Question

Chronic Obstructive Disease (COPD)

D.Z., a 65-year-old man, is admitted to a medical floor for exacerbation of his chronic obstructive pulmonary disease (COPD; emphysema). He has a past medical history (PMH) of hypertension (HTN), which has been well controlled by enalapril (Vasotec) for the past 6 years, and a diagnosis (Dx) of pneumonia yearly for the past 3 years. He appears as a cachectic man who is experiencing difficulty breathing at rest. He reports cough productive of thick yellow-green sputum. D.Z. seems irritable and anxious when he tells you that he has been a 2-pack-a-day smoker for 38 years. He complains of (C/O) sleeping poorly and lately feels tired most of the time.

His vital signs (VS) are 162/84, 124, 36, 102°F, Sao2 88%. His admitting diagnosis is chronic emphysema with an acute exacerbation, etiology to be determined.

His admitting orders are as follows: diet as tolerated; out of bed with assistance; oxygen (O2) to maintain Sao2 of 90%; maintenance IV of D5W at 50 ml/hr; intake and output (I&O); arterial blood gases (ABGs) in am; CBC with differential, basic metabolic panel (BMP), and theophylline (Theo-Dur) level on admission; chest x-ray (CXR) q24h; prednisone 60 mg/day PO; doxycycline 100 mg PO q12h × 10 days, azithromycin 500 mg IV piggyback (IVPB) q24h ×2 days then 500 mg PO × 7 days; theophylline 300 mg PO bid; heparin 5000 units SC q12h; albuterol 2.5 mg (0.5 ml) in 3 ml normal saline (NS) and ipratropium 500 mg by nebulizer q4-6h; enalapril 10 mg PO q am.

1) Identify the expected findings in patients with COPD.

2) Identify three measures you could try to improve oxygenation status.

3) Explain the priority nursing care needed for patients with COPD.

4) What are two of the most common side effects of bronchodilators?

5) Identify the acid-base imbalance expected for patients with COPD.

6) Identify the expected arterial blood gas value results commonly seen in patients with COPD.

You deliver D.Z.'s dietary tray, and he comments how hungry he is. As you leave the room, he is rapidly consuming the mashed potatoes. When you pick up the tray, you notice that he hasn't touched anything else. When you question him, he states, “I don't understand it. I can be so hungry, but when I start to eat, I have trouble breathing and I have to stop.”

One theory for the increased work of breathing is based on carbohydrate (CHO) loading. D.Z.'s wife approaches you in the hallway and says, “I don't know what to do. My husband used to be so active before he retired 6 months ago. Since then he's lost 35 pounds. He is afraid to take a bath, and it takes him hours to dress—that's if he gets dressed at all. He has gone downhill so fast that it scares me. He's afraid to do anything for himself. He wants me in the room with him all the time, but if I try to talk with him, he snarls and does things to irritate me. I have to keep working. His medical bills are draining all of our savings, and I have to be able to support myself when he's gone. You know, sometimes I go to work just to get away from the house and his constant demands. He calls me several times a day asking me to come home, but I can't go home. You may not think I'm much of a wife, but quite honestly, I don't want to come home anymore. I just don't know what to do.”

7) How would you respond to her statement?

8) What education will you provide for this patient his wife?

Answer 1

1) Identify the expected findings in patients with COPD.

People may experience:

• Cough: can be dry or with phlegm
• Respiratory: frequent respiratory infections, shortness of breath, or wheezing, cyanosis
• Whole body: fatigue or inability to exercise, edema
• Also common: chest pressure, loss of muscle, or weight loss

2) Identify three measures you could try to improve oxygenation status.

• Pulmonary rehabilitation:
  • Patients with COPD experience dyspnea with exertion and many restrict physical activity. Pulmonary rehabilitation is an effective intervention in COPD, and studies demonstrate that pulmonary rehabilitation can significantly improve dyspnea, exercise capacity, psychological symptoms, and quality of life. Pulmonary rehabilitation is a multidisciplinary intervention that includes education, psychosocial support, optimization of pharmacotherapy, and exercise training. Exercise training is key to improvement in dyspnea and performance. Although it does not alter airflow, by making activity more efficient, less tachypnea, dynamic hyperinflation and dyspnea are noted. Synergies between rehabilitation and pharmacotherapy may be observed and optimal performance achieved by combining both modalities.

• Supplemental Oxygen

  • ​​Hypoxemia occurs commonly in COPD patients, and is associated with increased mortality. In the 1970s, two trials demonstrated a mortality benefit of supplemental oxygen in patients with hypoxemia, although this has not been replicated in subsequent studies. The GOLD guidelines recommend supplemental oxygen in patients with severe hypoxemia, defined as a resting SpO2 of < 88%, a PaO2 < 55 mm Hg, or in patients with a PaO2 between 55-60 mmHg with evidence of right heart failure. Supplemental oxygen in patients with more moderate hypoxemia or with exercise-induced oxygen desaturation may benefit a select group, but a recent randomized trial showed no benefit of supplemental oxygen in this group.

• Retrain breathing:
  • Learning new breathing techniques will help move more air in and out of the lungs. This helps decrease shortness of breath.
  • Diaphragmatic breathing: Breathe in slowly and deeply through the nose. While breathing in, push the stomach out. This uses the diaphragm and the lower respiratory muscles.
  • Pursed lip breathing: use of same diaphragmatic breathing technique, but when breathing out, purse the lips slightly like going to whistle. Breathe out slowly through pursed lips. Do not force the air out.

• Learn techniques to bring up mucus

  • ​When mucus collects in the airways, it can make breathing difficult and also effect oxygenation eventually leads to infection. Use these techniques after using bronchodilator medicine.

    • Deep coughing: take a deep breath and hold it for 3 seconds. Use the stomach muscles to expel the air. Avoid a hacking cough or just clearing your throat.

    • Huff coughing: take a breath that is slightly deeper than normal. Use the stomach muscles to make a "ha, ha, ha" sound while exhale. Follow this by diaphragmatic breathing and a deep cough if the mucus moving.

3) Explain the priority nursing care needed for patients with COPD.

1. Avoid irritants: Quit smoking or being around smoke Be mindful of the weather (very cold can aggravate the bronchi) Allergens like dust or pollen

   • The key to avoiding a flare up of COPD is to avoid things that make it worse. If the patient is smoking still this is a priority, they need to quit smoking. Provide education on smoking with COPD and the benefits of quitting.

2. If the patient has been working very hard to breath for a long period of time and is getting worse, be prepared with an airway cart. And for the love of the airway, have your respiratory therapist aware of the patient!

   • Safety! Plus you do not want to wait until the impending airway closure happens to try to secure their airway. Sometimes the patient will be sedated and intubated to try to correct any respiratory acidosis or alkalosis.

3. Breathing Treatments and medications

   • Beta-Agonists: Such as albuterol work as bronchodilators
     
     Anticholinergics: Such as Ipratropium work to relax bronchospasms
     
     Corticosteroids: Such as Fluticasone work as an anti-inflammatory

4. Monitor Oxygen saturation

   • This is subjective as you need to make sure to understand the patient’s baseline. Plan the oxygen monitoring with the physician. Give oxygen as ordered and needed. Be careful about turning their drive to breath off by giving too much O2, as a general rule, COPD patients should be kept around 88%-92%.

5. Obtain an ECG

   • The lungs and the heart are in the same general area, if someone is having problems breathing, make sure their heart is ok. Sometimes people having a heart attack can feel like they can’t breath due to the pressure or pain on their chest. Also, COPD is stressful on the heart, so even if the main problem is breathing, monitoring the heart, especially during an episode/exacerbation is important.

6. Encourage a healthy weight Can be either overweight or underweight

   • Having access weight on the patient decreases the space for the lungs to expand. Plus, generally those who lose weight are also moving more to lose the weight, double win. Some patients (especially those with emphysema) can be very thin (barrel chested) and it is important to make sure they are getting the proper nutrition so their body is at optimal performance (for that patient).

7. Encourage movement/activity

   • Sedentary lifestyle causes increased shortness of breath and less tolerance for movement. Helping the patient move more often helps improve breathing abilities.

8. Assess for/Administer influenza vaccine and pneumococcal vaccine

   • Preventing complications such as influenza or pneumonia is important because the lungs are already working harder to keep the body balanced with oxygen and CO2, an increased risk of infection only complicates the patient’s ability to breathe.

4) What are two of the most common side effects of bronchodilators?

• nausea, vomiting, diarrhoea (R/t GI).
• Palpitations, rapid heartbeat, increased blood pressure(R/t CVS).

5) Identify the acid-base imbalance expected for patients with COPD.

• Respiratory acidosis is an acid-base balance disturbance due to alveolar hypoventilation.
• Production of carbon dioxide occurs rapidly and failure of ventilation promptly increases the partial pressure of arterial carbon dioxide (PaCO₂).
• The normal reference range for PaCO₂ is 35-45 mm Hg.
• Alveolar hypoventilation leads to an increased PaCO₂ (ie, hypercapnia).
• The increase in PaCO₂, in turn, decreases the bicarbonate (HCO₃^–)/PaCO₂ ratio, thereby decreasing the pH.
• Hypercapnia and respiratory acidosis ensue when impairment in ventilation occurs and the removal of carbon dioxide by the respiratory system is less than the production of carbon dioxide in the tissues.

6) Identify the expected arterial blood gas value results commonly seen in patients with COPD.