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Transcript of Emphysema
Reduction of modifiable risk factors
Stages of Change Model
Initiate medication therapy
Purpose and dosing of medications
Proper inhaler technique
Supplemental oxygen use and safety
End-of- life decision making
self-management by patient
enhances patient/physician partnership
increases adherence to treatment plan
fewer hospitalizations, fewer ER visits
(Bickley, 2013; Ferguson & Make, 2014; ICIS,2013)
THREE CARDINAL SYMPTOMS OF COPD
1, Chronic cough (lasting longer than 3 mos.)
productive or nonproductive
2. Dyspnea (exertional or at rest) with or without
3. Chronic sputum production
Other symptoms include:
Wheezing, prolonged expiratory phase of respiration, rhonchi
• Hyperinflation of the chest with increase in anterior-posterior (A-P) diameter
• Accessory breathing
• Pursed lip breathing
• Signs of cor pulmonale:
o Increased pulmonic component of the second heart sound (S2)
o Neck vein distention
o Lower extremity edema
Obtain Health History:
Assess for Clinical Manifestations
Calculate PACK YEAR HISTORY:
Packs of cigarettes smoked per day X number of years smoked
Selected Abnormal Physical Findings:
Increased AP diameter (Barrel Chest)
Scabs on arms from orthopneic positions
Clubbing of the fingernails is NOT a diagnostic sign of COPD
Decreased to absent breath sounds; expiratory wheezes, rhonchi
Emphysema: Hyperresonant lung sounds
louder intensity lower pitch longer duration
NUR 556: Applied Clinical Management
November 12, 2014
Donita Hartman BSN, RN; Teresa Russo BSN, RN, CMSRN; Ashley Smith BSN, RN
• Define emphysema as a chronic adult illness and as a component of chronic obstructive pulmonary disease (COPD) (Knowledge).
• Describe normal physiological findings of the respiratory system in the adult (Comprehension).
• Analyze the pathology of emphysema (Analysis).
• Differentiate normal respiratory system physiologic findings from pathological findings related to emphysema (Analysis)
• Identify environmental, lifestyle, and congenital risk factors for emphysema (Knowledge).
• Summarize common clinical manifestations of emphysema. (Comprehension).
• Identify key elements of the patient history related to emphysema (Analysis).
• Discuss expected physical assessment findings in the patient with emphysema (Analysis).
• Summarize diagnostic tools for COPD/emphysema (Comprehension).
• Apply GOLD staging of COPD to selection of pharmacological interventions for COPD (Application).
• Explain mechanism of action of select respiratory medications (Comprehension).
• Give examples of nonpharmacologic treatments for emphysema (Comprehension).
• Discuss major nursing implications of COPD/emphysema (Analysis).
“Emphysema is defined as:
• an abnormal permanent enlargement of the air spaces distal to the terminal bronchioles,
• accompanied by destruction of alveolar walls
• and without obvious fibrosis.”
Normal Structure and Function vs. Emphysema
SMOKING!!!!!! (Majority cause)
Occupations with exposure to dust and chemicals (firefighters, welders)
Biomass fuel exposure
• Chronic respiratory infections
Emphysema is preventable, progressive, and nonreversible obstructive airway disease characterized by alveolar wall destruction.
COPD is the third leading cause of death in the United States.
Smoking is the majority risk factor for emphysema.
Chronic cough, dyspnea, and sputum production are the cardinal symtoms of COPD.
Diagnosis is based on medical history and physical exam; spirometry is needed to confirm persistent airflow limitation.
Pharmacologic and nonpharmacologic therapies, including surgery, treat symptoms and are not curative.
Health prevention, health promotion, and patient education strategies produce the best patient outcomes.
Chronic Obstructive Pulmonary Disease
A group of diseases that cause airflow blockage and breathing-related problems:
and in some cases, asthma. (CDC, 2013).
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) definition:
“A preventable and treatable disease characterized by chronic airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. Exacerbations and comorbidities contribute to the overall severity in individual patients.” ( Rennard, 2014; ICSI, 2013).
• 3rd leading cause of death in the
United States in 2011 (CDC, 2013)
• Fifteen million Americans diagnosed with
• Following groups more likely to report COPD:
o Age 65-74 years
o Non-Hispanic whites
o Disabled, unemployed, retired
o Lower income
o Current or former smokers
o History of asthma
• Chronic inflammation (characterized by presence of CD8+ T-lympocytes, neutrophils, and CD68+ monocytes/macrophages in the airways—
specific to emphysema and chronic bronchitis
• Increased # of goblet cells
• Mucus gland hyperplasia
• Narrowing and reduction in number of small airways
• Airway collapse due to alveolar wall destruction (
specific to emphysema
• Smooth muscle hypertrophy/hyperplasia due to chronic hypoxic vasoconstriction of the small pulmonary arteries
• Destruction of alveoli due to emphysema can lead to the loss of the associated areas of the pulmonary capillary bed
Emphysema affects the structures distal to the terminal bronchiole (constituting the acinus:
Subtypes of emphysema are:
Proximal acinar (Centrilobar):
abnormal dilation or destruction of the respiratory bronchiole—the central portion of the acinus'
enlargement or destruction of all parts of the acinus
Distal Acinar (Paraseptal):
alveolar ducts are predominantly affected
• Childhood infections
• Alpha 1- antitypsin
• Family history
• Extremely sedentary lifestyle
The National Emphysema Treatment Trial (NETT):
patients with severe empysema. Compared LVRS with maximal medial therapy:
Overall survival advantage was most marked in patients with UPPER LOBE emphysema and low exercise capacity
is the BEST nonpharmacologic intervention the smoker can take (Slows decline of FEV1)
Increased activity, exercise
Avoid, environmental exposure)
a. Pneumococcal polysaccharide vaccine
b. Influenza vaccine
• Breathing techniques
• Energy-saving strategies
• Individualized exercise program
• Nutritional counseling: >30% of severe COPD patients
protein calorie malnutrition, which causes:
impaired respiratory muscle function
diminished immune competence
(Ferguson & Make, 2014).
Decreases health care utilization
May reduce mortality (Ferguson & Make, 2014).
Improves exercise capacity, quality of life, and perception of symptoms
(Soysa, et al., p. 334)
• Benefits have shown to decline 1-2 years after initial pulmonary rehab
• Maintenance programs and self-motivational strategies (phone interventions, home visits, pedometers) may sustain benefits of pulmonary rehab
(Soysa, et al. pp. 335-336).
NON UPPER LOBE emphysema, patients with FEV1 <20 are not
Surgical resection of bullae in giant bullous emphysema
May improve functional capacity; Survival benefit is less clear (Ferguson & Make 2014).
Oxygen is the ONLY LIFE SUSTAINING therapy. All other therapies TREAT SYMPTOMS
• Improves mortality in
• Improves QOL in patients
with significant hypoxemia at rest
Techniques to treat hyperinflation due to emphysema via flexible bronchoscopy:
o Endobronchial placement of one-way valves, plugs, and
o Endobronchial instillation of biologic sealants
o Thermal airway ablation
o Airway stents for decompression of bullae
Posited that removal of diseased, hyperinflated areas of lung would:
Improve diaphragm and chest wall mechanics, decreasing
work of breathing
Restore outward circumferential pull on the bronchioles,o Increase expiratory flow, and
Remaining lung tissue would have more normal elastic
****None are FDA approved yet****
Bickley, L. S. (2013). Bates’ pocket guide to physical examination and history
taking (7th ed.). Philadelphia, PA: WoltersKluwer.
Centers for Disease Control and Prevention. (2012). What is COPD?
Retrieved from: http://www.cdc.gov/copd/
Ferguson, G.T. and Make, B. (2014, August 07). Management of stable chronic
obstructive pulmonary disease. 2014 UpToDate. Retrieved from: www.uptodate.com
Institute for Clinical Systems Improvement (ISCI). (2013, March). Diagnosis and
management of chronic obstructive pulmonary disease (COPD). Retrieved from: http://www.guideline.gov/content.aspx?id=44345&search=emphysema
Machuzak, M.S. and Gildea, T.R. (2014, October 30). Emerging therapies for
COPD: Bronchoscopic treatment of emphysema. 2014UpToDate. Retrieved from: www.uptodate.com
Martinez, F.J. (2014, June 05). Lung volume reduction surgery in COPD.
2014UpToDate. Retrieved from: www.uptodate.com
Rennard, S.I. (2014, October 09). Chronic obstructive pulmonary disease:
Definition, clinical manifestations, diagnosis, and staging. 2014UpToDate. Retrieved from: www.uptodate.com
Soysa, S., Mckeough, Z., Spencer, L., & Alison, J. (2012). Effects of maintenance
programs on exercise capacity and quality of life in chronic obstructive pulmonary disease. Physical Therapy Reviews, 17(5), 335-345. doi:10.1179/1743288X12Y.0000000033
Zelman, M., Tompary, E., Raymond, J., Holdaway, P., & Mulvihill, M.L. (2010).
Human diseases: A systemic approach (7th ed.). Upper Saddle River, NJ: Pearson.
Randomized, placebo-controlled trial of 125 patients with COPD—Vaccination reduced incidence of influenza by 76%, regardless of severity of COPD
Bronchoscopic Lung Volume Reduction (LVR ) Techniques
Lung Volume Reduction Surgery (LVRS)
(Bickley, 2013, p. 128; ICIS, 2013)
Bickley, 2013, pp. 127-146
The Global Initiative for Chronic Obstructive Lung Disease
developed a categorization system for COPD severity
• Degree of airflow limitation
• Risk of exacerbation
% of predicted FEV1 (Forced expiratory volume over 1 second)
Determines the SEVERITY of airflow limitation
Positive result: FEV1 <80% predicted, decreases with severity
FEV1/FVC ratio (Forced Expiratory Volume over 1 second/Forced Vital Capacity)
Determines if airflow limitation is PRESENT
Positive result: less than 70% (0.7) after treatment
PULSE OXIMETRY & ABG
CXR: Exclude alternate diagnoses
CT Scan: Greater sensitivity for
(Ferguson & Makes, 2014)
PRIMARY PHARMACOLOGIC AGENTS
Chronic antibiotic therapy
(Ferguson & Make, 2014)
MILD MODERATE SEVERE VERY SEVERE
(Ferguson & Make, 2014)
(Machuzak & Gildea, 2014)
Noninvasive, easily performed
Reduces # of patients requiring ABG when result >88 %
Does not provide information about alveolar ventilation or hypercapnia (PaCO2 > 45mmHg)
Arterial Blood Gases (ABG):
More specific diagnostic tool
Invasive, but provides better measurements of PaO2, PaCO2
Rennard, 2014; ICSI, 2013).
Not required to diagnose COPD