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Bronchitis Emphysema
COPD: Etiology
Cigarette smoking #1 Recurrent respiratory infection Alpha 1-antitrypsin deficiency Aging
1. 2. 3. 4.
Excessive tracheobronchial mucus production sufficient to cause cough with expectoration for most days of at least 3 months of the year for 2 consecutive years. Classification: Simple chronic bronchitis Chronic mucopurulent bronchitis Chronic bronchitis with obstruction Chronic bronchitis with obstruction and airway hyperreactivity.
Chronic Bronchitis
Recurrent or chronic productive cough for a minimum of 3 months for 2 consecutive years. Risk factors
Chronic inflammation Hypertrophy & hyperplasia of bronchial glands that secrete mucus Increase number of goblet cells Cilia are destroyed
Narrowing of airway
Starting w/ bronchi smaller airways airflow resistance work of breathing Hypoventilation & CO2 retention hypoxemia & hypercapnea
Hypoxemia Hypercapnea Polycythemia (increase RBCs) Cyanosis Cor pulmonale (enlargement of right side of heart)
In early stages
Clients may not recognize early symptoms Symptoms progress slowly May not be diagnosed until severe episode with a cold or flu Productive cough
Especially in the morning Typically referred to as cigarette cough
Advanced stages
Dyspnea on exertion Dyspnea at rest Hypoxemia & hypercapnea Polycythemia Cyanosis Bluish-red skin color Pulmonary hypertension Cor pulmonale
PFTs
FVC: Forced vital capacity FEV1: Forcible exhale in 1 second FEV1/FVC = <70% PaCO2 PaO2 Hct
ABGs
RBC
Emphysema
Def: Emphysema
1. 2. 3. 4.
Permanent abnormal distention of air spaces distal to the terminal bronchiole with destruction of alveolar septa (containing alveolar capillaries) and attachments to the bronchial walls. Classification: Centriacinar ( centrilobular) emphysema Panacinar emphysema Paraseptal emphysema Senile emphysema
Emphysema: Pathophysiology
Structural changes
Hyperinflation of alveoli Destruction of alveolar & alveolar-capillary walls Small airways narrow Lung elasticity decreases
Emphysema: Pathophysiology
Emphysema: Pathophysiology
The end result: Alveoli lose elastic recoil, then distend, & eventually blow out. Small airways collapse or narrow Air trapping Hyperinflation Decreased surface area for ventilation
Early stages
Later stages
Hypercapnea Purse-lip breathing Use of accessory muscles to breathe Underweight
Pulmonary function
residual volume, lung capacity, DECREASED FEV1, vital capacity maybe normal
Normal in moderate disease May develop respiratory alkalosis Later: hypercapnia and respiratory acidosis
Flattened diaphragm hyperinflation
Chest x-ray
Cough intermittent or daily present throughout day- seldom only nocturnal Sputum Any pattern of chronic sputum production Dyspnea Progressive and Persistent "increased effort to breathe" "heaviness" "air hunger" or "gasping" Worse on exercise Worse during respiratory infections Exposure to risk factors Tobacco smoke Occupational dusts and chemicals Smoke from home cooking and heating fuels
Assess and Monitor Disease Classification of COPD Stage 0 At Risk Stage I Mild COPD Stage II Moderate COPD Stage III Severe COPD Stage IV Very Severe COPD
Stage 0
At Risk
Stage I
Mild COPD
FEV1/FVC <70% FEV1 >80% predicted With or without chronic symptoms (cough, sputum production)
Stage II
Moderate COPD
FEV1/FVC <70% 50% <FEV1 <80% predicted With or without chronic symptoms (cough, sputum production)
Stage III
Severe COPD
FEV1/FVC <70% 30% <FEV1 <50% predicted With or without chronic symptoms (cough, sputum production)
Stage IV
FEV1/FVC <70% FEV1 <30% predicted or FEV1 <50% predicted plus chronic respiratory failure
Anti-inflammatory
Bronchodilators
Client teaching
Chest physiotherapy
Percussion, vibration Postural drainage
Self-manage medications
Inhaler & oxygen equipment
Bronchodilators Beta2-agonists
Short-acting
Fenoterol Salbutamol (albuterol) Terbutaline
Long-acting
Formoterol Salmeterol
Bronchodilators Anticholinergics
Mode of Action
Cholinergic tone is only reversible component of COPD Normal airway have small degree of vagal cholinergic tone Ipratropium bromide Oxitropium bromide Tiotropium
Short-acting
Long-acting
Methylxanthines
Aminophylline (slow release preparations) Theophylline (slow release preparations) RARELY OF SIGNIFICNAT BENEFIT LEVEL 8-12 mcg/ml