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Emphysema

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Teresa Russo

on 1 February 2015

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Transcript of Emphysema

Patient education:

Reduction of modifiable risk factors
SMOKING CESSATION
Stages of Change Model
Initiate medication therapy
 Purpose and dosing of medications
 Proper inhaler technique
 Minimizing dyspnea
Supplemental oxygen use and safety
 End-of- life decision making
Benefits :
self-management by patient
enhances patient/physician partnership
enhances health
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
wheezing
3. Chronic sputum production
Other symptoms include:
Wheezing, prolonged expiratory phase of respiration, rhonchi
and cough
• Hyperinflation of the chest with increase in anterior-posterior (A-P) diameter
(Barrel Chest)
• 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
o Hepatomegaly

Obtain Health History:
Assess for Clinical Manifestations
Calculate PACK YEAR HISTORY:
Packs of cigarettes smoked per day X number of years smoked
Family history
Environmental exposure

Selected Abnormal Physical Findings:

Inspection:
Increased AP diameter (Barrel Chest)
Orthopneic position
Scabs on arms from orthopneic positions
Clubbing of the fingernails is NOT a diagnostic sign of COPD

Auscultation:

Decreased to absent breath sounds; expiratory wheezes, rhonchi

Percussion:
Emphysema: Hyperresonant lung sounds

louder intensity lower pitch longer duration

Emphysema
Waynesburg University
NUR 556: Applied Clinical Management
November 12, 2014
Donita Hartman BSN, RN; Teresa Russo BSN, RN, CMSRN; Ashley Smith BSN, RN

PHYSICAL ASSESSMENT
LEARNING OBJECTIVES
• 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).

PATHOPHYSIOLOGY
GOLD DEFINITION

“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
References
PHYSICAL ASSESSMENT

SMOKING!!!!!! (Majority cause)
• Asthma
Occupations with exposure to dust and chemicals (firefighters, welders)
Biomass fuel exposure
• Chronic respiratory infections
DIAGNOSTIC TOOLS
PHARMACOLOGIC INTERVENTIONS
SPIROMETRY
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.
Summary
COGNITIVE DOMAIN
COPD
Chronic Obstructive Pulmonary Disease
A group of diseases that cause airflow blockage and breathing-related problems:
emphysema,
chronic bronchitis,
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
COPD

• Following groups more likely to report COPD:
o Age 65-74 years
o Non-Hispanic whites
o Women
o Disabled, unemployed, retired
o Lower income
o Current or former smokers
o History of asthma
(CDC, 2013).

Statistics
• 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
• Fibrosis
• Narrowing and reduction in number of small airways
• Airway collapse due to alveolar wall destruction (
specific to emphysema
)
Predominant Pathological
Airway Changes:
Pulmonary Vasculature:

• 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

Lung parenchyma:

Emphysema affects the structures distal to the terminal bronchiole (constituting the acinus:
Respiratory bronciole
Alveoloar ducts
Alveoli

Subtypes of emphysema are:

Proximal acinar (Centrilobar):
abnormal dilation or destruction of the respiratory bronchiole—the central portion of the acinus'

Paracinar:
enlargement or destruction of all parts of the acinus

Distal Acinar (Paraseptal):
alveolar ducts are predominantly affected


Pathological Changes
• Prematurity
• Childhood infections
• Alpha 1- antitypsin
deficiency
• Family history



• Extremely sedentary lifestyle
RISK FACTORS
Nursing Implications
The National Emphysema Treatment Trial (NETT):


1,218

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
Risk Reduction
SMOKING CESSATION
is the BEST nonpharmacologic intervention the smoker can take (Slows decline of FEV1)

Increased activity, exercise

Avoid, environmental exposure)

Vaccination
a. Pneumococcal polysaccharide vaccine
b. Influenza vaccine
Pulmonary Rehab
INTERVENTIONS:
• Breathing techniques
• Energy-saving strategies
• Individualized exercise program
(CDC, 2013).

• Nutritional counseling: >30% of severe COPD patients
protein calorie malnutrition, which causes:
increased mortality
impaired respiratory muscle function
diminished immune competence
(Ferguson & Make, 2014).
BENEFITS:
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)
CONSIDERATIONS:
• 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).
Surgery
 NON UPPER LOBE emphysema, patients with FEV1 <20 are not
candidates.


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
hypoxemic patients

• Improves QOL in patients
with significant hypoxemia at rest


Supplemental Oxygen
Emerging Treatments
Techniques to treat hyperinflation due to emphysema via flexible bronchoscopy:
o Endobronchial placement of one-way valves, plugs, and
blockers
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
recoil pressure

****None are FDA approved yet****
NONPHARMACOLOGIC INTERVENTIONS
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
FACT!
Bronchoscopic Lung Volume Reduction (LVR ) Techniques
Lung Volume Reduction Surgery (LVRS)
Bullectomy
Lung Transplantation
(Bickley, 2013, p. 128; ICIS, 2013)
Bickley, 2013, pp. 127-146
Clinical Manifestations
Physical Examination
(Rennard, 2014)
The Global Initiative for Chronic Obstructive Lung Disease
(GOLD)
developed a categorization system for COPD severity
Defined by:
• Degree of airflow limitation
• Risk of exacerbation
• Symptoms

% 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
IMAGING STUDIES

CXR: Exclude alternate diagnoses
CT Scan: Greater sensitivity for
emphysema

(Ferguson & Makes, 2014)
Respiratory Medications
PRIMARY PHARMACOLOGIC AGENTS
Bronchodilators
Short-acting
Beta agonists
Anticholinergics
Long-acting
Beta agonists
Anticholinergics
Inhaled glucocorticoids

REFRACTORY AGENTS
Theophylline
PDE-4 Inhibitors
Systemic glucocorticoids
Mucoactive agents
Chronic antibiotic therapy

(Ferguson & Make, 2014)
(Rennard, 2014).

MILD MODERATE SEVERE VERY SEVERE
(Ferguson & Make, 2014)
(Machuzak & Gildea, 2014)
Pulse oximetry:
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).
Lesson Plan
Questions
Not required to diagnose COPD
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