COPD is a lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing and is not

fully reversible. WHO

it is one of most common diseases. also known as chronic obstructive lung disease.

Smoking is the primary risk factor for COPD. The numerous irritants found in cigarette smoke stimulate excess mucus production and coughing destroy ciliary function, and lead to inflammation and damage of bronchiolar and alveolar walls.

Other Risk Factors: - air pollution - second-hand smoke - Hx. Of childhood respiratory tract infection - heredity

THERE ARE FOUR MAIN FORMS OF COPD:

Asthma Bronchitis Emphysema Bronchiectasis

ASTHMA
Is a disorder of the bronchial airways characterizes by periods or reversible bronchospasm.

Is often called reactive airway disease.

Is a obstruction of the bronchioles characterized by attacks that occur suddenly and last from 30 to 60 minutes; an attack that is difficult to control is referred to status asthmaticus .

a disorder that causes the airways of the lungs to swell and narrow, leading to wheezing, shortness of breath, chest tightness, and coughing.

Status Asthmaticus is a severe, life-threatening complication of asthma. It is an acute episode of bronchospasm, that leads to intensify. With severe bronchospasm, the workload of breathing increases 5 to 10 times, which can lead to acute cor pulmonale ( right-sided heart failure resulting from lung disease)

STATUS ASTHMATICUS
pneumothorax

commonly develops.

If continues: hypoxemia will be worsen acidosis begins if untreated/ not reversed: respiratory or cardiac arrest ensues.

ASTHMA OCCURS IN FAMILIES, WHICH SUGGESTS THAT IT IS AN INHERITED DISORDER.

Environmental factors. ex: viral infection, allergens, pollutants Itching factors can excitatory states ex: stress, laughing, crying. Exercise Changes in temperature Strong odor

Asthma also is a component of triad disease: asthma nasal polyps allergy to aspirin

SUBSTANCES THAT TRIGGER ASTHMA

Type of Substance
Air pollutants, including dusts, smoke, mists & fumes

Examples
Diesel exhaust; tobacco smoke; mineral, rock, coal, & wood dusts; gases; fumes & vapors from aerosol agents, chemicals, cleaning materials, solvents, paints, welding & from heating & cooling metals quickly
Trees, flowers, weeds, hay, plants Birds, cats, dogs Aspirin, anti-inflammatory drugs

Pollens, mites & molds Animal dander Medications

Foods

Egg, wheat, nuts

 coughing wheezing, a whistling sound Shortness of breath Chest tightness sneezing and runny nose Itchy and inflamed eyes Substances that trigger asthma.

Subjective a. Fatigue b. Headache Ojective a. Orthopnea, expiratory wheezing, breathing sounds, cough. stertorous

b. cyanosis, clubbing of the finger nails c. Distention of the neck veins e. Increased PCO2 and decreased PO2 of arterial blood gases.

 Increased visit to: Doctor, Urgent care clinic or ER Hospitalization Limitations in daily activities Lost of work days Lower quality of life DEATH

 identify and minimize contact with your asthma triggers

understand and take asthma medications as prescribed

recognize early signs that your asthma is getting worse know what to do when your asthma is getting worse.

PHYSICAL ASSESSMENT

MEDICAL HISTORY
What are your exact symptoms? When do they occur, and does anything specific seem to trigger them? Are you often exposed to tobacco smoke, chemical fumes, dust or other airborne irritants? Do you have hay fever or another allergic condition? Do you have any blood relatives with asthma, hay fever, or other allergies? What health problems do you have? What medications or herbal supplements do you take? (Many medications can trigger asthma.) What is your occupation? Do you have pet birds or raise pigeons? (In some people, exposure to birds can cause asthma-like symptoms.)

PHYSICAL EXAM
Your doctor may:
Examine your nose, throat and upper airways (upper respiratory tract). Use a stethoscope to listen to your breathing. Wheezing high-pitched whistling sounds when you breathe out is one of the main signs of asthma. Examine your skin for signs of allergic conditions such as eczema and hives. Your doctor will want to know whether you have common signs and symptoms of asthma, such as: Recurrent wheezing Coughing Trouble breathing Chest tightness Symptoms that occur or worsen at night Symptoms that are triggered by cold air, exercise or exposure to allergens.

Spirometry. This test estimates the narrowing of your bronchial tubes by checking how much air you can exhale after a deep breath and how fast you can breathe out. Peak flow. A peak flow meter is a simple device that measures how hard you can breathe out. Lower than usual peak flow readings are a sign your lungs may not be working as well and that your asthma may be getting worse.

Methacholine challenge. Methacholine is a known asthma trigger that, when inhaled, will cause mild constriction of your airways. If you react to the methacholine, you likely have asthma. This test may be used even if your initial lung function test is normal.

Imaging tests.
A chest X-ray and high-resolution computerized tomography (CT) scan of your lungs and nose cavities (sinuses) can identify any structural abnormalities or diseases (such as infection) that can cause or aggravate breathing problems.

Sputum Exam
This test looks for certain white blood cells (eosinophils) in the

mixture of saliva and mucus (sputum) you discharge during coughing.

INEFFECTIVE BREATHING PATTERN

Related to: Impaired exhalation and anxiety Outcomes: The client will have improved breathing patterns, as evidence by 1. A decreasing respiratory rate w/n normal limits. 2. A decreased dyspnea, less nasal flaring, and reduced use of accessory muscle. 3. Decreased manifestations of anxiety. 4. A return of ABG levels w/n normal limits. 5. O2 saturation greater than 95% 6. VC measurements w/n normal limits or greater than 40%.

INTERVENTIONS
a. Assess the client frequently, observing respiratory rate and depth. b. Assess the breathing pattern for shortness of breath, pursed-lip breathing, nasal flaring, strenal and intercostal retractioins, or a prolonged expiratory phase. c. Place the client in a Fowlers Position, and give O2 as ordered.

d. Monitor ABGs and O2 saturation levels to determine the effectiveness of tx.

INEFFECTIVE AIRWAY CLEARANCE

Related to: Increased production of secretions and bronchospasm Outcomes: The client will have effective airway clearance, as evidence by 1. Decreased inspiratory and expiratory wheezing 2. Decreased rhonchi 3. Decreased dry and non-productive cough

INTERVENTIONS
a. If the clients airway is compromised, the clients secretion may require suctioning.

b. Monitor the color and consistency of the sputum.

c. Assist the client to cough effectively. d. Encourage oral fluids to thin the secretions and replace fluid lost through rapid respiration. e. If chest secretions are thick and difficult to expectorate, client may benefit from postural drainage, lung percussion and vibration, expectorants, and frequent position changes.

f. Give frequent oral care, q 2 to 4 hrs; to remove the taste of secretions and remoisten the oral mucous mm. that have dried from mouth breathing.

NURSING MANAGEMENT

Ask the client to rate dyspnea on a scale of 0 to 10. Determine know medication allergies. Hx. of cardiac disease

Assist the client to determine whether there is a pattern to the manifestation in order to help identify a trigger that precipitate the asthma.
Ask the client about current medication that may induce bronchospasms. (propranolol) Ask the clients ability to manage asthma as well as the clients gen. adaptation to the illness. Denial of the illness can interfere w/ early tx. Determine whether the client is experiencing and increased no. of stressors. (can exacerbate asthma)

Cromolyn sodium and nedocromil

are generally well tolerated with most side effects decreasing with continued use. Make sure to tell your doctor if side effects do not resolve or become bothersome. Side effects include: Bad taste in mouth Cough Itching or Sore Throat Headache Sneezing or stuffy nose Make sure to notify your doctor promptly if you experience: Shortness of breath Wheezing

 ALBUTEROL AND IPRATROPIUM INHALER BRAND NAME: COMBIVENT, COMBIVENT RESPIMAT DRUG CLASS AND MECHANISM: Albuterol/ipratropium is a combination product consisting of two bronchodilators, albuterol (Proventil; Ventolin) and ipratropium (Atrovent) that is used in the treatment of chronic obstructive pulmonary disease (bronchitis and emphysema) when there is evidence of spasm (narrowing) of the airways (bronchi). Bronchodilators dilate or enlarge the airways by relaxing the muscles surrounding the airways. Albuterol and ipratropium work by different mechanisms, but both cause the muscles of the airways to relax. PRESCRIBED FOR: is used in the treatment of bronchospasm or narrowing of the airways caused by emphysema or bronchitis in patients who require a second bronchodilator. SIDE EFFECTS: Headache, nausea, nervousness, trouble sleeping,dizziness, dry mouth/throat, coughing, or runny nose may occur.

 ALBUTEROL, VENTOLIN, PROVENTIL, PROVENTIL-HFA, ACCUNEB, VOSPIRE, PROAIR (SALBUTAMOL)

DRUG CLASS:

It dilates the airways of the lung and is used for treating asthma and other conditions of the lung.
PRESCRIBED FOR:

Is used for relief and prevention of airway obstruction (bronchospasm) in patients with asthma or exercise induced asthma. Albuterol is also used for treating patients with emphysema or chronic bronchitis when their symptoms are related to reversible airway obstruction. The inhaled form of albuterol starts working within 15 minutes and can last up to 6 hours.
SIDE EFFECTS:

nervousness, tremor ,headache, palpitation, fast heart rate, elevated blood pressure, nausea, dizziness, and heartburn. Throat irritation and nosebleed can also occur. Allergic reactions may rarely occur and may manifest as rash, hives, swelling, bronchospasm, or anaphylaxis (shock). Worsening of diabetes and lowering of potassium have also been reported. In rare patients, inhaled albuterol can paradoxically precipitate lifethreatening bronchospasm.

GENERIC NAME: BRAND NAME:

ZAFIRLUKAST ACCOLATE

DRUG CLASS AND MECHANISM:

Zafirlukast is an oral leukotriene receptor antagonist used for treating asthma. Leukotrienes are a group of chemicals manufactured in the body from arachidonic acid. Release of leukotrienes within the body, for example, by allergic reactions, promotes inflammation in many diseases such as asthma, a disease in which inflammation occurs in the lungs. : The most common side effects of zafirlukast are headache, dizziness, nausea, diarrhea, abdominal pain, sore throat, respiratory infections, and rhinitis. Liver failure has been associated with zafirlukast treatment.

GENERIC NAME: BRAND NAME:

terbutaline Brethine

DRUG CLASS AND MECHANISM:

Terbutaline is a member of a class of drugs called beta adrenergic receptor agonists (stimulators) that is used for treating asthma and other diseases of the airways.

SIDE EFFECTS: Terbutaline may cause side effects such as tremor,nausea, nervousness, dizziness, headache, drowsiness, heartburn, heart palpitations, fast heart rate, and elevated blood pressure. Vomiting, anxiety, restlessness, lethargy, excessive sweating, chest pain, and muscle cramping also may occur. Low blood potassium (hypokalemia) and high blood glucose have been associated with terbutaline.

BRONCHITIS
describes inflammation of the bronchial tubes (inflammation -itis). The inflammation causes swelling of the lining of these breathing tubes, narrowing the tubes and promoting secretion of inflammatory fluid.

The main symptom of bronchitis is a hacking cough. It is likely that your cough will bring up thick yellow-grey mucus, although this does not always happen.

People with bronchitis breathe less air and oxygen into their lungs; they also have heavy mucus or phlegm forming in the airways. Bronchitis may be acute or chronic (long-term): Acute bronchitis is a shorter illness that commonly follows a cold or viral infection, such as the flu. It generally consists of a cough with green sputum, chest discomfort or soreness, fever, and sometimes shortness of breath. Acute bronchitis usually lasts a few days or weeks.

Chronic bronchitis is characterized by a persistent, mucus-producing cough on most days of the month, three months of a year for two successive years in absence of a secondary cause of the cough. People with chronic bronchitis have varying degrees of breathing difficulties, and symptoms may get better and worsen during different parts of the year.

Causes bronchitis
Bronchitis is caused by viruses, bacteria, and other particles that irritate the bronchial tubes.

Acute bronchitis is usually caused by a viral infection in the bronchi - often the same viruses that causes cold and flu. Bronchitis is actually part of the immune response to fighting against the infection, since additional swelling occurs in the bronchial tubes as the immune systems actions generate mucus. In addition to viruses, bacteria, exposure to tobacco smoke, exposure to pollutants or solvents, and gastroesophageal reflux disease (GERD) can also cause acute bronchitis.
Chronic bronchitis is most commonly caused by cigarette smoking. However, it can also be the result of continuous attacks of acute bronchitis. Air pollution, dust, toxic gases, and other industrial fumes are known to be responsible for the condition

Cigarette smoke. People who smoke or who live with a smoker are at higher risk of both acute bronchitis and chronic bronchitis.

Low resistance. This may result from another acute illness, such as a cold, or from a chronic condition that compromises your immune system. Older adults, infants and young children have greater vulnerability to infection.

Exposure to irritants on the job. Risk of developing bronchitis is greater if you work around certain lung irritants, such as grains or textiles, or are exposed to chemical fumes.

Signs and symptoms for both acute and chronic bronchitis include: Inflammation or swelling of the bronchi

Coughing Production of clear, white, yellow, grey, or green mucus (sputum) Shortness of breath

Wheezing Fatigue Fever and chills Chest pain or discomfort Blocked or runny nose

GENERIC NAME: OFLOXACIN BRAND NAME: FLOXIN (DISCONTINUED BRAND)

DRUG CLASS AND MECHANISM: Ofloxacin is an antibiotic that is used to treat bacterial infections. It belongs to the fluoroquinolone class of antibiotics which includes levofloxacin (Levaquin), ci profloxacin (Cipro), gatifloxacin (Tequin), norfloxacin (Noroxin), moxifloxacin (Avelox), trovafloxacin (Trovan) and others. Ofloxacin stops the multiplication of bacteria by inhibiting the reproduction and repair of their genetic material (DNA).
PRESCRIBED FOR: Ofloxacin is used to treat pneumonia and bronchitiscau sed by Haemophilus influenzae and Streptococcus pneumoniae. It also is used in treating skin infections caused by Staphylococcus aureus, andStreptococcus pyogenes bacteria. Ofloxacin is used to treat sexually transmitted diseases, such as gonorrhea and chlamydia, but is not effective against syphilis. Ofloxacin is used often to treat urinary infections and prostate infections caused by E. Coli

SIDE EFFECTS: The most frequent side effects of ofloxacin include nausea,vomiting, diarrhea, insomnia, heada che, dizziness, itching, and vaginitis in women.
DRUG INTERACTION: Ofloxacin reduces the elimination of theophylline, elevating blood levels of theophylline. (Theophylline is used to open airways in the treatment of asthma.)

 terbutaline fluticasone furoate and vilanterol inhalation powder

Emphysema is a disorder in which the alveolar walls are destroyed. This destruction leads to permanent over distention of the air spaces.
Emphysema occurs when the air sacs in your lungs are gradually destroyed, making you progressively more short of breath. Emphysema is one of several diseases known collectively as chronic obstructive pulmonary disease (COPD). Smoking is the leading cause of emphysema.

Characterized by distended, inelastic, or destroyed alveoli with bronchiolar obstruction and collapse; these alterations greatly impair the diffusion of gases through the alveolar capillary membrane.
which involves destruction of the lungs over time.

Causes
The actual cause of emphysema is unknown. Risk factors for the development of emphysema include cigarette smoking, living or working in a highly polluted area, and a family history of pulmonary disease. Frequent childhood pulmonary infections have been identified as a cause of bronchiectasis.

1.Centriacinar or Centrilobular Emphysema

2.Panacinar Emphysema

3.Paraseptal Emphysema

CENTRIACINAR OR CENTRILOBULAR EMPHYSEMA

Is the most common type, produces destruction in the bronchioles, usu. in the upper lung regions. Inflammation begins in the bronchioles and spreads peripherally, but usu. The alveolar sac remains intact. This type of emphysema occurs most often in smokers.

PANACINAR EMPHYSEMA
it destroys the entire alveolus and most commonly involves the lower portions of the lungs. This form of the disease is generally observed in individuals with AAT deficiencies. focal panacinar emphysema can be seen at the lung bases in smokers

PARASEPTAL EMPHYSEMA
or distal acinar It involves the distal airway structure, alveolar ducts, and alveolar sacs.

The process is localized around the septa of the lungs and pleura, resulting in isolated blebs along the lung periphery.

Client who have primary emphysema have progressive dyspnea on exertion that eventually becomes dyspnea at rest.

The anterioposterior diameter of the chest is enlarged, and the chest has hyper resonant sounds to percussion.

Chest films diaphragms.

show

overflation

and

flattened

ABG values are usu. Normal until later stage, when compensated respiratory acidosis is often evident.

Factors that increase your risk of developing emphysema include:

Smoking. Emphysema is most likely to develop in cigarette smokers, but cigar and pipe smokers also are susceptible. The risk for all types of smokers increases with the number of years and amount of tobacco smoked. Age. Although the lung damage that occurs in emphysema develops gradually, most people with tobacco-related emphysema begin to experience symptoms of the disease between the ages of 40 and 60.

Breathlessness Other Emphysema Symptoms o Wheezing: This symptom of emphysema is shared with asthma. Wheezing often improves with inhaled medicines called bronchodilators. o Cough: A large proportion of people with emphysema experience a cough. Often this is related to smoking. However, cough can persist as one of the symptoms of emphysema after quitting smoking. oChest tightness or pain: These may be symptoms of emphysema or of coexisting heart disease. Chest tightness occurs more often with exercise or during periods of breathlessness.

People with emphysema may also face some other less common emphysema symptoms: oLoss of appetite and weight loss oDepression oPoor sleep quality oDecreased sexual function

Anorexia, fatigue, weight loss Feeling of breathlessness,cough, sputum production, flaring of the nostrils, use of accessory muscles of respiration, increased rate and depth of breathing, dyspnea. Decreased respiratory excursion,resonance to hyperresonance, decreased breath sounds with prolonged expiration, normal or decreased fremitus

LABORATORY EXAM

Oximetry Oximetry is a non-invasive test, in which a sensor is taped or clipped onto a finger or earlobe to measure the percentage of red blood cells that have oxygen. This value is usually greater than 92%. Results less than 90% may signal the need for supplemental oxygen. Blood Tests A complete blood cell count (CBC) may be performed to check for an increase in the number of red blood cells. In response to lower blood oxygen concentrations, the body manufactures more red blood cells to try to deliver as much oxygen as possible to cells.

Alpha-1 antitrypsin levels may be measured to look for the genetic form of emphysema The arterial blood gas can also give parameters to establish the diagnosis of chronic respiratory failure.

Radiology
A plain chest X-ray may show lungs that have become too inflated and have lost normal lung markings, consistent with destruction of alveoli and lung tissue. A CT scan can reveal more detail regarding the amount of lung destruction but is not a normal part of the evaluation of patients with emphysema. Pulmonary function tests or spirometry, can measure the air flow into and out of the lungs and be used to predict the severity of emphysema.

Some measurements include: FVC (forced vital capacity): the amount of air that can be forcibly exhaled after the largest breath possible. FEV1 (forced expiratory volume in 1 second): the amount of air that is forcibly exhaled in 1 second. Even though total air exhalation may be less affected, as the lung loses its elasticity, it takes longer for the air to get out and FEV1 becomes a good marker for disease severity. FEV (forced expiratory volume): can be measured throughout the exhalation cycle often at 25%, 50%, and 75% to help measure function of different sized bronchi and bronchioles.

PEF (peak expiratory flow): maximal speed of air during exhalation. DLCO (diffusion capacity): measures how much carbon monoxide can be inhaled and absorbed into the bloodstream within a period of time. A small amount of tracer carbon monoxide is inhaled and then quickly exhaled. The amount of carbon monoxide in the exhaled air is measured and determines how well the lungs work in absorbing the gas. This helps determine and measure lung function.

 Emphysema is a pathological diagnosis defined by permanent enlargement of airspaces distal to the terminal bronchioles. This leads to a dramatic decline in the alveolar surface area available for gas exchange. Furthermore, loss of alveoli leads to airflow limitation by 2 mechanisms. First, loss of the alveolar walls results in a decrease in elastic recoil, which leads to airflow limitation. Second, loss of the alveolar supporting structure leads to airway narrowing, which further limits airflow.

 Emphysema commonly presents with chronic bronchitis. Chronic bronchitis leads to obstruction by causing narrowing of both the large and small (< 2 mm) airways. In the large airways, an increase in Goblet cells, squamous metaplasia of ciliary epithelial cells, and loss of serous acini can be seen. In the small airways, Goblet cell metaplasia, smooth muscle hyperplasia, and subepithelial fibrosis can be seen. In healthy individuals, small airways contribute little to airway resistance; however, in COPD patients, these become the main site of airflow limitation

PRIMARY NURSING DIAGNOSIS IMPAIRED

GAS EXCHANGE

RELATED TO DESTRUCTION OF
ALVEOLAR WALLS

MEDICAL MANAGEMENT

Treatment is directed at improving ventilation, decreasing work of breathing and preventing infection. Smoking cessation Physical therapy to conserve and increase pulmonary ventilation Maintenance of proper environmental conditions to facilitate breathing Psychological support

Ongoing program of patient education and rehabilitation

Bronchodilators and metered-dose inhalers (aerosol therapy, dispensing particles in fine mist).

Treatment of infection (antimicrobial therapy at the first sign of respiratory infection)

Oxygenation in low concentrations for severe hypoxemia.

MEDICATIONS

Bronchodilators: Anticholinergic agents such as atropine sulfate, ipratropium bromide are used in reversal of bronchoconstriction.
Bronchodilators: Beta2-adrenergic agents such as( inhaled beta2-adrenergic agonists by metered-dose inhaler (MDI) such as albuterol, metaproterenol, or terbutaline )are used in reversal of bronchoconstriction. Systemic corticosteroids such as methylprednisolone IV; prednisone PO is used to decrease inflammatory response and improve airflow in some patients for a few days during acute exacerbations

Other Drug Therapy:

Bronchodilators, which are used for prevention and maintenance therapy, can be administered as aerosols or oral medications. Generally, inhaled anticholinergic agents are the first-line therapy for emphysema, with the addition of betaadrenergic agonists added in a stepwise fashion. Antibiotics are ordered if a secondary infection develops. As a preventive measure, influenza and pneumonia vaccines are administered.

Maintaining a patent airway is a priority. Use a humidifier at night to help the patient mobilize secretions in the morning.
Encourage the patient to use controlled coughing to clear secretions that might have collected in the lungs during sleep. Place patients who are experiencing dyspnea in a high Fowler position to improve lung expansion. Placing pillows on the overhead table and having the patient lean over in the orthopneic position may also be helpful. Teach the patient pursed-lip and diaphragmatic breathing. To avoid infection, screen visitors for contagious diseases and instruct the patient to avoid crowds.

Conserve the patients energy in every possible way. Plan activities to allow for rest periods, eliminating nonessential procedures until the patient is stronger. It may be necessary to assist with the activities of daily living and to anticipate the patients needs by having supplies within easy reach. Refer the patient to a pulmonary rehabilitation program if one is available in the community. Patient education is vital to long-term management. Teach the patient about the disease and its implications for lifestyle changes, such as avoidance of cigarette smoke and other irritants, activity alterations, and any necessary occupational changes. Provide information to the patient and family about medications and equipment.

DISCHARGE PLANNING

Be sure the patient and family understand any medication prescribed, including dosage, route, action, and side effects.
Instruct the patient to report any signs and symptoms of infection to the primary healthcare provider. Explain necessary dietary adjustments to the patient and family. Recommend eating small, frequent meals, including high-protein, high-density foods Encourage the patient to plan rest periods around his or her activities, conserving as much energy as possible. Arrange for return demonstrations of equipment used by the patient and family. If the patient requires home oxygen therapy, refer the patient to the appropriate rental service, and explain the hazards of combustion and increasing the flow rate without consultation from the primary healthcare provider.

Bronchiectasis is an uncommon disease, most often secondary to an infectious process, that results in the abnormal and permanent distortion of one or more of the conducting bronchi or airways.
o oAn

extreme form of obstructive bronchitis, causes permanent, abnormal dilation and distortion of bronchi and bronchioles. It develop when bronchial walls are weakened by chronic inflammation conditions. Any condition producing a narrowing of the lumen of the bronchioles, however may result in bronchiectasis, including tuberculosis, adenoviral infections, and pneumonia

3 types of bronchiectasis:
1. Cylindrical bronchiectasis is the mildest form and reflects the loss of the normal tapering of the airways. The symptoms may be quite mild, like a chronic cough, and usually are discovered on CT scans of the chest. 2. Saccular bronchiectasis is more severe, with further distortion of the airway wall and symptomatically, affected persons produce more sputum. 3. Cystic bronchiectasis is the most severe form of bronchiectasis, and fortunately it is the least common form. This often occurred in the preantibiotic era when an infection would run its course and the patient would survive with residual lung damage. These patients often would have a chronic productive cough, bringing up a cup or more of discolored mucus each

Within the lungs, air passages called bronchi form a tree-like structure through which air travels in and out. The bronchi are lined with tiny hair-like projections called cilia, which work to sweep mucus upwards within the lungs, allowing it to be easily coughed out.

Bronchiectasis is a condition in which some of the bronchi have become scarred and permanently enlarged. During the disease process the cilia are damaged so that they are unable to effectively sweep away the mucus. As a result, mucus accumulates in parts of the lung that are affected and the risk of developing lung infections is increased. Recurrent infections can then cause further scarring and bronchial enlargement thereby perpetuating the condition.

Causes
Prior to the introduction of widespread immunizations programs, bronchiectasis often occurred as the result of infection with measles or whooping cough. Currently bronchiectasis usually occurs as the result of an illness such as pneumonia (approximately 25% of all cases). Other causes include: Cystic fibrosis Immune deficiency Recurrent aspiration of fluid into the lungs (as occurs with gastroesophageal reflux) Inhalation of a foreign object into the lungs (if left untreated) Inhalation of harmful chemicals eg: ammonia In rare cases it may be congenital (present at birth

SIGNS AND SYMPTOMS

The main symptom of bronchiectasis is a mucusproducing cough. The cough is usually worse in the mornings and is often brought on by changes in posture. The mucus may be yellow-green in colour and foul smelling, indicating the presence of infection. Other symptoms may include:

Coughing up blood (more common in adults) Bad breath Wheezing chest - a characteristic crackling sound may be heard when listening with a stethoscope. Recurring lung infections A decline in general health In advanced bronchiectasis, breathlessness can occur.

DIAGNOSIS

An initial diagnosis of bronchiectasis is based on the patient's symptoms, their medical history and a physical examination. Further diagnostic tests may include: Chest x-ray CT (computerized tomography) scan Blood tests Testing of the mucus to identify any bacteria present Checking oxygen levels in the blood Lung function tests (spirometry).

Bronchiectasis is a chronic (long-term) condition that requires lifelong maintenance. Good management of the condition is vital to prevent ongoing damage to the lungs and worsening of the condition The ultimate goal of treatment is to clear mucus from the chest and prevent further damage to the lungs. The two main types of treatments used are: Medications Physiotherapy and exercise Chest physiotherapy and postural drainage are used to remove secretions from the lungs. An individual program is usually developed where exercise and breathing techniques to clear the lungs of mucus are taught.

Prevention To help prevent bronchiectasis in children: Not smoking during pregnancy and having a smoke free home Breastfeeding your children Eating a healthy balanced diet Early detection and treatment of chest infections Making sure homes are warm and dry (making chest infections less likely)

Immunization for diseases like measles and whooping cough which can lead to bronchiectasis.

CAUSES OF COPD?
ABOUT 90% OF PEOPLE WITH COPD ARE CURRENT OR FORMER SMOKERS -- AND THEIR DISEASE USUALLY APPEARS AFTER AGE 40. SECONDHAND SMOKE AND
EXPOSURE TO ENVIRONMENTAL IRRITANTS AND POLLUTION
ALSO CAN INCREASE YOUR RISK OF THE

COPD. IN RARE CASES,

DNA PASSED DOWN THROUGH A FAMILY CAN LEAD TO COPD, EVEN IN "NEVER SMOKERS." ONE OF THESE GENETIC CONDITIONS IS CALLED ALPHA-1 ANTITRYPSIN (AAT) DEFICIENCY.

Smoking is the leading cause of COPD. The more a person smokes, the more likely that person will develop COPD. Exposure to certain gases or fumes in the workplace Exposure to heavy amounts of secondhand smoke and pollution Frequent use of cooking fire without proper ventilation. Rarely, a genetic condition called alpha-1 antitrypsin deficiency may play a role in causing COPD. People who have this condition have low levels of alpha-1 antitrypsin (AAT)a protein made in the liver.

SIGNS AND SYMPTOMS INSIDE THE LUNGS, COPD CAN CLOG THE AIRWAYS AND DAMAGE THE TINY, BALLOON-LIKE SACS (ALVEOLI) THAT ABSORB OXYGEN. THESE CHANGES CAN CAUSE THE FOLLOWING SYMPTOMS:
Shortness of breath in everyday activities Wheezing Chest tightness Constant coughing Producing a lot of mucus (sputum) Feeling tired Frequent colds or flu

Severe COPD can make it difficult to walk, cook, clean house, or even bathe. Coughing up excess mucus and feeling short of breath may worsen. Advanced illness can also cause:
Swollen legs or feet from fluid buildup o Weight loss o Less muscle strength and endurance o A headache in the morning o Blue or grey lips or fingernails (due to low oxygen levels)
o

PHYSICAL ASSESSMENT

PULMONARY EXAM INSPECTION (CHEST SHAPE AND SYMMETRY) PALPATION PERCUSSION AUSCULTATIONIN GI EXAM, YOU AUSCULTATE BEFORE YOU PALPATEIF YOU PALPATE FIRST, YOULL
CREATE BOWEL SOUNDS (THUS YOU WONT KNOW IF THEY WERE ABSENT TO BEGIN WITH)

Nasal flaring
Cyanosis

Dyspnea
Decreased respiratory effort

Decreased LOC
Accessory muscle use Decreased breath sounds Decreased oxygen saturation

FIRST, YOUR DOCTOR

WILL LISTEN TO YOUR CHEST
AS YOU BREATHE, THEN WILL ASK ABOUT YOUR SMOKING

HISTORY AND WHETHER YOU

HAVE A FAMILY HISTORY OF

COPD. THE AMOUNT OF

OXYGEN IN YOUR BLOOD MAY
BE MEASURED WITH A BLOOD TEST OR A PULSE OXIMETER, A PAINLESS DEVICE THAT CLIPS TO A FINGER.

MEDICAL CHART REVIEW

Allergies Chief

Complaint or History of Present Illness Patient history and physical Past Medical and Surgical History Social and Family History Diagnosis Current orders (medicine, diet, activity, etc) Physician Progress Note

EXTREMITIES INSPECTION
Clubbing loss of angle between nail and terminal phalanx - Look at the nail bed; the skin is a little higher and the nail is a little lower - Have patient put their fingers nail bed to nail bed you should be able to see light thru a space b/t the nail beds no clubbing - If you dont see light between the 2 nail beds, then theres clubbing. Picture: Angel b/t nail bed and terminal phalanx is lostyou would not see light coming through the nail bed

PULMONARY EXAM INSPECTION (CHEST SHAPE AND SYMMETRY) PALPATION PERCUSSION AUSCULTATIONIN GI EXAM, YOU AUSCULTATE BEFORE YOU PALPATEIF YOU PALPATE FIRST, YOULL
CREATE BOWEL SOUNDS (THUS YOU WONT KNOW IF THEY WERE ABSENT TO BEGIN WITH)

SPIROMETRY BREATH TEST

This involves blowing out as hard as possible into a small machine that tests lung capacity. The results can be checked right away, and the test does not involve exercising, drawing blood, or exposure to radiation.
Using a stethoscope to listen to the lungs can also be helpful. However, sometimes the lungs sound normal even when COPD is present.

A chest X-ray isn't used to diagnose COPD, but it may help rule out conditions that cause similar symptoms, such as pneumonia. In advanced COPD, a chest X-ray might show lungs that appear much larger than normal.

Sometimes patients need to have a blood test (called arterial blood gas) to measure the amounts of oxygen and carbon dioxide in the blood.

Is used to confirm you have COPD and not asthma, your doctor might ask you to take regular measurements of your breathing using a peak flow meter, at different times over several days. The peak flow meter measures how fast you can breathe out.

COMPUTERIZED TOMOGRAPHY (CT)

SCAN

Some people may need a CT scan. This provides more information than an Xray and can be useful in diagnosing other lung diseases or assessing changes to your lungs due to COPD

PATHOPHYSIOLOGY

PATHOPHYSIO

Ineffective airway clearance

Intervention:
Give the patient 6 to 8 glasses of fluid / day unless there is a cor pulmonale.

related to: bronchoconstriction, increased sputum production, ineffective cough, fatigue / lack of energy, bronchopulmonary infection.

Teach and give encouragement use of diaphragmatic breathing and coughing techniques. Assist in the provision of action nebulizer, metered dose inhalers. Perform postural drainage with percussion and vibration in the morning and evening according to the required. Instruct patient to avoid irritants such as cigarette smoke, aerosols, temperature extremes, and smoke. Teach about the early signs of infection should be reported to your doctor immediately: increased sputum, change in sputum color, viscosity ofsputum, increased shortness of breath, chest tightness, fatigue. Give encouragement to patients to immunize against influenzae and Streptococcus pneumoniae.

Activity intolerance

INTERVENTIONS:
Assess the individual response to the activity; pulse, blood pressure, respiration.
Measure vital signs immediately after the activity, the client rest for 3 minutes then measuring the vital signs again. Support the patient in establishing a regular exercise using a treadmill and exercise, walking or other exercise appropriate, such as walking slowly. Assess the patient's level of function of the last and develop training plans based on the status of basic functions. Provide oxygen as represented is required before and during the run of activity just in case.

related to: imbalance between oxygen supply with demand

increase activity gradually; clients currently or long bed rest started doing range of motion at least 2 times a day.
Increase tolerance to the activity by encouraging clients to do the activity more slowly, or a shorter time, with more rest or with a lot of help.

ANXIETY RELATED TO ACUTE BREATHING DIFFICULTIES AND FEAR OF

SUFFOCATION. OUTCOME: THE CLIENT WILL EXPRESS AN INCREASE IN PSYCHOLOGICAL COMFORT AND DEMONSTRATE THE USE OF EFFECTIVE COPING MECHANISM
Interventions Remain with the client during acute episodes of breathing difficulty, and provide care in a calm reassuring manner. Provide a quiet, calm environment. During acute episodes, open doors and curtains and limit # of people and unnecessary equip. in the room. Provide a fan if the client perceives a benefit from the moving air. Encourage the use of breathing retraining and relaxation techniques. Give sedatives and tranquilizers with extreme caution. Nonpharmaceutical methods of anxiety reduction are more useful. Rationales Reassures the client that competent help is available if needed. Anxiety can be contagious; remain calm. Reduction or external stimuli helps promote relaxation. Environmental changes may lessen the clients perceptions of suffocation. A feeling of self-control and success in facilitating breathing helps reduce anxiety. Oversedation may cause respiratory depression.

Evaluation: Anxiety can usu. Be controlled quickly but may recur with each episode of dyspnea and requires both short-term and long-term interventions.

DISTURBED SLEEP PATTERN R/T DYSPNEA AND EXTERNAL STIMULI.

OUTCOME: THE CLIENT WILL REPORT FEELING ADEQUATELY RESTED.

Intervention oPromote relaxation by providing a darkened, quiet environment; ensuring adequate room ventilation; and following bedtime routines. oSchedule care activities to allow periods of uninterrupted sleep. oAvoid the use of sleeping pills oInstruct the client in measures to promote sleep; a. Avoid stimulants, such as caffeine. b. Maintain a consistent bedtime and a regular bedtime routine,. Etc. Rationales oThe hospital environment ca interfere with relaxation and sleep. Using established bedtime rituals increases relaxation. oFor most people, completing four to five complete sleep cycles (60to90minutes) per night promote a feeling of being rested. oMany forms of hypnotics, sedatives, and barbiturates impair sleep cycles. a. Activity increases the need for sleep and contributes to a feeling of tiredness. b. Stimulants increase metabolism and inhibit relaxation.

Evaluation: During acute respiratory problems, sleep may be difficult because of interruptions and dyspnea. Short-term outcomes such as napping may be accomplishable. Long-term plans for sleep may have to be deferred until dsypnea is controlled.

Ineffective breathing pattern

o

Impaired gas I exchange related to: ventilation perfusion inequality Imbalanced Nutrition: less than body requirements

Bathing / Hygiene Self-care deficit related to: fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency.

related to: shortness of breath, mucus, bronchoconstriction airway irritants.

Ineffective individual coping related to: lack of socialization, anxiety, depression,' low activity levels and an inability to work.

related to: anorexia.

Anxiety related to: threat to selfconcept, threat of death, purposes that are not being met.

Disturbed sleep pattern related to: discomfort, sleeping position.

Deficient Knowledge related to: lack of information, do not know the source of information.

Ineffective individual coping related to: lack of socialization, anxiety, depression,' low activity levels and an inability to work.

1.

Advice the elimination of smoking and other external irritants, such as dust. Supervise the clients respiratory exercise, such as pursed lips. Teach the proper use of a nebulizer and other special equipments. Carefully observe for symptoms of CO2 intoxication (CO2 narcosis) if O2 is being administer. Teach the client to adjust his/her activities, to avoid exertion. Teach the client to avoid people with respiratory infections. Teach the client to avoid the use sedatives of hypnotics, which could compromise his/her respirations. Teach the client to maintain the highest resistance possible by getting adequate rest, eating nutrious. over

2. 3.

4.

5.

6. 7.

8.

9.

Provide nursing care for the client with chronic bronchitis or emphysema.

- Administer prescribed medications, which may include antibiotics, broncodilators, mucolytic agents and corticosteroids. -Antibiotics should be administered at the first sign of infection, such as change in sputum. Opioids, sedatives and tranquilizers, which can further depress respirations, should be avoided. - Clear airways with postural drainage, percussion or vibrating and suctioning as appropriate. - Promote infection control. Encourage the client to obtain influenza and pneumonia vaccines at prescribed times. - Improve breathing patterns. Demonstrate and encourage diaphragmatic and purse lip breathing. Have the client take a deep breath and blow out against closed lips. - Administer oxygen. A low arterial oxygen level is the clients primary drive for breathing. Oxygen flow rate should be no more than 2 to 3 L per minute. Higher levels will cause the client to quit breathing. -Discuss the importance of smoking cessation and avoiding secondhand smoke. Discuss ways to quit smoking and make appropriate referrals. Compromise is not acceptable; the client must stop smoking.

10.PROVIDE NURSING CARE FOR THE CLIENT WITH ASTHMA. - ADMINISTER PRESCRIBED MEDICATIONS, WHICH MAY INCLUDE ADRENERGICS, BRONCHODILATORS AND CORTICOSTEROIDS FOR ACUTE ATTACK. ENCOURAGE USE OF A CROMOLYN INHALER AS PROPHYLACTIC TREATMENT. -PROVIDE TREATMENT DURING AN ACUTE ASTHMATIC ATTACK. STAY WITH THE CLIENT AND KEEP HIM CALM AND IN AN UPRIGHT POSITION. DO PURSE-LIP BREATHING WITH THE CLIENT; ENCOURAGE RELAXATION TECHNIQUES. -IMPLEMENT MEASURES TO PREVENT ASTHMATIC ATTACKS. TEACH THE CLIENT WITH THE FOLLOWING SKILLS: (1) IDENTIFY AND ELIMINATE OR MINIMIZE EXPOSURE TO PULMONARY IRRITANTS. (2) REMOVE RUGS AND CURTAINS FROM THE HOME, CHANGE AIR FILTERS FREQUENTLY, KEEP THE HOME AS DUST FREE AS POSSIBLE, AND KEEP WINDOWS CLOSED DURING WINDY AND HIGH POLLEN DAYS. -USE AN INHALER AND TAKE MEDICATIONS AS PRESCRIBED, AND NOTIFY THE HEALTH CARE PROVIDER WHEN NOT GAINING COMPLETE RELIEF. -NOTIFY THE HEALTH CARE PROVIDER WHEN A RESPIRATORY INFECTION OCCURS. -OBTAIN INFLUENZA AND PNEUMONIA VACCINES AT PRESCRIBED TIMES.

BRONCHODILATORS
Bronchodilators

are medications that relax the muscles of the airways to help keep them open and make it easier to breathe. Anticholinergics, a type of bronchodilator, are often used by people with COPD. Shortacting bronchodilators last about four to six hours and are used on an as-needed basis. Longer-acting bronchodilators can be used every day for people with more persistent symptoms. People with COPD may use both types of bronchodilators.

ALBUTEROL OTHERS),

(PROAIR

HFA,

LEVALBUTEROL

IPRATROPIUM

VENTOLIN HFA, (XOPENEX), AND (ATROVENT).

BRONCHODILATORS

*THE
INCLUDE

LONG-ACTING

TIOTROPIUM

(SPIRIVA),

SALMETEROL

(SEREVENT), PERFOROMIST),
INDACATEROL

FORMOTEROL ARFORMOTEROL

(FORADIL, (BROVANA),
ACLIDINIUM

(ARCAPTA)

AND

(TUDORZA).
Depending on the severity of your disease, you may need a short-acting bronchodilator before activities, a long-acting bronchodilator that you use every day, or both.

CORTICOSTEROIDS

If bronchodilators don't provide enough relief, people with COPD may take corticosteroids. These are usually taken by inhaler. They may reduce inflammation in the airways. Steroids may also be given by pill or injection to treat flare-ups of COPD.

INHALED STEROIDS. INHALED CORTICOSTEROID MEDICATIONS CAN REDUCE AIRWAY INFLAMMATION AND HELP PREVENT EXACERBATIONS. SIDE EFFECTS MAY INCLUDE: BRUISING, ORAL INFECTIONS AND HOARSENESS. THESE MEDICATIONS ARE USEFUL FOR PEOPLE WITH FREQUENT EXACERBATIONS OF COPD. FLUTICASONE (FLOVENT) AND BUDESONIDE (PULMICORT) ARE EXAMPLES OF INHALED STEROIDS.

COMBINATION INHALERS. SOME MEDICATIONS COMBINE

BRONCHODILATORS AND INHALED STEROIDS.

SALMETEROL AND FLUTICASONE (ADVAIR) AND FORMOTEROL AND BUDESONIDE (SYMBICORT) ARE EXAMPLES OF COMBINATION INHALERS.

ORAL STEROIDS.

FOR PEOPLE WHO HAVE A MODERATE OR SEVERE ACUTE EXACERBATION, ORAL STEROIDS PREVENT FURTHER WORSENING OF COPD. HOWEVER, THESE MEDICATIONS CAN HAVE SERIOUS SIDE EFFECTS, SUCH AS WEIGHT GAIN, DIABETES, OSTEOPOROSIS, CATARACTS AND AN INCREASED RISK OF INFECTION.

ANTIBIOTICS
People with COPD are at greater risk for lung infections than healthy people. If your cough and shortness of breath get worse or you develop fever, talk to your doctor. These are signs that a lung infection may be taking hold, and your doctor may prescribe medications to help knock it out as quickly as possible. You may also need adjustments to your COPD regimen.

ANTIBIOTICS. RESPIRATORY INFECTIONS, SUCH AS ACUTE BRONCHITIS, PNEUMONIA AND INFLUENZA, CAN AGGRAVATE COPD SYMPTOMS. ANTIBIOTICS HELP FIGHT ACUTE EXACERBATIONS. THE
ANTIBIOTIC AZITHROMYCIN PREVENTS EXACERBATIONS, BUT IT ISN'T CLEAR WHETHER THIS IS DUE TO ITS ANTIBIOTIC EFFECT OR ITS ANTI-INFLAMMATORY PROPERTIES.

SURGERY
A

small number of people with COPD may benefit from surgery. Bullectomy and lung volume reduction surgery remove the diseased parts of the lung, allowing the healthy tissue to perform better and making breathing easier.
A

lung transplant may help some people with the most severe COPD who have lung failure, but it can have serious complications, such as organ rejection and the need for lifelong immunesuppressing medications.

EXERCISE
Walking is one of the best things you can do if you have COPD. Start with just five or 10 minutes at a time, three to five days a week. If you can walk without stopping to rest, add another minute or two. Even if you have severe COPD, you may be able to reach 30 minutes of walking at a time. Use your oxygen while exercising if you are on oxygen therapy. Discuss your exercise plans with your doctor.

HOW QUITTING SMOKING HELPS

SMOKERS WITH COPD WILL LOSE LUNG FUNCTION MORE QUICKLY. TOBACCO SMOKE DESTROYS THE TINY HAIR-LIKE CILIA THAT NORMALLY REPAIR AND CLEAN THE AIRWAYS -- AND HARMS THE LUNGS IN OTHER WAYS, TOO. QUITTING WILL SLOW OR STOP THE DAMAGE, AND IS SIMPLY THE MOST IMPORTANT STEP YOU CAN TAKE FOR COPD. YOU'LL ALSO GET THE OTHER BENEFITS OF QUITTING: FOODS TASTE BETTER,
AND YOUR BLOOD PRESSURE AND HEART RATE LOWER TO HEALTHIER LEVELS.

DIET A HEALTHY DIET IS IMPORTANT FOR PEOPLE WITH COPD. BEING OVERWEIGHT CAN MAKE IT HARDER TO BREATHE, AND BEING UNDERWEIGHT CAN MAKE YOU WEAK. TALK TO
YOUR DOCTOR ABOUT THE BEST EATING PLAN FOR YOU. COMMON GUIDELINES INCLUDE: DRINK 6-8 GLASSES OF WATER OR NONCAFFEINATED BEVERAGES DAILY. EAT HIGH-FIBER FOODS SUCH AS WHOLE GRAIN BREAD, BRAN, AND FRESH FRUIT.

DISCHARGE

PLANNING

Spirometer should be measured in all patients before discharge. Patients should be re-established on their optimal maintenance bronchodilator therapy before discharge. Patients who have had an episode of respiratory failure should have satisfactory oximetry or arterial blood gas results before discharge. All aspects of the routine care that patients receive(including appropriateness and risk of side effects) should be assessed before discharge. Patients (or home carers) should be given appropriate information to enable them to fully understand the correct use of medications, including oxygen, before discharge. Arrangements for follow-up and home care (such as visiting nurse, oxygen delivery, referral for other support) should be made before discharge. Before the patient is discharged, the patient, family and physician should be confident that he or she can manage successfully. When there is remaining doubt a formal activities of daily living assessment may be helpful.