Chronic Obstructive Pulmonary Disease System: Pathophysiology, Medical And Nursing Management

Pathophysiology of acute and chronic COPD

Discuss about the Chronic Obstructive Pulmonary Disease System.

Chronic- obstructive pulmonary disease (COPD) is a condition that is characterized by the air-flow limitation, which is not completely reversible (GOLD, 2010). It includes airflow obstructive diseases such as chronic- bronchitis and emphysema. In-spite of effective COPD control, the patients may experience many episodes of exacerbations affecting their physical as well as mental health. Additionally, COPD exacerbations incur a high cost and affect the pulmonary function and quality-of-life (Toy, 2010). This case study discusses about Mr. Bill McDonald, a 65 year old male who has got admitted in the hospital with chief complaints of dyspnea even at rest, increased lethargy, wheezing with chronic- productive cough producing excessive purulent- sputum and was diagnosed to have acute exacerbations of COPD. He is found to smoke one pocket of cigarettes per day for 35 years and has history of recurrent- bronchial infections. This essay discusses in detail about the pathophysiology, medical and nursing management for Mr. Bill with acute exacerbations including home-care considerations, community resources available and educational plan.   

COPD is a condition in which the airway is obstructed by chronic bronchitis and emphysema or a combination of both (Hinkle, 2014). Any damage or inflammation in the larger airways of lungs can result in chronic- bronchitis which is referred to as a condition in which an excessive production of sputum with recurrent cough persisting for at-least three months/year for two consecutive years due to chronic smoking (Lewis, 2013). As, Mr. Bill is a chronic smoker for 35 years, the cigarette smoke has irritated the walls of bronchioles causing hyperplasia of mucous-secreting glands (including goblet cells) in the bronchi leading to increased mucus production. Moreover, the hyperplasia of cells has reduced the diameter of the airway resulting in reduced clearance of mucus. Smoking has reduced the ciliary movements causing reduced clearance of secretion resulting in sputum accumulation leading to the multiplication of micro-organism bronchiolar infections (Barnes, 2014). Because of inadequate clearance, Bill has experienced chronic cough with production of purulent sputum. 

Because of recurrent bronchiolar infections, more number of neutrophils with macrophages were released, which in-turn has released proteolytic enzymes leading to the destruction of alveolar tissues that again increases inflammation, edema and infectious process causing formation of exudates. More frequently, the micro- organisms have colonized in Bill leading to recurrent bronchial- infections causing excessive mucus accumulation resulting in occlusion of smaller bronchioles (Hinkle, 2014). This has increased resistance to airflow that in-turn has increased the effort of breathing leading to decreased oxygen supply to tissues causing hypoxemia.

Additionally, there was a diminished respiratory drive with increased tendency to hypo-ventilate and retain CO2. Because of this, most of the lung areas are not ventilated and so oxygen diffusion could not occur leading to dyspnea both at rest and activities. Hence, Bill with chronic bronchitis requires oxygen both at rest and activities as the disease progresses. As Bill is a smoker, bronchospasm develops frequently that adds to the already existing airway resistance results in further increase in work of breathing and impaired gas exchange which is manifested by dyspnea and lethargy than usual. On auscultation, because of increased CO2 retention in lungs, the lung sounds such as scattered crackles, ronchi and wheezes were heard (Lewis, 2013).  

Medical management

Because of smoking, an acute exacerbation of COPD has occurred in Bill, which is an event in the course of COPD that is characterized by the acute- changes in the usual client’s dyspnea, cough and sputum production (Hurst, 2009, Eisner, 2010). Its severity has been ranked as level-I (treated at home), level-II (needs hospitalization), level-III (results in respiratory failure) in which Bill lies in level-II (Ghoshal, 2012).

The first step to treat acute-exacerbations involves increasing the dose and frequency of short-acting bronchodilators. If it is unresponsive, bronchodilators with oral corticosteroids should be given. Short-acting β2- agonist (e.g. Salbutamol- 100-to-200 mcg) with nebulizer and Tab. Prednisolone (30mg) OD was administered for 7 days for Bill (Hurst, 2009). If there are changes in the characteristics of sputum, antibiotics should be added based on the causative bacterial-pathogen. Antibiotics should be started only for patients with sputum (Garvey, 2012). In regard to Bill, Levofloxacin (500mg daily) was administered for 11days because of the presence of Pseudomonas spp. in his sputum specimen (Currie, 2009).

Theophylline might be administered in patients who are unresponsive to treatment which is not administered for Bill. Oxygen should be administered at any stage of exacerbation in the presence of hypoxemia to improve his base-line oxygenation to at-least 60 mmHg and to maintain oxygen saturation of at-least 90% (Garvey, 2012). Bill was administered with 2 liters/min of oxygen through nasal-cannula and his O2 saturation was < 88% and PaO2 <55 in ABG. Non-invasive positive-pressure ventilation could be used to reverse acute- respiratory failure which was not used for Bill.

As Bill was having COPD exacerbation, he was monitored for PaO2, PaCO2 with pH, at the time of admission, treatment and at the time of changes in patient’s condition. Pulse oximeter was connected to monitor the oxygen saturation. Oxygen was administered to Bill at the rate of 2 liters/min through nasal-cannula to maintain normal oxygen-saturation thereby to prevent occurrence of respiratory acidosis/hypercapnia. Mechanical ventilation should be started only when pH <7.35 (Ghoshal, 2012). He was monitored carefully to prevent increased CO2 washout that may lead to respiratory depression as CO2 act as a respiratory-drive for Bill (Lewis, 2013). Therefore, oxygen should be given at lower rate to prevent CO2-narcosis. Upright position was provided to expand the lungs to promote oxygenation.

Bill was demonstrated to perform pursed-lip-breathing that was helpful to increase expiration so as to prevent bronchiolar-collapse with air-trapping (Lewis, 2013). He was guided to practice abdominal-breathing that helped him to use diaphragm in-stead of accessory-muscles so as to promote maximal inspiration as well as to reduce the respiratory rate. In case of abdominal-breathing, the abdomen will protrude at inspiration and contract at expiration, where the diaphragm pushes the air outside the lungs and promotes control over Bill’s breathing especially during dyspnea and exercises. Deep-breathing with coughing-exercise was demonstrated to promote expulsion of lung secretions so as to promote normal breathing. His position was changed once in 2 hours to prevent aspirations. Chest physiotherapy (bronchial tapping) was performed to remove excess lung secretions (Hinkle, 2014). 

Nursing management

Bill has experienced difficulty in breathing and consuming food simultaneously and hence small and frequent diet (six meals) was encouraged (Seo, 2014). He was encouraged to drink 3 liters of fluid/day to promote hydration so as to liquefy the lung secretions and promote mucus expulsion (Hanania, 2010). The fluid was given only in-between the meals but not with meals to avoid abdominal distention that might increase his dyspnea. Gas-forming and carbonated foods were avoided as they will cause abdominal distention causing dyspnea.  Very cold and hot foods were avoided as it may cause coughing spasms. 

The role of nurse is crucial in educating home-care considerations to COPD patients (Zakrisson, 2011). Bill is discharged with portable oxygen to prevent hypoxemia as he is a chronic COPD patient. Nasal-cannula (2 liters/min) was arranged for Bill as it is safe and simple to use at home and is comfortable and acceptable. It will not interfere with eating, talking, coughing, walking or moving. But, its position should be maintained to avoid dislodgement. Long-term oxygen therapy (LTOT) will help to improve neuro-psychological function, increase activity- tolerance, reduce hematocrit and decrease pulmonary-hypertension. As, Bill was stable with PaO2 of 55 mmHg and SaO2 (less than 88%), LTOT was allowed. Regular nasal-cannula was arranged to deliver O2 from central source at home. He was given with liquid O2 as it is portable and holds 6-8 hr O2 supply at 2 L/min and the reservoir will lasts for 7-10 days (Lewis, 2013).

He was instructed about the methods of using oxygen at home, its importance, advantages, disadvantages and precautions to be followed. He was instructed to put the nasal straps properly and not to be too tight. Observe the ear-tops for skin breakdown and pad it, if needed (Hanania, 2010). Bill was educated to assess oral as well as nasal mucous membrane for 2-3 times/ day and advised to apply water-based gel over the nasal membrane and lips (Lewis, 2013). Encouraged to wash mouth frequently and use humidifier to avoid dryness in skin resulting in skin breakdown and infection.

He was advised to remove the nasal-cannula and clean it with water for 2-3 times/ day and clean the skin carefully and observe for bruises, scratches and cuts. He was instructed to change disposable equipments regularly and to remove sputum that is coughed-out. He was advised to post ‘No Smoking’ boards at home and not to use electric razors, open flames, mineral oils, blankets (wool) or portable- radios near the oxygen area and not to allow smoking in home (Lewis, 2013). He was encouraged to remain active and travel normally. Oxygen could be arranged by private companies at the destination point. If, he wishes to travel by bus, train or flight, notifications should be given to make O2 reservations. High-altitude stimulation-test should be performed in a hospital to determine the amount of O2 needed for traveling in flight.

In Government, COPD National-Program as well as Lung-cancer programs are the major programs available within Lung- Foundation. They are supported by the Information with Support-Centre of Lung- Foundation which operates a toll-free telephonic number for COPD patients, care-takers and physicians to make a call and speak with team member (who can guide them to get resources and get link to the support- services) or to talk to a Lung-Care Nurse. There are other foundation areas as Respiratory-infectious diseases, Bronchiectasis registry, Multi-centre clinical-trial network, telephonic support- group and community- awareness events (Harper, 2013).

Home-care considerations

Usually, home oxygen- systems are also rented from a private company, which sends a pulmonary nurse and/or respiratory therapists to the patient’s home. These therapists will teach about the method of using O2 system, method of caring O2 system and how to identify, when the system is getting low and needs to re-order (Lewis, 2013). The staff nurse has to make arrangements with the community-health nurse to obtain O2 equipments from an agency and receive follow-up home-care regularly. The agency will make arrangements to receive an O2 concentrator with portable tanks and concentrated O2 with oxygen regulators and supplies (20m of tubing with nasal-cannula).

He was educated about basic anatomy with physiology of lung along with pathophysiology, features with complications for COPD through Australian Lung Association videos. Breathing retraining techniques as pursed-lip breathing and abdominal-breathing techniques were demonstrated. Energy-conservation methods as pacing the activities and performing pursed- lip breathing while performing activities was educated. The medication list with all the medications such as oral/ inhalant corticosteroids, antibiotics, β-adrenergic receptors and anti-cholinergics was given with instructions for dosage, frequency, route, mode of action and side effects. He was demonstrated about the method of using inhaler (Lewis, 2013).

He was educated about method of using oxygen at home with precautions. His family was guided to manage emotional issues as depression, anxiety, panic attacks, dependency, intimacy and interpersonal relationship issues. He was educated about COPD management plan that involves focusing on self-management and knowing features of exacerbations that may exacerbate in winter (Jenkins, 2012, Bruce, 2007). He should be educated with the need to report changes with reasons for flare-ups, recognizing features of respiratory infection and yearly follow-up. He was advised about the support and rehabilitative sources available (Casey, 2011). He was advised to avoid crowds and contact with persons with respiratory infections and to obtain influenza immunization.

Conclusion

Epidemiologic data indicate that chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality. Patients with poorly managed COPD are likely to experience exacerbations that require emergency department visits or hospitalization—two important drivers contributing to escalating healthcare resource use and costs associated with the disease. Exacerbations also contribute to worsening lung function and negative outcomes in COPD. The aim of this review is to present the perspective of nurse practitioners and physician assistants in terms of providing the pharmacologic and non-pharmacologic modalities needed to treat current and prevent future exacerbations. Major respiratory guidelines recommend treatment of acute exacerbations with short-acting bronchodilators, oral corticosteroids and antibiotics, as appropriate. Supplementary oxygen and/or ventilatory support may also be beneficial to selected patients. Treatments to minimize the risk of future exacerbations should include maintenance pharmacotherapies, risk-reduction measures (e.g. smoking cessation, influenza and pneumonia vaccinations), pulmonary rehabilitation, self-management support and follow-up care.

Thus, this case study discusses in detail about chronic and acute COPD. I have learnt about the pathophysiological sequence of acute and chronic COPD that is caused by chronic smoking. I have learnt about the medical as well as nursing management plans of a patient with acute exacerbations of COPD. I understood about the home-care considerations of patient with portable oxygen and community-support services available with discharge plan for COPD patients. 

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