageway for air leads to trachea
the voice box where vocal chords are located
tube from pharynx to bronchi
rings of cartilage provide structure keeps the
windpipe open
trachea is lined with fine hairs called cilia which
filter air before it reaches the lungs
two branches at the end of the trachea each
lead to a lung
a network of smaller branches leading from the
bronchi into the lung tissue amp ultimately to air
sacs
the functional respiratory units in the lung
where gases (oxygen amp carbon dioxide) are
exchanged (enter amp exit the blood stream)
Summary of FUNCTIONS
LIST OF RESPIRATORY AND LUNG DISEASES
bull Upper respiratory tract infections
bull Lower respiratory tract infections
bull Asthma
bull Copd
bull Inflammatory lung diseases
bull Obstructive lung diseases
bull Restrictive lung diseases
bull Respiratory tumors
bull Pleural cavity diseases
bull Pulmonary vascular diseases
Diagnostic Test
bull CHEST XRAY
bull ABG ANALYSIS
bull EXERCISE TESTING
bull MEDIASTINOSCOPY amp MEDIASTINOTOMY
bull BRONCHOSCOPY
bull CHEST IMAGING
bull CHEST TUBE INSERTION
bull NEEDLE BIOPSY OF THE PLEURA OR LUNG
bull PULMONARY FUNCTION TEST (PFT)
bull SUCTIONING
bull THORACOCENTESIS
bull THORACOSCOPY
bull THORACOTOMY
COPD
bull Also known as
COLD (Chronic Obstructive Lung Disease )
COAD (Chronic Obstructive Airway Disease)
Smokerrsquos lung
CAL (Chronic Airflow Limitation)
CORD (Chronic Obstructive Respiratory Disease)
DEFINITION
Chronic obstructive pulmonary disease (COPD) is
a preventable and treatable disease characterized
by airflow limitation that is progressive not fully
reversible and associated with an abnormal
inflammatory response of the lungs
Chronic Bronchitis
bull Chronic bronchitis is a chronic inflammatory
condition in the lungs
bull It causes a cough that often brings up mucus as well as shortness of
breathwheezing and
chest tightness
Emphysema
bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs
EPIDEMIOLOGYbull More common in older people especially those
gt65 years
bull Fifth leading cause of death and disabilityworldwide
bull Death rates for males and females are roughlyequivalent
bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod
Risk Factors
Exposures Host Factors
Environmental tobacco smoke
Genetic predisposition (AAT deficiency)
Occupational dusts and chemicals
Airway hyperresponsiveness
Air pollution Impaired lung growth
Risk Factors
bull Exposures
ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD
ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD
Host Factors
bull Host factor refers to the traits of an individual person that affect susceptibility to disease
ndash AAT deficiency accounts for less than 1 of COPD cases
ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function
ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses
Pathophysiology of COPD
1 Airway inflammation
2 Structural changes
3 Mucociliary dysfunction
- Chronic inflammatory cascade for COPD
ASSESSMENT
1 Clinical presentation
ndash History
ndash Physical examination
2 Diagnostic testing
ndash Pulmonary function testing
ndash Laboratories
ndash Imaging
Clinical Presentation
HistoryPhysical
Examination
- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors
- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles
ASSESSMENT
bull General appearance
bull Vital signs Heart rhythm
bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
bull ABGs SaO2 CBC WBC and chest x-ray results
bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea
bull Nutrition and weight loss
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
LUNGS
bull One on either side
bull Large cone-shaped spongy structures
which occupy most of thoracic cavity
bull Left lung is divided into 2 lobes and right
into 3
bull Lined by pleura (visceral and parietal)
Terminal branches
bull Bronchioles branch further
and the smallest
subdivisions being terminal
bronchiole
bull It is estimated no of
divisions from tracheal
bifurcation to terminal
bronchiole is 16
bull Total no of divisions till
alveoli is 23
The right lung has three lobes
The left lung has two lobes
Each lobe is composed of lobules
that contain air passages alveoli nerves
blood vessels lymphatic vessels
and connective tissues
Pulmonary alveolibull Alveoli are lined by a single layer of flat epithelialcellsbull Alveolar type I cells are principal liningbull Type II are cuboidal cells secrete surfactantbull Average width is 03 mmbull 300 million alveoli in human lung
Surfactantbull Formed from fatty acids by alveolar type II cellsbull Complex mixture of several phospholipidsproteins and ionsbull Most important components are phospholipiddipalmitoyl phosphatidyl choline (DDPC)surfactant appoproteins and calcium ions
The Pleural Cavities
A layer of serous membrane between the visceral pleura and the parietal pleura
bull It contains a lubricating fluid secretedby the membranes that preventsfriction between the membranes and allows their easy movement on one another during breathing
The Alveoli
They are cup-shaped out pouching lined by epithelium and supported by a thin elastic basement membrane
bull With that you can imagine having bunch of grapeswith each grape indicating and alveolus
Alveolar sacs are 2 or more alveoli that share a common opening
This is where the primary exchange of gases occur
STRUCTURE
nose nasal cavity
pharynx (throat)
larynx
trachea (windpipe)
bronchi
bronchioles
alveoli
FUNCTION
warms moistens amp filters air as it is inhaled
passageway for air leads to trachea
the voice box where vocal chords are located
tube from pharynx to bronchi
rings of cartilage provide structure keeps the
windpipe open
trachea is lined with fine hairs called cilia which
filter air before it reaches the lungs
two branches at the end of the trachea each
lead to a lung
a network of smaller branches leading from the
bronchi into the lung tissue amp ultimately to air
sacs
the functional respiratory units in the lung
where gases (oxygen amp carbon dioxide) are
exchanged (enter amp exit the blood stream)
Summary of FUNCTIONS
LIST OF RESPIRATORY AND LUNG DISEASES
bull Upper respiratory tract infections
bull Lower respiratory tract infections
bull Asthma
bull Copd
bull Inflammatory lung diseases
bull Obstructive lung diseases
bull Restrictive lung diseases
bull Respiratory tumors
bull Pleural cavity diseases
bull Pulmonary vascular diseases
Diagnostic Test
bull CHEST XRAY
bull ABG ANALYSIS
bull EXERCISE TESTING
bull MEDIASTINOSCOPY amp MEDIASTINOTOMY
bull BRONCHOSCOPY
bull CHEST IMAGING
bull CHEST TUBE INSERTION
bull NEEDLE BIOPSY OF THE PLEURA OR LUNG
bull PULMONARY FUNCTION TEST (PFT)
bull SUCTIONING
bull THORACOCENTESIS
bull THORACOSCOPY
bull THORACOTOMY
COPD
bull Also known as
COLD (Chronic Obstructive Lung Disease )
COAD (Chronic Obstructive Airway Disease)
Smokerrsquos lung
CAL (Chronic Airflow Limitation)
CORD (Chronic Obstructive Respiratory Disease)
DEFINITION
Chronic obstructive pulmonary disease (COPD) is
a preventable and treatable disease characterized
by airflow limitation that is progressive not fully
reversible and associated with an abnormal
inflammatory response of the lungs
Chronic Bronchitis
bull Chronic bronchitis is a chronic inflammatory
condition in the lungs
bull It causes a cough that often brings up mucus as well as shortness of
breathwheezing and
chest tightness
Emphysema
bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs
EPIDEMIOLOGYbull More common in older people especially those
gt65 years
bull Fifth leading cause of death and disabilityworldwide
bull Death rates for males and females are roughlyequivalent
bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod
Risk Factors
Exposures Host Factors
Environmental tobacco smoke
Genetic predisposition (AAT deficiency)
Occupational dusts and chemicals
Airway hyperresponsiveness
Air pollution Impaired lung growth
Risk Factors
bull Exposures
ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD
ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD
Host Factors
bull Host factor refers to the traits of an individual person that affect susceptibility to disease
ndash AAT deficiency accounts for less than 1 of COPD cases
ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function
ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses
Pathophysiology of COPD
1 Airway inflammation
2 Structural changes
3 Mucociliary dysfunction
- Chronic inflammatory cascade for COPD
ASSESSMENT
1 Clinical presentation
ndash History
ndash Physical examination
2 Diagnostic testing
ndash Pulmonary function testing
ndash Laboratories
ndash Imaging
Clinical Presentation
HistoryPhysical
Examination
- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors
- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles
ASSESSMENT
bull General appearance
bull Vital signs Heart rhythm
bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
bull ABGs SaO2 CBC WBC and chest x-ray results
bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea
bull Nutrition and weight loss
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Terminal branches
bull Bronchioles branch further
and the smallest
subdivisions being terminal
bronchiole
bull It is estimated no of
divisions from tracheal
bifurcation to terminal
bronchiole is 16
bull Total no of divisions till
alveoli is 23
The right lung has three lobes
The left lung has two lobes
Each lobe is composed of lobules
that contain air passages alveoli nerves
blood vessels lymphatic vessels
and connective tissues
Pulmonary alveolibull Alveoli are lined by a single layer of flat epithelialcellsbull Alveolar type I cells are principal liningbull Type II are cuboidal cells secrete surfactantbull Average width is 03 mmbull 300 million alveoli in human lung
Surfactantbull Formed from fatty acids by alveolar type II cellsbull Complex mixture of several phospholipidsproteins and ionsbull Most important components are phospholipiddipalmitoyl phosphatidyl choline (DDPC)surfactant appoproteins and calcium ions
The Pleural Cavities
A layer of serous membrane between the visceral pleura and the parietal pleura
bull It contains a lubricating fluid secretedby the membranes that preventsfriction between the membranes and allows their easy movement on one another during breathing
The Alveoli
They are cup-shaped out pouching lined by epithelium and supported by a thin elastic basement membrane
bull With that you can imagine having bunch of grapeswith each grape indicating and alveolus
Alveolar sacs are 2 or more alveoli that share a common opening
This is where the primary exchange of gases occur
STRUCTURE
nose nasal cavity
pharynx (throat)
larynx
trachea (windpipe)
bronchi
bronchioles
alveoli
FUNCTION
warms moistens amp filters air as it is inhaled
passageway for air leads to trachea
the voice box where vocal chords are located
tube from pharynx to bronchi
rings of cartilage provide structure keeps the
windpipe open
trachea is lined with fine hairs called cilia which
filter air before it reaches the lungs
two branches at the end of the trachea each
lead to a lung
a network of smaller branches leading from the
bronchi into the lung tissue amp ultimately to air
sacs
the functional respiratory units in the lung
where gases (oxygen amp carbon dioxide) are
exchanged (enter amp exit the blood stream)
Summary of FUNCTIONS
LIST OF RESPIRATORY AND LUNG DISEASES
bull Upper respiratory tract infections
bull Lower respiratory tract infections
bull Asthma
bull Copd
bull Inflammatory lung diseases
bull Obstructive lung diseases
bull Restrictive lung diseases
bull Respiratory tumors
bull Pleural cavity diseases
bull Pulmonary vascular diseases
Diagnostic Test
bull CHEST XRAY
bull ABG ANALYSIS
bull EXERCISE TESTING
bull MEDIASTINOSCOPY amp MEDIASTINOTOMY
bull BRONCHOSCOPY
bull CHEST IMAGING
bull CHEST TUBE INSERTION
bull NEEDLE BIOPSY OF THE PLEURA OR LUNG
bull PULMONARY FUNCTION TEST (PFT)
bull SUCTIONING
bull THORACOCENTESIS
bull THORACOSCOPY
bull THORACOTOMY
COPD
bull Also known as
COLD (Chronic Obstructive Lung Disease )
COAD (Chronic Obstructive Airway Disease)
Smokerrsquos lung
CAL (Chronic Airflow Limitation)
CORD (Chronic Obstructive Respiratory Disease)
DEFINITION
Chronic obstructive pulmonary disease (COPD) is
a preventable and treatable disease characterized
by airflow limitation that is progressive not fully
reversible and associated with an abnormal
inflammatory response of the lungs
Chronic Bronchitis
bull Chronic bronchitis is a chronic inflammatory
condition in the lungs
bull It causes a cough that often brings up mucus as well as shortness of
breathwheezing and
chest tightness
Emphysema
bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs
EPIDEMIOLOGYbull More common in older people especially those
gt65 years
bull Fifth leading cause of death and disabilityworldwide
bull Death rates for males and females are roughlyequivalent
bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod
Risk Factors
Exposures Host Factors
Environmental tobacco smoke
Genetic predisposition (AAT deficiency)
Occupational dusts and chemicals
Airway hyperresponsiveness
Air pollution Impaired lung growth
Risk Factors
bull Exposures
ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD
ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD
Host Factors
bull Host factor refers to the traits of an individual person that affect susceptibility to disease
ndash AAT deficiency accounts for less than 1 of COPD cases
ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function
ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses
Pathophysiology of COPD
1 Airway inflammation
2 Structural changes
3 Mucociliary dysfunction
- Chronic inflammatory cascade for COPD
ASSESSMENT
1 Clinical presentation
ndash History
ndash Physical examination
2 Diagnostic testing
ndash Pulmonary function testing
ndash Laboratories
ndash Imaging
Clinical Presentation
HistoryPhysical
Examination
- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors
- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles
ASSESSMENT
bull General appearance
bull Vital signs Heart rhythm
bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
bull ABGs SaO2 CBC WBC and chest x-ray results
bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea
bull Nutrition and weight loss
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
The right lung has three lobes
The left lung has two lobes
Each lobe is composed of lobules
that contain air passages alveoli nerves
blood vessels lymphatic vessels
and connective tissues
Pulmonary alveolibull Alveoli are lined by a single layer of flat epithelialcellsbull Alveolar type I cells are principal liningbull Type II are cuboidal cells secrete surfactantbull Average width is 03 mmbull 300 million alveoli in human lung
Surfactantbull Formed from fatty acids by alveolar type II cellsbull Complex mixture of several phospholipidsproteins and ionsbull Most important components are phospholipiddipalmitoyl phosphatidyl choline (DDPC)surfactant appoproteins and calcium ions
The Pleural Cavities
A layer of serous membrane between the visceral pleura and the parietal pleura
bull It contains a lubricating fluid secretedby the membranes that preventsfriction between the membranes and allows their easy movement on one another during breathing
The Alveoli
They are cup-shaped out pouching lined by epithelium and supported by a thin elastic basement membrane
bull With that you can imagine having bunch of grapeswith each grape indicating and alveolus
Alveolar sacs are 2 or more alveoli that share a common opening
This is where the primary exchange of gases occur
STRUCTURE
nose nasal cavity
pharynx (throat)
larynx
trachea (windpipe)
bronchi
bronchioles
alveoli
FUNCTION
warms moistens amp filters air as it is inhaled
passageway for air leads to trachea
the voice box where vocal chords are located
tube from pharynx to bronchi
rings of cartilage provide structure keeps the
windpipe open
trachea is lined with fine hairs called cilia which
filter air before it reaches the lungs
two branches at the end of the trachea each
lead to a lung
a network of smaller branches leading from the
bronchi into the lung tissue amp ultimately to air
sacs
the functional respiratory units in the lung
where gases (oxygen amp carbon dioxide) are
exchanged (enter amp exit the blood stream)
Summary of FUNCTIONS
LIST OF RESPIRATORY AND LUNG DISEASES
bull Upper respiratory tract infections
bull Lower respiratory tract infections
bull Asthma
bull Copd
bull Inflammatory lung diseases
bull Obstructive lung diseases
bull Restrictive lung diseases
bull Respiratory tumors
bull Pleural cavity diseases
bull Pulmonary vascular diseases
Diagnostic Test
bull CHEST XRAY
bull ABG ANALYSIS
bull EXERCISE TESTING
bull MEDIASTINOSCOPY amp MEDIASTINOTOMY
bull BRONCHOSCOPY
bull CHEST IMAGING
bull CHEST TUBE INSERTION
bull NEEDLE BIOPSY OF THE PLEURA OR LUNG
bull PULMONARY FUNCTION TEST (PFT)
bull SUCTIONING
bull THORACOCENTESIS
bull THORACOSCOPY
bull THORACOTOMY
COPD
bull Also known as
COLD (Chronic Obstructive Lung Disease )
COAD (Chronic Obstructive Airway Disease)
Smokerrsquos lung
CAL (Chronic Airflow Limitation)
CORD (Chronic Obstructive Respiratory Disease)
DEFINITION
Chronic obstructive pulmonary disease (COPD) is
a preventable and treatable disease characterized
by airflow limitation that is progressive not fully
reversible and associated with an abnormal
inflammatory response of the lungs
Chronic Bronchitis
bull Chronic bronchitis is a chronic inflammatory
condition in the lungs
bull It causes a cough that often brings up mucus as well as shortness of
breathwheezing and
chest tightness
Emphysema
bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs
EPIDEMIOLOGYbull More common in older people especially those
gt65 years
bull Fifth leading cause of death and disabilityworldwide
bull Death rates for males and females are roughlyequivalent
bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod
Risk Factors
Exposures Host Factors
Environmental tobacco smoke
Genetic predisposition (AAT deficiency)
Occupational dusts and chemicals
Airway hyperresponsiveness
Air pollution Impaired lung growth
Risk Factors
bull Exposures
ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD
ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD
Host Factors
bull Host factor refers to the traits of an individual person that affect susceptibility to disease
ndash AAT deficiency accounts for less than 1 of COPD cases
ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function
ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses
Pathophysiology of COPD
1 Airway inflammation
2 Structural changes
3 Mucociliary dysfunction
- Chronic inflammatory cascade for COPD
ASSESSMENT
1 Clinical presentation
ndash History
ndash Physical examination
2 Diagnostic testing
ndash Pulmonary function testing
ndash Laboratories
ndash Imaging
Clinical Presentation
HistoryPhysical
Examination
- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors
- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles
ASSESSMENT
bull General appearance
bull Vital signs Heart rhythm
bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
bull ABGs SaO2 CBC WBC and chest x-ray results
bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea
bull Nutrition and weight loss
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Pulmonary alveolibull Alveoli are lined by a single layer of flat epithelialcellsbull Alveolar type I cells are principal liningbull Type II are cuboidal cells secrete surfactantbull Average width is 03 mmbull 300 million alveoli in human lung
Surfactantbull Formed from fatty acids by alveolar type II cellsbull Complex mixture of several phospholipidsproteins and ionsbull Most important components are phospholipiddipalmitoyl phosphatidyl choline (DDPC)surfactant appoproteins and calcium ions
The Pleural Cavities
A layer of serous membrane between the visceral pleura and the parietal pleura
bull It contains a lubricating fluid secretedby the membranes that preventsfriction between the membranes and allows their easy movement on one another during breathing
The Alveoli
They are cup-shaped out pouching lined by epithelium and supported by a thin elastic basement membrane
bull With that you can imagine having bunch of grapeswith each grape indicating and alveolus
Alveolar sacs are 2 or more alveoli that share a common opening
This is where the primary exchange of gases occur
STRUCTURE
nose nasal cavity
pharynx (throat)
larynx
trachea (windpipe)
bronchi
bronchioles
alveoli
FUNCTION
warms moistens amp filters air as it is inhaled
passageway for air leads to trachea
the voice box where vocal chords are located
tube from pharynx to bronchi
rings of cartilage provide structure keeps the
windpipe open
trachea is lined with fine hairs called cilia which
filter air before it reaches the lungs
two branches at the end of the trachea each
lead to a lung
a network of smaller branches leading from the
bronchi into the lung tissue amp ultimately to air
sacs
the functional respiratory units in the lung
where gases (oxygen amp carbon dioxide) are
exchanged (enter amp exit the blood stream)
Summary of FUNCTIONS
LIST OF RESPIRATORY AND LUNG DISEASES
bull Upper respiratory tract infections
bull Lower respiratory tract infections
bull Asthma
bull Copd
bull Inflammatory lung diseases
bull Obstructive lung diseases
bull Restrictive lung diseases
bull Respiratory tumors
bull Pleural cavity diseases
bull Pulmonary vascular diseases
Diagnostic Test
bull CHEST XRAY
bull ABG ANALYSIS
bull EXERCISE TESTING
bull MEDIASTINOSCOPY amp MEDIASTINOTOMY
bull BRONCHOSCOPY
bull CHEST IMAGING
bull CHEST TUBE INSERTION
bull NEEDLE BIOPSY OF THE PLEURA OR LUNG
bull PULMONARY FUNCTION TEST (PFT)
bull SUCTIONING
bull THORACOCENTESIS
bull THORACOSCOPY
bull THORACOTOMY
COPD
bull Also known as
COLD (Chronic Obstructive Lung Disease )
COAD (Chronic Obstructive Airway Disease)
Smokerrsquos lung
CAL (Chronic Airflow Limitation)
CORD (Chronic Obstructive Respiratory Disease)
DEFINITION
Chronic obstructive pulmonary disease (COPD) is
a preventable and treatable disease characterized
by airflow limitation that is progressive not fully
reversible and associated with an abnormal
inflammatory response of the lungs
Chronic Bronchitis
bull Chronic bronchitis is a chronic inflammatory
condition in the lungs
bull It causes a cough that often brings up mucus as well as shortness of
breathwheezing and
chest tightness
Emphysema
bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs
EPIDEMIOLOGYbull More common in older people especially those
gt65 years
bull Fifth leading cause of death and disabilityworldwide
bull Death rates for males and females are roughlyequivalent
bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod
Risk Factors
Exposures Host Factors
Environmental tobacco smoke
Genetic predisposition (AAT deficiency)
Occupational dusts and chemicals
Airway hyperresponsiveness
Air pollution Impaired lung growth
Risk Factors
bull Exposures
ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD
ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD
Host Factors
bull Host factor refers to the traits of an individual person that affect susceptibility to disease
ndash AAT deficiency accounts for less than 1 of COPD cases
ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function
ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses
Pathophysiology of COPD
1 Airway inflammation
2 Structural changes
3 Mucociliary dysfunction
- Chronic inflammatory cascade for COPD
ASSESSMENT
1 Clinical presentation
ndash History
ndash Physical examination
2 Diagnostic testing
ndash Pulmonary function testing
ndash Laboratories
ndash Imaging
Clinical Presentation
HistoryPhysical
Examination
- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors
- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles
ASSESSMENT
bull General appearance
bull Vital signs Heart rhythm
bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
bull ABGs SaO2 CBC WBC and chest x-ray results
bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea
bull Nutrition and weight loss
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
The Pleural Cavities
A layer of serous membrane between the visceral pleura and the parietal pleura
bull It contains a lubricating fluid secretedby the membranes that preventsfriction between the membranes and allows their easy movement on one another during breathing
The Alveoli
They are cup-shaped out pouching lined by epithelium and supported by a thin elastic basement membrane
bull With that you can imagine having bunch of grapeswith each grape indicating and alveolus
Alveolar sacs are 2 or more alveoli that share a common opening
This is where the primary exchange of gases occur
STRUCTURE
nose nasal cavity
pharynx (throat)
larynx
trachea (windpipe)
bronchi
bronchioles
alveoli
FUNCTION
warms moistens amp filters air as it is inhaled
passageway for air leads to trachea
the voice box where vocal chords are located
tube from pharynx to bronchi
rings of cartilage provide structure keeps the
windpipe open
trachea is lined with fine hairs called cilia which
filter air before it reaches the lungs
two branches at the end of the trachea each
lead to a lung
a network of smaller branches leading from the
bronchi into the lung tissue amp ultimately to air
sacs
the functional respiratory units in the lung
where gases (oxygen amp carbon dioxide) are
exchanged (enter amp exit the blood stream)
Summary of FUNCTIONS
LIST OF RESPIRATORY AND LUNG DISEASES
bull Upper respiratory tract infections
bull Lower respiratory tract infections
bull Asthma
bull Copd
bull Inflammatory lung diseases
bull Obstructive lung diseases
bull Restrictive lung diseases
bull Respiratory tumors
bull Pleural cavity diseases
bull Pulmonary vascular diseases
Diagnostic Test
bull CHEST XRAY
bull ABG ANALYSIS
bull EXERCISE TESTING
bull MEDIASTINOSCOPY amp MEDIASTINOTOMY
bull BRONCHOSCOPY
bull CHEST IMAGING
bull CHEST TUBE INSERTION
bull NEEDLE BIOPSY OF THE PLEURA OR LUNG
bull PULMONARY FUNCTION TEST (PFT)
bull SUCTIONING
bull THORACOCENTESIS
bull THORACOSCOPY
bull THORACOTOMY
COPD
bull Also known as
COLD (Chronic Obstructive Lung Disease )
COAD (Chronic Obstructive Airway Disease)
Smokerrsquos lung
CAL (Chronic Airflow Limitation)
CORD (Chronic Obstructive Respiratory Disease)
DEFINITION
Chronic obstructive pulmonary disease (COPD) is
a preventable and treatable disease characterized
by airflow limitation that is progressive not fully
reversible and associated with an abnormal
inflammatory response of the lungs
Chronic Bronchitis
bull Chronic bronchitis is a chronic inflammatory
condition in the lungs
bull It causes a cough that often brings up mucus as well as shortness of
breathwheezing and
chest tightness
Emphysema
bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs
EPIDEMIOLOGYbull More common in older people especially those
gt65 years
bull Fifth leading cause of death and disabilityworldwide
bull Death rates for males and females are roughlyequivalent
bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod
Risk Factors
Exposures Host Factors
Environmental tobacco smoke
Genetic predisposition (AAT deficiency)
Occupational dusts and chemicals
Airway hyperresponsiveness
Air pollution Impaired lung growth
Risk Factors
bull Exposures
ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD
ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD
Host Factors
bull Host factor refers to the traits of an individual person that affect susceptibility to disease
ndash AAT deficiency accounts for less than 1 of COPD cases
ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function
ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses
Pathophysiology of COPD
1 Airway inflammation
2 Structural changes
3 Mucociliary dysfunction
- Chronic inflammatory cascade for COPD
ASSESSMENT
1 Clinical presentation
ndash History
ndash Physical examination
2 Diagnostic testing
ndash Pulmonary function testing
ndash Laboratories
ndash Imaging
Clinical Presentation
HistoryPhysical
Examination
- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors
- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles
ASSESSMENT
bull General appearance
bull Vital signs Heart rhythm
bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
bull ABGs SaO2 CBC WBC and chest x-ray results
bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea
bull Nutrition and weight loss
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
The Alveoli
They are cup-shaped out pouching lined by epithelium and supported by a thin elastic basement membrane
bull With that you can imagine having bunch of grapeswith each grape indicating and alveolus
Alveolar sacs are 2 or more alveoli that share a common opening
This is where the primary exchange of gases occur
STRUCTURE
nose nasal cavity
pharynx (throat)
larynx
trachea (windpipe)
bronchi
bronchioles
alveoli
FUNCTION
warms moistens amp filters air as it is inhaled
passageway for air leads to trachea
the voice box where vocal chords are located
tube from pharynx to bronchi
rings of cartilage provide structure keeps the
windpipe open
trachea is lined with fine hairs called cilia which
filter air before it reaches the lungs
two branches at the end of the trachea each
lead to a lung
a network of smaller branches leading from the
bronchi into the lung tissue amp ultimately to air
sacs
the functional respiratory units in the lung
where gases (oxygen amp carbon dioxide) are
exchanged (enter amp exit the blood stream)
Summary of FUNCTIONS
LIST OF RESPIRATORY AND LUNG DISEASES
bull Upper respiratory tract infections
bull Lower respiratory tract infections
bull Asthma
bull Copd
bull Inflammatory lung diseases
bull Obstructive lung diseases
bull Restrictive lung diseases
bull Respiratory tumors
bull Pleural cavity diseases
bull Pulmonary vascular diseases
Diagnostic Test
bull CHEST XRAY
bull ABG ANALYSIS
bull EXERCISE TESTING
bull MEDIASTINOSCOPY amp MEDIASTINOTOMY
bull BRONCHOSCOPY
bull CHEST IMAGING
bull CHEST TUBE INSERTION
bull NEEDLE BIOPSY OF THE PLEURA OR LUNG
bull PULMONARY FUNCTION TEST (PFT)
bull SUCTIONING
bull THORACOCENTESIS
bull THORACOSCOPY
bull THORACOTOMY
COPD
bull Also known as
COLD (Chronic Obstructive Lung Disease )
COAD (Chronic Obstructive Airway Disease)
Smokerrsquos lung
CAL (Chronic Airflow Limitation)
CORD (Chronic Obstructive Respiratory Disease)
DEFINITION
Chronic obstructive pulmonary disease (COPD) is
a preventable and treatable disease characterized
by airflow limitation that is progressive not fully
reversible and associated with an abnormal
inflammatory response of the lungs
Chronic Bronchitis
bull Chronic bronchitis is a chronic inflammatory
condition in the lungs
bull It causes a cough that often brings up mucus as well as shortness of
breathwheezing and
chest tightness
Emphysema
bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs
EPIDEMIOLOGYbull More common in older people especially those
gt65 years
bull Fifth leading cause of death and disabilityworldwide
bull Death rates for males and females are roughlyequivalent
bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod
Risk Factors
Exposures Host Factors
Environmental tobacco smoke
Genetic predisposition (AAT deficiency)
Occupational dusts and chemicals
Airway hyperresponsiveness
Air pollution Impaired lung growth
Risk Factors
bull Exposures
ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD
ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD
Host Factors
bull Host factor refers to the traits of an individual person that affect susceptibility to disease
ndash AAT deficiency accounts for less than 1 of COPD cases
ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function
ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses
Pathophysiology of COPD
1 Airway inflammation
2 Structural changes
3 Mucociliary dysfunction
- Chronic inflammatory cascade for COPD
ASSESSMENT
1 Clinical presentation
ndash History
ndash Physical examination
2 Diagnostic testing
ndash Pulmonary function testing
ndash Laboratories
ndash Imaging
Clinical Presentation
HistoryPhysical
Examination
- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors
- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles
ASSESSMENT
bull General appearance
bull Vital signs Heart rhythm
bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
bull ABGs SaO2 CBC WBC and chest x-ray results
bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea
bull Nutrition and weight loss
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
STRUCTURE
nose nasal cavity
pharynx (throat)
larynx
trachea (windpipe)
bronchi
bronchioles
alveoli
FUNCTION
warms moistens amp filters air as it is inhaled
passageway for air leads to trachea
the voice box where vocal chords are located
tube from pharynx to bronchi
rings of cartilage provide structure keeps the
windpipe open
trachea is lined with fine hairs called cilia which
filter air before it reaches the lungs
two branches at the end of the trachea each
lead to a lung
a network of smaller branches leading from the
bronchi into the lung tissue amp ultimately to air
sacs
the functional respiratory units in the lung
where gases (oxygen amp carbon dioxide) are
exchanged (enter amp exit the blood stream)
Summary of FUNCTIONS
LIST OF RESPIRATORY AND LUNG DISEASES
bull Upper respiratory tract infections
bull Lower respiratory tract infections
bull Asthma
bull Copd
bull Inflammatory lung diseases
bull Obstructive lung diseases
bull Restrictive lung diseases
bull Respiratory tumors
bull Pleural cavity diseases
bull Pulmonary vascular diseases
Diagnostic Test
bull CHEST XRAY
bull ABG ANALYSIS
bull EXERCISE TESTING
bull MEDIASTINOSCOPY amp MEDIASTINOTOMY
bull BRONCHOSCOPY
bull CHEST IMAGING
bull CHEST TUBE INSERTION
bull NEEDLE BIOPSY OF THE PLEURA OR LUNG
bull PULMONARY FUNCTION TEST (PFT)
bull SUCTIONING
bull THORACOCENTESIS
bull THORACOSCOPY
bull THORACOTOMY
COPD
bull Also known as
COLD (Chronic Obstructive Lung Disease )
COAD (Chronic Obstructive Airway Disease)
Smokerrsquos lung
CAL (Chronic Airflow Limitation)
CORD (Chronic Obstructive Respiratory Disease)
DEFINITION
Chronic obstructive pulmonary disease (COPD) is
a preventable and treatable disease characterized
by airflow limitation that is progressive not fully
reversible and associated with an abnormal
inflammatory response of the lungs
Chronic Bronchitis
bull Chronic bronchitis is a chronic inflammatory
condition in the lungs
bull It causes a cough that often brings up mucus as well as shortness of
breathwheezing and
chest tightness
Emphysema
bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs
EPIDEMIOLOGYbull More common in older people especially those
gt65 years
bull Fifth leading cause of death and disabilityworldwide
bull Death rates for males and females are roughlyequivalent
bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod
Risk Factors
Exposures Host Factors
Environmental tobacco smoke
Genetic predisposition (AAT deficiency)
Occupational dusts and chemicals
Airway hyperresponsiveness
Air pollution Impaired lung growth
Risk Factors
bull Exposures
ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD
ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD
Host Factors
bull Host factor refers to the traits of an individual person that affect susceptibility to disease
ndash AAT deficiency accounts for less than 1 of COPD cases
ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function
ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses
Pathophysiology of COPD
1 Airway inflammation
2 Structural changes
3 Mucociliary dysfunction
- Chronic inflammatory cascade for COPD
ASSESSMENT
1 Clinical presentation
ndash History
ndash Physical examination
2 Diagnostic testing
ndash Pulmonary function testing
ndash Laboratories
ndash Imaging
Clinical Presentation
HistoryPhysical
Examination
- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors
- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles
ASSESSMENT
bull General appearance
bull Vital signs Heart rhythm
bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
bull ABGs SaO2 CBC WBC and chest x-ray results
bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea
bull Nutrition and weight loss
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
LIST OF RESPIRATORY AND LUNG DISEASES
bull Upper respiratory tract infections
bull Lower respiratory tract infections
bull Asthma
bull Copd
bull Inflammatory lung diseases
bull Obstructive lung diseases
bull Restrictive lung diseases
bull Respiratory tumors
bull Pleural cavity diseases
bull Pulmonary vascular diseases
Diagnostic Test
bull CHEST XRAY
bull ABG ANALYSIS
bull EXERCISE TESTING
bull MEDIASTINOSCOPY amp MEDIASTINOTOMY
bull BRONCHOSCOPY
bull CHEST IMAGING
bull CHEST TUBE INSERTION
bull NEEDLE BIOPSY OF THE PLEURA OR LUNG
bull PULMONARY FUNCTION TEST (PFT)
bull SUCTIONING
bull THORACOCENTESIS
bull THORACOSCOPY
bull THORACOTOMY
COPD
bull Also known as
COLD (Chronic Obstructive Lung Disease )
COAD (Chronic Obstructive Airway Disease)
Smokerrsquos lung
CAL (Chronic Airflow Limitation)
CORD (Chronic Obstructive Respiratory Disease)
DEFINITION
Chronic obstructive pulmonary disease (COPD) is
a preventable and treatable disease characterized
by airflow limitation that is progressive not fully
reversible and associated with an abnormal
inflammatory response of the lungs
Chronic Bronchitis
bull Chronic bronchitis is a chronic inflammatory
condition in the lungs
bull It causes a cough that often brings up mucus as well as shortness of
breathwheezing and
chest tightness
Emphysema
bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs
EPIDEMIOLOGYbull More common in older people especially those
gt65 years
bull Fifth leading cause of death and disabilityworldwide
bull Death rates for males and females are roughlyequivalent
bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod
Risk Factors
Exposures Host Factors
Environmental tobacco smoke
Genetic predisposition (AAT deficiency)
Occupational dusts and chemicals
Airway hyperresponsiveness
Air pollution Impaired lung growth
Risk Factors
bull Exposures
ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD
ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD
Host Factors
bull Host factor refers to the traits of an individual person that affect susceptibility to disease
ndash AAT deficiency accounts for less than 1 of COPD cases
ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function
ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses
Pathophysiology of COPD
1 Airway inflammation
2 Structural changes
3 Mucociliary dysfunction
- Chronic inflammatory cascade for COPD
ASSESSMENT
1 Clinical presentation
ndash History
ndash Physical examination
2 Diagnostic testing
ndash Pulmonary function testing
ndash Laboratories
ndash Imaging
Clinical Presentation
HistoryPhysical
Examination
- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors
- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles
ASSESSMENT
bull General appearance
bull Vital signs Heart rhythm
bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
bull ABGs SaO2 CBC WBC and chest x-ray results
bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea
bull Nutrition and weight loss
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
bull Obstructive lung diseases
bull Restrictive lung diseases
bull Respiratory tumors
bull Pleural cavity diseases
bull Pulmonary vascular diseases
Diagnostic Test
bull CHEST XRAY
bull ABG ANALYSIS
bull EXERCISE TESTING
bull MEDIASTINOSCOPY amp MEDIASTINOTOMY
bull BRONCHOSCOPY
bull CHEST IMAGING
bull CHEST TUBE INSERTION
bull NEEDLE BIOPSY OF THE PLEURA OR LUNG
bull PULMONARY FUNCTION TEST (PFT)
bull SUCTIONING
bull THORACOCENTESIS
bull THORACOSCOPY
bull THORACOTOMY
COPD
bull Also known as
COLD (Chronic Obstructive Lung Disease )
COAD (Chronic Obstructive Airway Disease)
Smokerrsquos lung
CAL (Chronic Airflow Limitation)
CORD (Chronic Obstructive Respiratory Disease)
DEFINITION
Chronic obstructive pulmonary disease (COPD) is
a preventable and treatable disease characterized
by airflow limitation that is progressive not fully
reversible and associated with an abnormal
inflammatory response of the lungs
Chronic Bronchitis
bull Chronic bronchitis is a chronic inflammatory
condition in the lungs
bull It causes a cough that often brings up mucus as well as shortness of
breathwheezing and
chest tightness
Emphysema
bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs
EPIDEMIOLOGYbull More common in older people especially those
gt65 years
bull Fifth leading cause of death and disabilityworldwide
bull Death rates for males and females are roughlyequivalent
bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod
Risk Factors
Exposures Host Factors
Environmental tobacco smoke
Genetic predisposition (AAT deficiency)
Occupational dusts and chemicals
Airway hyperresponsiveness
Air pollution Impaired lung growth
Risk Factors
bull Exposures
ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD
ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD
Host Factors
bull Host factor refers to the traits of an individual person that affect susceptibility to disease
ndash AAT deficiency accounts for less than 1 of COPD cases
ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function
ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses
Pathophysiology of COPD
1 Airway inflammation
2 Structural changes
3 Mucociliary dysfunction
- Chronic inflammatory cascade for COPD
ASSESSMENT
1 Clinical presentation
ndash History
ndash Physical examination
2 Diagnostic testing
ndash Pulmonary function testing
ndash Laboratories
ndash Imaging
Clinical Presentation
HistoryPhysical
Examination
- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors
- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles
ASSESSMENT
bull General appearance
bull Vital signs Heart rhythm
bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
bull ABGs SaO2 CBC WBC and chest x-ray results
bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea
bull Nutrition and weight loss
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Diagnostic Test
bull CHEST XRAY
bull ABG ANALYSIS
bull EXERCISE TESTING
bull MEDIASTINOSCOPY amp MEDIASTINOTOMY
bull BRONCHOSCOPY
bull CHEST IMAGING
bull CHEST TUBE INSERTION
bull NEEDLE BIOPSY OF THE PLEURA OR LUNG
bull PULMONARY FUNCTION TEST (PFT)
bull SUCTIONING
bull THORACOCENTESIS
bull THORACOSCOPY
bull THORACOTOMY
COPD
bull Also known as
COLD (Chronic Obstructive Lung Disease )
COAD (Chronic Obstructive Airway Disease)
Smokerrsquos lung
CAL (Chronic Airflow Limitation)
CORD (Chronic Obstructive Respiratory Disease)
DEFINITION
Chronic obstructive pulmonary disease (COPD) is
a preventable and treatable disease characterized
by airflow limitation that is progressive not fully
reversible and associated with an abnormal
inflammatory response of the lungs
Chronic Bronchitis
bull Chronic bronchitis is a chronic inflammatory
condition in the lungs
bull It causes a cough that often brings up mucus as well as shortness of
breathwheezing and
chest tightness
Emphysema
bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs
EPIDEMIOLOGYbull More common in older people especially those
gt65 years
bull Fifth leading cause of death and disabilityworldwide
bull Death rates for males and females are roughlyequivalent
bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod
Risk Factors
Exposures Host Factors
Environmental tobacco smoke
Genetic predisposition (AAT deficiency)
Occupational dusts and chemicals
Airway hyperresponsiveness
Air pollution Impaired lung growth
Risk Factors
bull Exposures
ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD
ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD
Host Factors
bull Host factor refers to the traits of an individual person that affect susceptibility to disease
ndash AAT deficiency accounts for less than 1 of COPD cases
ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function
ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses
Pathophysiology of COPD
1 Airway inflammation
2 Structural changes
3 Mucociliary dysfunction
- Chronic inflammatory cascade for COPD
ASSESSMENT
1 Clinical presentation
ndash History
ndash Physical examination
2 Diagnostic testing
ndash Pulmonary function testing
ndash Laboratories
ndash Imaging
Clinical Presentation
HistoryPhysical
Examination
- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors
- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles
ASSESSMENT
bull General appearance
bull Vital signs Heart rhythm
bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
bull ABGs SaO2 CBC WBC and chest x-ray results
bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea
bull Nutrition and weight loss
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
bull BRONCHOSCOPY
bull CHEST IMAGING
bull CHEST TUBE INSERTION
bull NEEDLE BIOPSY OF THE PLEURA OR LUNG
bull PULMONARY FUNCTION TEST (PFT)
bull SUCTIONING
bull THORACOCENTESIS
bull THORACOSCOPY
bull THORACOTOMY
COPD
bull Also known as
COLD (Chronic Obstructive Lung Disease )
COAD (Chronic Obstructive Airway Disease)
Smokerrsquos lung
CAL (Chronic Airflow Limitation)
CORD (Chronic Obstructive Respiratory Disease)
DEFINITION
Chronic obstructive pulmonary disease (COPD) is
a preventable and treatable disease characterized
by airflow limitation that is progressive not fully
reversible and associated with an abnormal
inflammatory response of the lungs
Chronic Bronchitis
bull Chronic bronchitis is a chronic inflammatory
condition in the lungs
bull It causes a cough that often brings up mucus as well as shortness of
breathwheezing and
chest tightness
Emphysema
bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs
EPIDEMIOLOGYbull More common in older people especially those
gt65 years
bull Fifth leading cause of death and disabilityworldwide
bull Death rates for males and females are roughlyequivalent
bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod
Risk Factors
Exposures Host Factors
Environmental tobacco smoke
Genetic predisposition (AAT deficiency)
Occupational dusts and chemicals
Airway hyperresponsiveness
Air pollution Impaired lung growth
Risk Factors
bull Exposures
ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD
ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD
Host Factors
bull Host factor refers to the traits of an individual person that affect susceptibility to disease
ndash AAT deficiency accounts for less than 1 of COPD cases
ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function
ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses
Pathophysiology of COPD
1 Airway inflammation
2 Structural changes
3 Mucociliary dysfunction
- Chronic inflammatory cascade for COPD
ASSESSMENT
1 Clinical presentation
ndash History
ndash Physical examination
2 Diagnostic testing
ndash Pulmonary function testing
ndash Laboratories
ndash Imaging
Clinical Presentation
HistoryPhysical
Examination
- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors
- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles
ASSESSMENT
bull General appearance
bull Vital signs Heart rhythm
bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
bull ABGs SaO2 CBC WBC and chest x-ray results
bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea
bull Nutrition and weight loss
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
bull NEEDLE BIOPSY OF THE PLEURA OR LUNG
bull PULMONARY FUNCTION TEST (PFT)
bull SUCTIONING
bull THORACOCENTESIS
bull THORACOSCOPY
bull THORACOTOMY
COPD
bull Also known as
COLD (Chronic Obstructive Lung Disease )
COAD (Chronic Obstructive Airway Disease)
Smokerrsquos lung
CAL (Chronic Airflow Limitation)
CORD (Chronic Obstructive Respiratory Disease)
DEFINITION
Chronic obstructive pulmonary disease (COPD) is
a preventable and treatable disease characterized
by airflow limitation that is progressive not fully
reversible and associated with an abnormal
inflammatory response of the lungs
Chronic Bronchitis
bull Chronic bronchitis is a chronic inflammatory
condition in the lungs
bull It causes a cough that often brings up mucus as well as shortness of
breathwheezing and
chest tightness
Emphysema
bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs
EPIDEMIOLOGYbull More common in older people especially those
gt65 years
bull Fifth leading cause of death and disabilityworldwide
bull Death rates for males and females are roughlyequivalent
bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod
Risk Factors
Exposures Host Factors
Environmental tobacco smoke
Genetic predisposition (AAT deficiency)
Occupational dusts and chemicals
Airway hyperresponsiveness
Air pollution Impaired lung growth
Risk Factors
bull Exposures
ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD
ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD
Host Factors
bull Host factor refers to the traits of an individual person that affect susceptibility to disease
ndash AAT deficiency accounts for less than 1 of COPD cases
ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function
ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses
Pathophysiology of COPD
1 Airway inflammation
2 Structural changes
3 Mucociliary dysfunction
- Chronic inflammatory cascade for COPD
ASSESSMENT
1 Clinical presentation
ndash History
ndash Physical examination
2 Diagnostic testing
ndash Pulmonary function testing
ndash Laboratories
ndash Imaging
Clinical Presentation
HistoryPhysical
Examination
- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors
- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles
ASSESSMENT
bull General appearance
bull Vital signs Heart rhythm
bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
bull ABGs SaO2 CBC WBC and chest x-ray results
bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea
bull Nutrition and weight loss
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
COPD
bull Also known as
COLD (Chronic Obstructive Lung Disease )
COAD (Chronic Obstructive Airway Disease)
Smokerrsquos lung
CAL (Chronic Airflow Limitation)
CORD (Chronic Obstructive Respiratory Disease)
DEFINITION
Chronic obstructive pulmonary disease (COPD) is
a preventable and treatable disease characterized
by airflow limitation that is progressive not fully
reversible and associated with an abnormal
inflammatory response of the lungs
Chronic Bronchitis
bull Chronic bronchitis is a chronic inflammatory
condition in the lungs
bull It causes a cough that often brings up mucus as well as shortness of
breathwheezing and
chest tightness
Emphysema
bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs
EPIDEMIOLOGYbull More common in older people especially those
gt65 years
bull Fifth leading cause of death and disabilityworldwide
bull Death rates for males and females are roughlyequivalent
bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod
Risk Factors
Exposures Host Factors
Environmental tobacco smoke
Genetic predisposition (AAT deficiency)
Occupational dusts and chemicals
Airway hyperresponsiveness
Air pollution Impaired lung growth
Risk Factors
bull Exposures
ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD
ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD
Host Factors
bull Host factor refers to the traits of an individual person that affect susceptibility to disease
ndash AAT deficiency accounts for less than 1 of COPD cases
ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function
ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses
Pathophysiology of COPD
1 Airway inflammation
2 Structural changes
3 Mucociliary dysfunction
- Chronic inflammatory cascade for COPD
ASSESSMENT
1 Clinical presentation
ndash History
ndash Physical examination
2 Diagnostic testing
ndash Pulmonary function testing
ndash Laboratories
ndash Imaging
Clinical Presentation
HistoryPhysical
Examination
- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors
- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles
ASSESSMENT
bull General appearance
bull Vital signs Heart rhythm
bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
bull ABGs SaO2 CBC WBC and chest x-ray results
bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea
bull Nutrition and weight loss
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
DEFINITION
Chronic obstructive pulmonary disease (COPD) is
a preventable and treatable disease characterized
by airflow limitation that is progressive not fully
reversible and associated with an abnormal
inflammatory response of the lungs
Chronic Bronchitis
bull Chronic bronchitis is a chronic inflammatory
condition in the lungs
bull It causes a cough that often brings up mucus as well as shortness of
breathwheezing and
chest tightness
Emphysema
bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs
EPIDEMIOLOGYbull More common in older people especially those
gt65 years
bull Fifth leading cause of death and disabilityworldwide
bull Death rates for males and females are roughlyequivalent
bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod
Risk Factors
Exposures Host Factors
Environmental tobacco smoke
Genetic predisposition (AAT deficiency)
Occupational dusts and chemicals
Airway hyperresponsiveness
Air pollution Impaired lung growth
Risk Factors
bull Exposures
ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD
ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD
Host Factors
bull Host factor refers to the traits of an individual person that affect susceptibility to disease
ndash AAT deficiency accounts for less than 1 of COPD cases
ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function
ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses
Pathophysiology of COPD
1 Airway inflammation
2 Structural changes
3 Mucociliary dysfunction
- Chronic inflammatory cascade for COPD
ASSESSMENT
1 Clinical presentation
ndash History
ndash Physical examination
2 Diagnostic testing
ndash Pulmonary function testing
ndash Laboratories
ndash Imaging
Clinical Presentation
HistoryPhysical
Examination
- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors
- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles
ASSESSMENT
bull General appearance
bull Vital signs Heart rhythm
bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
bull ABGs SaO2 CBC WBC and chest x-ray results
bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea
bull Nutrition and weight loss
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Chronic Bronchitis
bull Chronic bronchitis is a chronic inflammatory
condition in the lungs
bull It causes a cough that often brings up mucus as well as shortness of
breathwheezing and
chest tightness
Emphysema
bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs
EPIDEMIOLOGYbull More common in older people especially those
gt65 years
bull Fifth leading cause of death and disabilityworldwide
bull Death rates for males and females are roughlyequivalent
bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod
Risk Factors
Exposures Host Factors
Environmental tobacco smoke
Genetic predisposition (AAT deficiency)
Occupational dusts and chemicals
Airway hyperresponsiveness
Air pollution Impaired lung growth
Risk Factors
bull Exposures
ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD
ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD
Host Factors
bull Host factor refers to the traits of an individual person that affect susceptibility to disease
ndash AAT deficiency accounts for less than 1 of COPD cases
ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function
ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses
Pathophysiology of COPD
1 Airway inflammation
2 Structural changes
3 Mucociliary dysfunction
- Chronic inflammatory cascade for COPD
ASSESSMENT
1 Clinical presentation
ndash History
ndash Physical examination
2 Diagnostic testing
ndash Pulmonary function testing
ndash Laboratories
ndash Imaging
Clinical Presentation
HistoryPhysical
Examination
- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors
- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles
ASSESSMENT
bull General appearance
bull Vital signs Heart rhythm
bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
bull ABGs SaO2 CBC WBC and chest x-ray results
bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea
bull Nutrition and weight loss
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Emphysema
bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs
EPIDEMIOLOGYbull More common in older people especially those
gt65 years
bull Fifth leading cause of death and disabilityworldwide
bull Death rates for males and females are roughlyequivalent
bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod
Risk Factors
Exposures Host Factors
Environmental tobacco smoke
Genetic predisposition (AAT deficiency)
Occupational dusts and chemicals
Airway hyperresponsiveness
Air pollution Impaired lung growth
Risk Factors
bull Exposures
ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD
ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD
Host Factors
bull Host factor refers to the traits of an individual person that affect susceptibility to disease
ndash AAT deficiency accounts for less than 1 of COPD cases
ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function
ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses
Pathophysiology of COPD
1 Airway inflammation
2 Structural changes
3 Mucociliary dysfunction
- Chronic inflammatory cascade for COPD
ASSESSMENT
1 Clinical presentation
ndash History
ndash Physical examination
2 Diagnostic testing
ndash Pulmonary function testing
ndash Laboratories
ndash Imaging
Clinical Presentation
HistoryPhysical
Examination
- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors
- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles
ASSESSMENT
bull General appearance
bull Vital signs Heart rhythm
bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
bull ABGs SaO2 CBC WBC and chest x-ray results
bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea
bull Nutrition and weight loss
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
EPIDEMIOLOGYbull More common in older people especially those
gt65 years
bull Fifth leading cause of death and disabilityworldwide
bull Death rates for males and females are roughlyequivalent
bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod
Risk Factors
Exposures Host Factors
Environmental tobacco smoke
Genetic predisposition (AAT deficiency)
Occupational dusts and chemicals
Airway hyperresponsiveness
Air pollution Impaired lung growth
Risk Factors
bull Exposures
ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD
ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD
Host Factors
bull Host factor refers to the traits of an individual person that affect susceptibility to disease
ndash AAT deficiency accounts for less than 1 of COPD cases
ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function
ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses
Pathophysiology of COPD
1 Airway inflammation
2 Structural changes
3 Mucociliary dysfunction
- Chronic inflammatory cascade for COPD
ASSESSMENT
1 Clinical presentation
ndash History
ndash Physical examination
2 Diagnostic testing
ndash Pulmonary function testing
ndash Laboratories
ndash Imaging
Clinical Presentation
HistoryPhysical
Examination
- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors
- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles
ASSESSMENT
bull General appearance
bull Vital signs Heart rhythm
bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
bull ABGs SaO2 CBC WBC and chest x-ray results
bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea
bull Nutrition and weight loss
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Risk Factors
Exposures Host Factors
Environmental tobacco smoke
Genetic predisposition (AAT deficiency)
Occupational dusts and chemicals
Airway hyperresponsiveness
Air pollution Impaired lung growth
Risk Factors
bull Exposures
ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD
ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD
Host Factors
bull Host factor refers to the traits of an individual person that affect susceptibility to disease
ndash AAT deficiency accounts for less than 1 of COPD cases
ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function
ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses
Pathophysiology of COPD
1 Airway inflammation
2 Structural changes
3 Mucociliary dysfunction
- Chronic inflammatory cascade for COPD
ASSESSMENT
1 Clinical presentation
ndash History
ndash Physical examination
2 Diagnostic testing
ndash Pulmonary function testing
ndash Laboratories
ndash Imaging
Clinical Presentation
HistoryPhysical
Examination
- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors
- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles
ASSESSMENT
bull General appearance
bull Vital signs Heart rhythm
bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
bull ABGs SaO2 CBC WBC and chest x-ray results
bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea
bull Nutrition and weight loss
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Risk Factors
bull Exposures
ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD
ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD
Host Factors
bull Host factor refers to the traits of an individual person that affect susceptibility to disease
ndash AAT deficiency accounts for less than 1 of COPD cases
ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function
ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses
Pathophysiology of COPD
1 Airway inflammation
2 Structural changes
3 Mucociliary dysfunction
- Chronic inflammatory cascade for COPD
ASSESSMENT
1 Clinical presentation
ndash History
ndash Physical examination
2 Diagnostic testing
ndash Pulmonary function testing
ndash Laboratories
ndash Imaging
Clinical Presentation
HistoryPhysical
Examination
- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors
- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles
ASSESSMENT
bull General appearance
bull Vital signs Heart rhythm
bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
bull ABGs SaO2 CBC WBC and chest x-ray results
bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea
bull Nutrition and weight loss
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Host Factors
bull Host factor refers to the traits of an individual person that affect susceptibility to disease
ndash AAT deficiency accounts for less than 1 of COPD cases
ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function
ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses
Pathophysiology of COPD
1 Airway inflammation
2 Structural changes
3 Mucociliary dysfunction
- Chronic inflammatory cascade for COPD
ASSESSMENT
1 Clinical presentation
ndash History
ndash Physical examination
2 Diagnostic testing
ndash Pulmonary function testing
ndash Laboratories
ndash Imaging
Clinical Presentation
HistoryPhysical
Examination
- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors
- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles
ASSESSMENT
bull General appearance
bull Vital signs Heart rhythm
bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
bull ABGs SaO2 CBC WBC and chest x-ray results
bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea
bull Nutrition and weight loss
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Pathophysiology of COPD
1 Airway inflammation
2 Structural changes
3 Mucociliary dysfunction
- Chronic inflammatory cascade for COPD
ASSESSMENT
1 Clinical presentation
ndash History
ndash Physical examination
2 Diagnostic testing
ndash Pulmonary function testing
ndash Laboratories
ndash Imaging
Clinical Presentation
HistoryPhysical
Examination
- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors
- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles
ASSESSMENT
bull General appearance
bull Vital signs Heart rhythm
bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
bull ABGs SaO2 CBC WBC and chest x-ray results
bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea
bull Nutrition and weight loss
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
ASSESSMENT
1 Clinical presentation
ndash History
ndash Physical examination
2 Diagnostic testing
ndash Pulmonary function testing
ndash Laboratories
ndash Imaging
Clinical Presentation
HistoryPhysical
Examination
- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors
- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles
ASSESSMENT
bull General appearance
bull Vital signs Heart rhythm
bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
bull ABGs SaO2 CBC WBC and chest x-ray results
bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea
bull Nutrition and weight loss
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Clinical Presentation
HistoryPhysical
Examination
- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors
- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles
ASSESSMENT
bull General appearance
bull Vital signs Heart rhythm
bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
bull ABGs SaO2 CBC WBC and chest x-ray results
bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea
bull Nutrition and weight loss
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
ASSESSMENT
bull General appearance
bull Vital signs Heart rhythm
bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
bull ABGs SaO2 CBC WBC and chest x-ray results
bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea
bull Nutrition and weight loss
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
bull Monitor for signs and symptoms
Chronic dyspnea Chronic cough
Hypoxemia Hypercarbia (increased PaCO2)
Respiratory acidosis and
compensatory metabolic alkalosis
bull Crackles Rapid and shallow respirations
bull Use of accessory muscles
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
bull Barrel chest or increased
chest diameter
bull Hyper resonance on percussion
due to ldquotrapped airrdquo (emphysema)
bull Asynchronous breathing
bull Thin extremities and enlarged neck muscles
bull Dependent edema secondary to right-sided heart failure
bull
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Diagnostic Testingbull Pulmonary function testing or
Spirometry
ndash Comprehensive assessment of lung volumes and capacities
ndash Performed in all patients suspected of COPD
ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality
bull Bronchodilator reversibility
ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Diagnostic Testingbull Laboratories
ndashABG Monitoring
bull Done for patients with severe COPD respiratory failure or a severe exacerbation
ndashATT levels (15 - 35 gram liter)
bull Measured in young patients who develop COPD and have a strong family history
bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Diagnostic Testingbull Imaging
ndash Chest radiographs
bull Not sensitive for the diagnosis of COPD
bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)
ndash Chest CT
bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
COPD Management
bull Goals of COPD Management
ndash To relieve symptoms
ndash To improve quality of life
ndash To decrease the frequency amp severity of acute attacks
ndash To slow the progression of disease
ndash To prolong survival
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
COPD Management
Nonpharmacologic Treatment
Smoking cessation
Immunization
Long term oxygen therapy
Pulmonaryrehabilitation
Pharmacologic Treatment
Corticosteroids
Bronchodilators
AAT Replacement therapy
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Smoking Cessationbull Only proven intervention to affect long term
decline in FEV1 amp slow the progression of COPD
ndash Nicotine replacement therapy
bull Transdermal patch
bull Chewing gum
bull Inhaler
bull Nasal spray
bull Lozenges
ndash Non-nicotine pharmacotherapy
bull Bupropion
bull Varenicline
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Smoking Cessation
Product Side effectsPrecautions
Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision
Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors
Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Immunizationbull Influenza vaccination
ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients
ndash Patients with serious allergy to eggs should not be given this vaccine
ndash Brand available Fluarixreg
ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects
ndash Available brand Tamiflureg
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Immunizationbull Polyvalent pnuemococcal vaccine
ndash Recommended for all COPD patients
bull 65 years and older
bull Less than 65 years only if the FEV1 is less than 40 predicted
ndash Dosage 05ml IM
ndash Available brand Pneumovaxreg (05ml pre-filled syringes)
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Long-term Oxygen Therapy
bull Should be started if
ndash Resting PaO2 is less than 55 mm Hg
ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Pulmonary Rehabilitation
bull Improves symptoms and quality of life
bull Reduces frequency of exacerbations
bull Components include
ndash Exercise training
ndash Nutritional counselling
ndash Psychosocial support
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Pharmacologic Treatment
Bronchodilators
Long-acting
2-agonists
Anticholinergics
Methylxanthines
Short-acting
2-agonists
Anticholinergics
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Short-acting 2-agonists
bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation
bull Improve mucociliary clearance
MOA
bull 4 to 6 hoursDuration of action
bull Albuterol (Ventolinreg) levalbuterol pirbuterol
Selective 2-agonists
bull Metaproterenol isoetharine isoproterenol epinephrine
Less selective 2-agonists
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Short-acting Anticholinergics
bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle
MOA
bull 4 to 6 hours slower onset of action in comparison to -agonists
Duration of action
bull Ipratropium (Atroventreg Atemreg)
bull AtropineExamples
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Long-acting 2-agonists
bull Same as that of short-acting 2-agonistsMOA
bull 12 hoursDuration of action
bull Salmeterol (Sereventreg)
bull Formoterol
bull ArformoterolExamples
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Long-acting Anticholinergics
bull Same as that of short-acting anticholinergicsMOA
bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing
Duration of action
bull TiotropiumExample
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Combination Anticholinergics amp 2-agonists
bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects
bull Albuterol and Ipratropium available as an MDI Combiventreg
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Methylxanthines
bull Produce bronchodilation by
bull Inhibition of PDE increasing cAMP levels
bull Inhibition of calcium ion influx intosmooth muscle
bull Prostaglandin antagonism
bull Stimulation of endogenouscatecholamines
bull Inhibition of release of mediators frommast cells and leukocytes
MOA
bull 8-12 mcgmlTherapeutic
Serum Levels
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Methylxanthines
bull Minor side effects
ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia
bull Serious toxic effects
ndash arrhythmias and seizures
bull Considered in patients who donot respond well to bronchodilators
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Corticosteroids
bull Mechanism of Action
ndash Reduction in capillary permeability to decrease mucus
ndash Inhibition of release of proteolytic enzymes from leukocytes
ndash Inhibition of prostaglandins
bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone
bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Corticosteroids
bull Inhaled CS
ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy
bull Systemic CS
ndashShort term use for acute exacerbations
ndashNot used in chronic management because of high risk of toxicity
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Combination ICS amp Bronchodilators
bull Effective in reducing the rate of COPD exacerbations
bull Reduces the number of total inhalations needed more patient compliance
bull Available combination
ndash Beclomethasone with salbutamol (Clenil Compositumreg)
ndash Budesonide with formeterol
ndash Fluticasone with salmeterol
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
AAT Replacement Therapy
bull Considered for patients with AAT deficiency
bull Life time treatment
bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma
bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Indacaterol
bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist
bull Approved by FDA on July 1 2011
bull Requires once daily dosing unlike other long-acting
bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea
bull Recommended dose is one capsule (75mcg) per day
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Devices used in COPDbull Inhalers
bull Small handheld devices that
deliver a puff of medicine into the airways
bull Metered-dose inhalers (MDIs)
bull Dry powder inhalers (DPIs) or
breath activated inhalers
bull Inhalers with spacer devices
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Metered-dose Inhalersbull Contains a liquid
medication delivered as an aerosol spray
bull Quick to use small and convenient to carry
bull Needs good co-ordination to press the canister and breathe in fully at the same time
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Breath-activated inhalersor DPI
bull It releases a puff of drypowder instead of aliquid mist
bull Require less co-ordination than thestandard MDI
bull Slightly bigger than thestandard MDI
bull Example Rotahaler
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Inhalers with spacer devices
bull Spacer devices are used with pressurised MDIs
bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Nebulizers
bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol
bull Useful in people whoare very breathless egIn severe attack ofCOPD
bull They are not portable
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
Nanda Nursing Diagnosis for COPD
1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection
2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants
3 Impaired gas exchange related to ventilation perfusion inequality
4 Activity intolerance related to imbalance between oxygen supply with demand
5 Imbalanced Nutrition less than body requirements related to anorexia
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
6 Disturbed sleep pattern related to discomfort sleeping position
7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency
8 Anxiety related to threat to self-concept threat of death purposes that are not being met
9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work
10 Deficient Knowledge related to lack of information do not know the source of information
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD
In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status
bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study
Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3
Author information
bull BACKGROUND
Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established
bull CONCLUSION
Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph
References
bull BMJ Best Practices
bull American Thoracic Society COPD guidelines
bull The Washingtonrsquos manual of medical therapeutics
bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro
bull Respiratory care pharmacology Rau Joseph