Chronic Obstructive Pulmonary Disease can also be referred to as Chronic Obstructive Lung Disease or Chronic Obstructive Airways Disease is an array of conditions that tend to affect the airways and lungs. Thus COPD is a general term for diseases that curtail the movement of air out of the lungs. By it being chronic, it means that the patient will have this disease for the rest of his or her life. A vast majority of patients who are diagnosed with COPD are heavy cigarette smokers or at one time were heavy smokers. The disease normally gets worse with time; however, this disease can be managed. This paper seeks to discuss the various aspects of this disease (Quinn, C. 2005).
I. Etiology and Pathophysiology
People with a history of suffering from asthma may be predisposed to developing COPD in the long run. Asthma results when the flow of air out of the lungs is obstructed, more often than not, the obstruction is reversible. In between asthma “attacks”, air flow through the airways is usually normal. These patients that have asthma do not have COPD. Should the asthma go untreated, then the inflammation associated with the disease may cause the obstruction of the airway to become fixed. This means that the patient will then have abnormal airflow in between asthma attacks, a process that is called lung remodeling. Asthma patients that have a fixed component of the destruction of the airway are considered to have developed COPD. The labeling of Patients with COPD usually depends on the symptoms they present in the event of an exacerbation of their illness. For example if they have coughs that produce mucus, they are considered to be suffering from chronic bronchitis whereas if they mainly exhibit shortness of breath, they are considered to be suffering from emphysema (MedicineNet.com).
Cigarette smoking is single handedly responsible for most deaths that occur as a result of COPD. As a result of smoking cigarettes, the cilia lining the air ways is destroyed and the formation of alpha-antitrypsin is repressed. The excessive production of mucus comes about when irritants and particles, that were previously done away with by the cilia gather in the airways resulting in inflammation and edema. This result in a chronic coughs thereby stimulating hypersecretion of mucosal glands, and hypertrophy which are features of chronic bronchitis (Rice, R., 2006).
Genetic predisposition can affect the manifestation of COPD. For this reason, it is quite important for people to take a health history because emphysema can come up as a result of an inherited deficiency of the alpha-antitrypsin enzyme whose function is to counteract the destruction of the lung tissues by other enzymes. Lungs, which are essentially a sterile area, accumulate debris that can be associated with smoking and mucus. This therefore makes the lungs a perfect breeding ground for infection. Bacterial infections and smoking can trigger a migration of inflammatory cells to the lungs, this result in an intense tissue irritation and also edema. These multiple infections that are normally repeated tend to narrow large air passages and destroy the smaller ones (Rice, R. 2006).
Airflow limitation is a characteristic feature of COPD. Expiratory airflow faces increased resistance as a result of their narrowing. There is chronic inflammation, airway narrowing and tissue destruction. As a result of the destruction of the alveolar walls, lung elasticity is compromised and reduced; significantly reducing the elastic recoil of the lungs or collapsing tendency. The alveoli then thicken and reduce both in number and size thereby resulting in an ineffective exchange of gas. Due to emphysema, thickening of the walls of the airway occurs as a result of the inflammation of the cells that are lining them. Due to the expiratory air flow resistance, during expiration, air is trapped in the lungs; this happens progressively. This is responsible for most of the hyperinflation thereby reducing inspiratory capacity. Breathing then becomes noticeably elevated (Bales, C. W. & Ritchie, C. S., 2009).
II. Nursing Assessment
Measurements of arterial blood gas are important in order to assess the gas exchange and baseline oxygenation; this is important especially in cases where the patient suffers from advanced COPD. Chronic cough that is usually accompanied with sputum production in many cases may present years before the development of the limitation of the air flow which is commonly associated with COPD. However, not everyone who has a cough and sputum production goes on to develop COPD. The cough may be unproductive in some cases and may be intermittent. Dyspnea may become severe that it may interfere with the day to day activities of the patients. It is usually persistent, progressive and tends to get worse in case the patient exercises. Most patients with COPD tend to make abnormal breathing sounds (wheezing) more so after coughing. The patients also experience chest tightness and fever and may also complain of insomnia, malaise, confusion, fatigue and they may even become depressed. (Smeltzer, S.C., et al, 2009).
III. Nursing Diagnoses
Impaired gas exchange occurs in patients who suffer from chronic obstructive pulmonary disease as a result of complications that come about because of the destruction of the membrane of the alveolar capillary and also chronic pulmonary obstruction. These patients also exhibit an Ineffective airway clearance due to the sudden rise in the production of mucus, ineffective cough, broncoconstriction and a possible bronchopulmonary infection. An imbalanced nutrition can also be found in patients suffering from COPD, their intake may be less than what their body requires because of the increased rate of breathing which is taxing to the body, skeletal and respiratory muscles tend to waste away due to the effects of the drugs and also as a result of swallowing air. The patient may also exhibit deficient knowledge on the disease, its management, treatment, discharge needs and self care needs that is usually related to the misinterpretation of information, inadequate information, lack of information or even an apparent unfamiliarity with the sources of this information. They may also have ineffective breathing patterns in terms of the respiratory rate, synchrony, symmetry and depth. These patients also us their lips when breathing; which is characterized by wheezes, rhonchi and crackles. They may also present with anxiety and fear as a result of the difficulty in breathing that causes them sleepless nights. The patients may also have been exposed to risk factors with the most dominant being cigarette smoke; smoke from heated fuels or home cooking, occupational chemicals and even dusts. It is also important to establish if the patients’ family has a history of COPD or other respiratory diseases. (Meiner, S. E., 2005).
IV. Diagnostic Tests and Lab Findings
Pulmonary function tests are quite important in the diagnosis of COPD. Spirometry is necessary is not only important for the diagnosis of COPD but is also useful in assessing the severity of COPD. This test confirms the persistent wand partial airflow limitation that is reversible. The test includes an assessment of bronchodilator reversibility by making use of an inhaled bronchodilator. This test helps to establish the patient’s best lung function and also excludes asthma (Stockley, R. A. 2009).
The measuring of arterial blood gas is important in diagnosing COPD. In stable patients, it is recommended that the measurement of these gases while the individual breathes room air in case they have moderate or severe COPD. Oxygen therapy has proven that it can improve life expectancy in patients with this disease. The lungs diffusing capacity for carbon monoxide or DLCO is significantly reduced. The test provides information on the ease of the movement of molecules of carbon dioxide from alveolar gas to the pulmonary capillary hemoglobin. In smokers, the DLCO is lower when compared to non smokers even without spirometric abnormalities. When DLCO is reduced, asthma can often be excluded.
Imaging tests are quite useful especially in ruling out other diseases such as cancer, pneumonia, congestive heart failure, pneumothorax and pleural effusions.
Blood tests are important as there is some evidence of erythrocytosis among smokers and also patients that have sleep apnoea and hypoxia have increased red blood cells. Should the patient exhibit severe anemia, this should serve as a warning sign for the possibility of a coexisting disease. Sputum examination gives information about the functioning of both the lungs and airways. It is especially important in patients who manifest the disease in terms of chronic bronchitis. The sputum, in a stable state, should be mucoid and shows macrophages with neutrophils and in some instances even bacteria when examined using a microscope. The sputum is however mostly contaminated by secretions of the mouth hence any finding can be quite difficult to interpret (Stockley, R. A., 2009).
V. Methods of treatment
Bronchodilators are commonly used to treat the symptoms associated with COPD; they work by increasing the airway caliber. They relax and expand the muscle of the airway thereby making it easier for the patient to breathe. Patients suffering from COPD tend to exhibit airway hyperactivity; long term therapy using bronchodilators go a long way in preventing the constriction of the airways that comes about as a result of inhalation of irritants. These medications may however have other undesired effects other than bronchodilation. Sympathomimetic bronchodilators are the most commonly used with inhalation being the preferred method with which these drugs are administered using a metered-dose inhaler or MDI. The use of MDI’s results in more bronchodilation with relatively fewer side effects than other systematic routes and the most commonly used are; beta adrenergic agonists, methylxanthines and anticholinergics. Side effects associated with these medications include, a rapid heart rate, skeletal muscle tremors. Premature ventricular contractions and reduced potassium levels (Bordow, R, A. Ries, A. L. & Morris, T, A.).
Inhaled corticosteroids (ICS) reduce the risk of exacerbation in patients that have moderate and severe COPD and should not be used by patients with mild COPD. They improve lung function and also shorten the recovery time. Their use is however limited because of its side effects that can be dangerous; they include pharyngitis, upper respiratory infection and headache (Bordow, R, A. Ries, A, L. & Morris, T. A.).
Expectorants can be used in the treatment of COPD; they work by causing the body to secret mucus which is relatively thinner. Research is still ongoing on their use in the treatment of symptoms associated with COPD. They should however be used under the instructions of a physician. An example of methylxanthines used in the treatment of COPD is theophylline. It acts both as a respiratory stimulant and a weak bronchodilator. The drug the contractility of the diaphragm and also has anti inflammatory properties. It is however only used when the COPD symptoms persist despite bronchodilator therapy because of its adverse effects (Bordow, R. A., Ries. A. L. & Morris, T. A.).
VI. Patient Teaching
The patient needs to recognize the early signs of COPD such as a persistent cough that produces a large amount of sputum or mucus. Shortness of breath especially when the individual is involved in physical activity, a wheezing sound especially after coughing and a general feeling of tightness in the chest. The patient also has to be informed of the potential risk that he or she is exposed to especially through cigarette smoking. In the event of the patient receiving medication for this condition, he needs to be properly instructed on how to take the drugs for them to be effective. The patient should be encouraged to maintain a body weight that is healthy because when the patient is overweight, then his basic organs such as the lungs and heart will have to work harder. On the other hand patients suffering from COPD and are underweight might feel tired and weak and might therefore be at a higher risk of contracting an infection. The patient should also be encouraged to take in plenty of fluids so that the mucus can be kept thin and also easy to cough up. High fiber foods for example vegetables, legumes such as peas, whole grain foods and fresh fruit should be included in the diet. The patients should also make sure they get adequate rest as the disease causes fatigue (Barnett,M. 2006).
The general prognosis of an individual suffering from COPD is dependent on the severity of this disease when it was diagnosed. Whether or not the patient continues to smoke is also a determinant factor. The severity of this disease can be estimated by a physician by performing a spirometry, which is a lung measurement test. A measurement to test the functioning of the lungs is the “forced expiratory volume after 1 second (FEV1)”.the FEV1 test is a measure of the highest amount of air that an individual can breathe out in a single second. Should a person suffering from COPD have an FEV1 that is at least half of that of a person who does not have the disease and is of the same age and height, then he or she is said to have a very good prognosis. The survival chances of these patients is slightly less when compared to other patients who don’t suffer from COPD (Quinn, C. 2005).
People who are heavy smokers or were smokers are at a higher risk of developing this disease. Individuals with a family history of COPD increase their chances of developing the disease should they smoke. Exposure to lung irritants such as industrial dust, chemical fumes, air pollution and secondary smoking also put one at risk of developing the disease (MedicineNet.com).
In the risk stage is characterized by normal breathing; however development of COPD is a possibility. The patient may exhibit symptoms such as a chronic cough with sputum production. The mild stage is characterized by a mild limitation of airflow; the patient may not be aware that the flow of air in his lungs is reduced. He may exhibit symptoms such as a chronic cough with sputum production. The breathing test in the moderate stage shows the airflow limitation is worsening. He experiences shortness of breath especially when he is engaged in an activity. The patient normally seeks medical attention. When the COPD becomes severe, there is severe limitation of airflow; a little activity makes the person to suffer from shortness of breath. Very severe COPD may result in respiratory failure, the life of the individual is greatly impaired and the condition becomes life threatening (Matzo, M. & Sherman, D. W., 2009).
Chronic Obstructive Pulmonary Disorder is a serious disease affecting millions of people the world over. The condition is however manageable and the symptoms associated with it can be treated through a combination of medication therapy, a balanced diet and living a healthy lifestyle. Prevention however is the most effective way of dealing with this disease; smoking is the leading cause of COPD and should therefore be avoided at all costs.
- Bales,C.W. & Ritchie, C. S. Handbook of Clinical Nutrition and Aging. Springer Publishing Company(2009).
- Barnett, M. Chronic Obstructive Pulmonary Disease in primary care. John Wiley and Sons (2006).
- Matzo,M. & Sherman, D,W. Palliative Care Nursing: Quality Care to the End of Life. Springer Publishing Company (2009).
- MedicineNet.com Chronic Destrutive Pulmonary Disease (COPD, Chronic Obstructive Lung Disease, COLD). Retrieved from: http://www.medicinenet.com/script/main/hp.asp
- Meiner, S, E. Gerontologic Nursing. Elsevier Health Sciences (2005).
- Quinn, C. 100 questions and answers about chronic obstructive pulmonary disease. Jones & Bartlett Learning (2005).
- Rice, R. Homecare nursing practice: concepts and applications. Elsevier Health Sciences (2006).
- Smeltzer, S, C. Bare,B,G. Hinkle,J,L. & Cheever,K,H. Brunner and Suddarth’s textbook of medical-surgical nursing. Lippincott Williams and Wilkins (2009).
- Stockley,R, A. Chronic Obstructive Pulmonary Disease. Wiley-Blackwell (2009).
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