![• Corticosteroids (oral for exacerbations, inhaled corticosteroids)
• Inhaled corticosteroid therapy may be beneficial for patients with
moderate-to-severe COPD.
• Inhaled corticosteroid combined with long-acting β2-adrenergic
agonists (e.g., fluticasone/salmeterol [Advair]) are more effective
than the single-drug therapy.
3. O2 Therapy
• O2 therapy is frequently used in the treatment of COPD and other
problems associated with hypoxemia.
• Long-term O2 therapy (LTOT) improves survival, exercise capacity,
cognitive performance, and sleep in hypoxemic patients.](https://image.slidesharecdn.com/chroniobspuldiease-191218112542-250805034123-0763e559/75/Chronic-Obstructive-Pulmonary-Disease-COPD-18-2048.jpg)
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Similar to Chronic Obstructive Pulmonary Disease (COPD)
Chronic Obstructive Pulmonary Disease (COPD)
- 1.
- 2. CHRONIC OBSTRUCTIVE PULMONARY DISEASE COPD is alsoknown as chronic obstructive lung disease (COLD), chronic obstructive airway disease (COAD) Chronic obstructive pulmonary disease (COPD) includes chronic bronchitis and emphysema.
- 3. Definition “COPD is achronic disorder of the airway characterized by progressive airflow limitation which is associated with an abnormal inflammatory response of the lungs to noxious particles or gases and is irreversible.” • The term chronic obstructive pulmonary disease encompasses two types of obstructive airway diseases, chronic bronchitis and emphysema.
- 4. • Chronic bronchitis “Itis the presence of chronic productive cough for 3 months in each of 2 consecutive years in a patient in whom other causes of chronic cough have been excluded.” Emphysema “It is an abnormal permanent enlargement of the air spaces distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis.”
- 7. pathophysiology • COPD ischaracterized by chronic inflammation found in the airways and pulmonary vasculature . • The pathogenesis of COPD is complex and involves many mechanisms. • The primary process is inflammation. • The inflammatory process starts with inhalation of noxious particles and gases (e.g., cigarette smoke, air pollution). • The predominant inflammatory cells, macrophages and lymphocytes (primarily CD8 cells), increase and release inflammatory mediators, including leukotrienes, interleukins, and tumor necrosis factor. •
- 9. “It is anabnormal permanent enlargement of the air spaces distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis.” Emphysema
- 10. Classification of theemphysema • Centrilobular Emphysema: • It involves dilation and destruction of the respiratory bronchioles and is the most commonly seen in upper lobes in mild disease. • Panlobular Emphysema: It is type of emphysema involves destruction of the alveolar ducts, alveolar sacs, and respiratory bronchioles.
- 11. Clinical manifestati on Dyspnea is oftenprogressive, and usually occurs with exertion. However, patients may dismiss the importance of this symptom as they rationalize, “I'm just getting older.” In late stages of COPD, dyspnea may be present at rest. As more alveoli become over distended, increasing amounts of air are trapped. This causes a flattened diaphragm and an increased anterior-posterior diameter of the chest, forming the typical barrel chest.
- 13. Cough: initially may beintermittent. • Later it is present every day, but is seldom present during the night. • There are ranges in the amount of sputum produced. • Wheezing and chest tightness • Due to the bareel chest patient may sit upright with arms supported on a fixed surface such as an overbed table (tripod position).
- 14. • The patientmay naturally purse lips on expiration (pursed-lip breathing) and use accessory muscles, such as those in the neck, to aid with inspiration. Edema in the ankles may be the only clue to right-sided heart involvement.
- 15. Classification of COPD ClassificationLevel of Severity FEV1 Results STAGE 0 Mild FEV1 > 80% predicted STAGE 1 Moderate FEV1 50 - 80% predicted STAGE 2 Severe 30 - 50% predicted STAGE 4 Very Severe FEV1<30% predicted
- 16. Diagnostic evaluation • Historyand physical examination • Pulmonary function tests • Chest x-ray • Serum α1-antitrypsin levels • Sputum specimen for Gram stain and culture • ABGs • ECG • Exercise testing with oximetry • Echocardiogram or cardiac nuclear scans
- 17. Collaborative Therapy 1. Cessationof cigarette smoking 2. Bronchodilator therapy : “Bronchodilator drug therapy relaxes smooth muscles in the airway and improves the ventilation of the lungs, thus reducing the degree of breathlessness”. β2-Adrenergic agonists: Salmeterol (Serevent) is a widely used long-acting β2-adrenergic agonist, Formoterol (Foradil) is another long-acting β2 agonist. Anticholinergic agents: Methylxanthine
- 18. • Corticosteroids (oralfor exacerbations, inhaled corticosteroids) • Inhaled corticosteroid therapy may be beneficial for patients with moderate-to-severe COPD. • Inhaled corticosteroid combined with long-acting β2-adrenergic agonists (e.g., fluticasone/salmeterol [Advair]) are more effective than the single-drug therapy. 3. O2 Therapy • O2 therapy is frequently used in the treatment of COPD and other problems associated with hypoxemia. • Long-term O2 therapy (LTOT) improves survival, exercise capacity, cognitive performance, and sleep in hypoxemic patients.
- 19. • Methods ofAdministration • A, Simple face mask. B, Plastic face mask with reservoir bag. C, Venturi mask. D, Tracheostomy mask. E, Face tent. F, Standard nasal cannulas.
- 20. Complications of Oxygentherapy Combustion: • O2 supports combustion and increases the rate of burning. • This is why it is important that smoking be prohibited in the area in which O2 is being used.
- 21. CO2 Narcosis: The twochemoreceptors in the respiratory center that control the drive to breathe respond to CO2 and O2. Normally, CO2 accumulation is the major stimulant of the respiratory center. Over time some COPD patients develop a tolerance for high CO2 levels (the respiratory center loses its sensitivity to the elevated CO2 levels). Although O2 administration should be titrated to the lowest effective dose.
- 22. O2 Toxicity: • PulmonaryO2 toxicity may result from prolonged exposure to a high level of O2 (PaO2). • The development of O2 toxicity is relatively rare, but is determined by patient tolerance, exposure time, and effective dose. • High concentrations of O2 damage alveolar-capillary membranes, inactivate pulmonary surfactant, cause interstitial and alveolar edema, and decrease compliance. • The amount of O2 administered should be just enough to maintain the PaO2 within a normal or acceptable range for the patient.
- 23. Absorption Atelectasis: • Normally,nitrogen, which constitutes 79% of the air that is breathed, is not absorbed into the bloodstream. • This prevents alveolar collapse. • When high concentrations of O2 are given, nitrogen is washed out of the alveoli and replaced with O2. • If airway obstruction occurs, the O2 is absorbed into the bloodstream and the alveoli collapse. • This process is called absorption atelectasis.
- 24. • Infection. • Infectioncan be a major hazard of O2 administration. • Heated nebulizers present the highest risk. • The constant use of humidity supports bacterial growth, with the most common infecting organism being Pseudomonas aeruginosa. • Disposable equipment that operates as a closed system should be used.
- 25. 4. Surgical Therapyfor COPD • Three different surgical procedures have been used in severe COPD. A. LUNG VOLUME REDUCTION SURGERY (LVRS). • The goal of therapy is to reduce the size of the lungs by removing about 30% of the most diseased lung tissue so the remaining healthy lung tissue can perform better. • The rationale for this type of surgery is that by reducing the size of the hyperinflated emphysematous lungs, there is decreased airway obstruction and increased room for the remaining normal alveoli to expand and function. • The procedure reduces lung volume and improves lung and chest wall mechanics.
- 27. B. BULLECTOMY • Thisprocedure is used for patients with emphysematous COPD who have large bullae (>1 cm). • The bullae are usually resected via thoracoscope. • In certain patients this procedure has resulted in improved lung function and reduction in dyspnea.
- 28. C. LUNG TRANSPLANTATION •COPD patients are the largest group of patients on waiting lists for lung transplantation. • Although single-lung transplant is the most commonly used technique because of a shortage of donors. • In some cases LVRS is a bridge until transplantation. • In appropriately selected patients with very advanced COPD, lung transplantation improves functional capacity and enhances quality of life. • However, rejection and effects of immunosuppressive therapy remain an obstacle.
- 29. 5. Respiratory andPhysical Therapy • Respiratory therapy (RT) and physical therapy (PT) rehabilitation activities are performed by respiratory therapists or physical therapists depending on the institution. RT and/or PT activities include • Breathing retraining, • Effective cough techniques • Chest physiotherapy.
- 30. 6. Breathing Retraining •The patient with COPD develops an increased respiratory rate with a prolonged expiration to compensate for the obstruction to airflow resulting in dyspnea. • In addition, the accessory muscles of breathing in the neck and upper part of the chest are used excessively to promote chest wall movement. • These muscles are not designed for long-term use, and as a result the patient experiences increased fatigue. • Breathing exercises may assist the patient during rest and activity (e.g., lifting, walking, stair climbing) by decreasing dyspnea, improving oxygenation, and slowing the respiratory rate.
- 31. PURSED-LIP BREATHING: • Therationale for using pursed-lip breathing (PLB) is to prolong exhalation and thereby prevent bronchiolar collapse and air trapping. • The patient should be taught PLB before, during, and after any activity causing dyspnea or tachypnea. • The patient is taught to inhale slowly through the nose and then to exhale slowly through pursed lips, almost as if whistling. • Exhalation should be at least three times as long as inhalation.
- 32. 7. Effective Coughing •Many patients with COPD have developed ineffective coughing patterns that do not adequately clear their airways of sputum. • The main goals of effective coughing are to conserve energy, reduce fatigue, and facilitate removal of secretions. • Huff coughing is an effective technique that the patient can be easily taught. • Huff Coughing: Huff coughing, or huffing, is an alternative to deep coughing if you have trouble clearing your mucus. Take a breath that is slightly deeper than normal. Use your stomach muscles to make a series of three rapid exhalations with the airway open, making a "ha, ha, ha" sound.
- 34. 8. Chest Physiotherapy •Chest physiotherapy (CPT) is indicated in the patient with (1) Excessive bronchial secretions who has difficulty clearing secretions with expectorated sputum production greater than 25 ml per day, (2) Retained secretions in the presence of an artificial airway (3) lobar atelectasis caused by or suspected of being caused by mucous plugging. Chest physiotherapy consists of Percussion Vibration postural drainage Percussion, vibration, and postural drainage may assist in bringing secretions into larger, more central airways.
- 35. • Percussion: • Percussionis performed in the appropriate postural drainage position with the hands in a cuplike position. • The hands are cupped, and the fingers and thumbs are closed.
- 36. • Vibration: • Itis accomplished by tensing the hand and arm muscles repeatedly and pressing mildly with the flat of the hand on the affected area while the patient slowly exhales a deep breath. • The vibrations facilitate movement of secretions to larger airways.
- 37. • Postural Drainage:The purpose of various positions in postural drainage is to drain each segment toward the larger airways. • The lungs are divided into five lobes, with three on the right side and two on the left side. There are 18 segments in the lungs, which can be drained by 18 positions. • The modified postural drainage positions most often used in clinical practice.
- 38. Flutter Mucus ClearanceDevice • The Flutter mucus clearance device is a handheld device that is shaped like a small, fat pipe . • It provides positive expiratory pressure (PEP) treatment for patients with mucus-producing conditions. • The Flutter has a mouthpiece, a high-density stainless steel ball, and a cone that holds the ball. • When the patient exhales through the Flutter, the steel ball moves, which causes vibrations in the lungs and loosens mucus. • It helps move mucus up through the airways to the mouth where the mucus can be expectorated. • Although the Flutter valve is mostly used in patients with cystic fibrosis, it has been effectively used in patients with excessive secretions with COPD and bronchiectasis.
- 39. High-Frequency Chest Compression(ThAIRaphy Vest). • High-frequency chest compression uses an inflatable vest (ThAIRaphy vest) with hoses connected to a high-frequency pulse generator. • The pulse generator delivers air to the vest, which vibrates the chest. • The high-frequency air waves clear all lobes of the lungs. • The vest has been found to be more effective than conventional CPT in clearing mucus, and it can be done without the aid of another person. • The unit weighs only 30 lb and is quiet. It comes in its own suitcase and is portable.
- 40. Acapella • Acapella isa small handheld device that combines the benefits of both PEP therapy and airway vibrations of the Flutter valve to mobilize pulmonary secretions. • It works by using oscillating vibrations that travel to the lung, shaking free mucous plugs that the patient can then cough up. • It can be used in virtually any setting as the patients are free to sit, stand, or recline. • It improves clearance of secretions, is easier to tolerate than CPT, takes less than half the time of conventional CPT sessions, and facilitates opening of airways.
- 42. Aerosol Nebulization Therapy •Medications for COPD patients are most often delivered via metered- dose or dry powder inhalers. • This is the preferred delivery route, although devices that deliver a suspension of fine particles of liquid in a gas, called nebulizers, may also be used to deliver medications to the COPD patient. • Nebulizers are usually powered by a compressed air or O2 generator. • At home the patient may have an air-powered compressor; in the hospital, wall O2 or compressed air is used to power the nebulizer.
- 43. • Aerosolized medicationorders must include the medication, dose, diluent, and whether it is to be nebulized with O2 or compressed air. • Medication is nebulized or reduced to a fine spray, and depending on several factors, including droplet size, it can be inhaled into the patient's tracheobronchial tree. • The advantage to aerosol-nebulization therapy is that it is easy to use. Medications that are routinely nebulized include albuterol and ipratropium.
- 44. Nutritional Therapy • Weightloss and malnutrition are commonly seen in the patient with severe emphysematous COPD. • The cause of this weight loss is not entirely known but is likely multifactorial. • Eating becomes an effort because of dyspnea and O2 desaturation, especially in the later stages of COPD. • Patients may require more caloric expenditure than calories ingested. • A full stomach presses up on the flattened diaphragm, causing increased dyspnea and discomfort. • It is difficult for some patients to eat and breathe at the same time; therefore inadequate amounts of food are eaten. • Also large amounts of energy are expended to breathe and maintain even normal activities.
- 45. Complications • Cor Pulmonale. •Cor pulmonale is hypertrophy of the right side of the heart, with or without heart failure, resulting from pulmonary hypertension. • It is caused by diseases affecting the lungs or pulmonary blood vessels. • Cor pulmonale is a late manifestation of chronic pulmonary heart disease. • The patient benefits most when a diagnosis of pulmonary heart disease can be made early so therapy can be instituted.
- 46. Exacerbations of COPD. •Exacerbations of COPD are signaled by a change in the patient's usual dyspnea, cough, and/or sputum that is different from the usual daily patterns. • These flares require changes in management. • Patients have an increase in dyspnea, sputum volume, and/or sputum purulence. • They may also have nonspecific complaints of malaise, insomnia, fatigue, depression, confusion, decrease in exercise tolerance, increased wheezing, increased cough, or fever without other causes.
- 47. Peptic Ulcer and Gastroesophag ealReflux Disease • The incidence of peptic ulcer disease is increased in persons with COPD. • The reason for this occurrence is partly explained by hypersecretion of gastric acid resulting from increased arterial CO2 and decreased arterial O2 tension. • This occurs only in patients who chronically retain CO2. • The ulcers are more commonly in the duodenum rather than stomach and do not cause pain. • It is important to test gastric aspirates and feces for occult blood.
- 48. Depression/Anxiety Patients with COPDexperience many losses as the disease progresses over time. They can feel helpless with low self-esteem and unable to vent their emotions for fear of compromising their breathing. The reported prevalence of depression in COPD varies, but may be four times more frequent in COPD than in the general population. Anxiety can complicate respiratory compromise and may precipitate dyspnea and hyperventilation. When a person is exceptionally dyspneic, particularly if it occurs suddenly, the person becomes anxious and tries to breathe faster, thus affecting his or her oxygenation status. Proper screening for anxiety and depression by health care providers is needed for a proper diagnosis.