Category: Nursing Skills

Chronic Obstructive Pulmonary Disease (COPD) is an irreversible, preventable and controllable disease that presents as chronic dyspnoea due to airflow restriction. Whilst signs and symptoms of COPD can be managed and/or treated, COPD disease progression cannot be fully reversed. COPD nursing management and care play an important role in managing COPD exacerbations and patient education to avoid further worsening of the disease.

COPD can present as Chronic Bronchitis or Emphysema. Some COPD patients may have overlapping signs and symptoms of both.

Chronic Bronchitis Signs & Symptoms:

• Cough and Sputum Production – Chronic Bronchitis diagnosis requires the patient to experience persistent cough and sputum production for at least 3 months in at least 2 consecutive years. This happens due to irritation in the airway caused by pollutants or allergens that lead to an increase in sputum production by mucus-secreting glands and goblet cells. Mucus affects the mucociliary escalator, making it harder to expel sputum. Retained mucus gives way to an increased risk for viral, bacterial and fungal infections that trigger acute bronchitis.
• Overweight – gets tired easily so tends to avoid exercising.
• Cyanotic – due to the condition, not enough oxygen is produced within the lungs, leading to less oxygen perfusion throughout the body…this is why individuals with Chronic Bronchitis are usually referred to as Blue Bloaters.
• Elevated Haemoglobin – patients with Chronic Bronchitis are usually hypoxic. To compensate for the lack of oxygen, the body increases the production of erythropoietin, which in turn causes an increase in red blood cell production.
• Peripheral Oedema – caused by pulmonary hypertension where there is an increase in blood pressure within the arteries of the lungs.
• Rhonchi and Wheezing – the airway is compromised due to bronchoconstriction and increased mucus production.

Emphysema Signs & Symptoms:

• Usually Older and Thin – in patients with Emphysema, lungs become hyperinflated, pressing on the stomach. This reduces appetite, leading to weightloss. Individuals with Emphysema are commonly referred to as Pink Puffers.
• Severe Dyspnoea – increased respiratory rate. Increased dead space = air not contributing to gas exchange = less oxygen perfusion = hypoxia = hypoventilation.
• Quiet Chest – alveoli are damaged; less air reaches the alveoli for gas exchange.
• X-Ray shows Hyperinflation with a Flattened Diaphragm – anatomical damage as in abnormal distention of airspaces (bronchioles, alveoli and alveoli ducts) and destruction of the alveoli walls, and thus, an increase in the dead space (air not contributing to gas exchange), is visible in an x-ray.

There are 2 main types of Emphysema:

Panlobular: destruction of bronchiole, alveolar duct and alveolus.

Centrilobular: destruction mainly in the centre of the alveolar sac.

Pathophysiology of COPD

1. Increase in number of goblet cells and mucus secreting glands leading to hypersecretion of mucus and mucus plug which affects the mucociliary escalator;
2. Inflammation causes mucosal oedema and exudate to flow into the airway, narrowing the airway in the process;
3. Scar Formation is caused, leading to permanent airway lumen narrowing (hence why it’s called Chronic Bronchitis);
4. Alveolar wall destruction leads to a decrease in alveolar surface area in direct contact with pulmonary capillaries. Furthermore, there is also a decrease in elastic recoil and damage to connective tissue which supports the alveoli;
5. Alveoli remain inflated due to decrease in elastic recoil, causing alveolar hyperinflation;
6. Inflammation affects the pulmonary capillaries, causing vessel lining thickening, thus, narrowing of capillaries, leading to pulmonary hypertension;
7. High blood pressure in the pulmonary capillaries affects systemic blood circulation, leading to pulmonary oedema and less gas exchange between the alveoli and the pulmonary capillaries.

COPD Risk Factors

• Smoking – this is the primary risk factor for COPD. Smoking reduces white blood cells activity, affects the mucociliary escalator, irritates goblet cells and mucus secreting glands leading to an increase in mucus production. With the mucociliary escalator affected, it becomes hard for the patient to excrete or cough out sputum, thus increasing the risk of infection.
• Occupational Exposure – occupational dust, chemicals and air pollution increase the risk of developing COPD.
• Alpha 1 Antitrypsin Deficiency – a genetic abnormality where alpha 1 antitrypsin, an enzyme which helps in protecting the lung parenchyma from injury, is inhibited.

Clinical Manifestation of COPD

• Chronic Cough
• Sputum Production (white sputum is normal in COPD, but yellowish/greenish sputum indicates an infection)
• Dyspnoea on exertion (persistent and progressive dyspnoea)
• Dyspnoea at rest (in worsening COPD)
• Weight Loss (due to hyperinflation of the lungs)
• Use of Accessory Muscles (due to dyspnoea)
• Barrel Chest

COPD Complications

• Respiratory Failure: COPD progression > dyspnoea > tired respiratory muscles > respiratory failure.
• Pneumonia: excessive and stagnant mucus serves as a medium to pathogens, leading to infection.
• Chronic Atelectasis: partial or complete lung collapse caused by blockage or pressure build up within the lungs’ bronchial tubes.
• Pneumothorax: lung collapse due to air accumulating in the pleural cavity.
• Pulmonary Arterial Hypertension: resulting from hypertrophy of smooth muscle.

COPD Nursing Management – Assessment

• Health History – eg. smoking or potential exposure to irritants
• Pulmonary Function – help in the diagnosis of COPD as well as its progression and/or monitoring
• PEFR – helps in assessing severity of airflow obstruction
• ABGs – arterial blood gas measurement helps by providing a baseline reading of PaO2 (Partial Pressure of Oxygen) and PaCO2 (Partial Pressure of Carbon Dioxide)
• Chest X-ray – helps in excluding other possible diagnosis, and helps determine hyperinflation of lungs and diaphragm as well as decreased bullae
• CT Scan – helps in excluding other possible diagnosis such as lung cancer
• Alpha 1 Antitrypsin Deficiency Screening – ideally performed for patients with a family history of COPD
• Sputum Culture – helps investigate for the possibility of infection
• Peripheral Blood Culture – in the case of fever, this can determine presence of bacteria in the blood i.e. septicaemia

COPD Nursing Management – Therapy

COPD cannot be reversed but its symptoms can be controlled. COPD therapy is provided to relieve its symptoms.

• Bronchodilators – short and long-acting beta adrenergic agonists can help relieve bronchospasms and decrease airway obstruction
• Corticosteroids – help decrease COPD symptoms by reducing inflammation and reducing mucus production eg. Beclomethasone (inhaled) or Prednisolone (oral corticosteroids)
• Oxygen Therapy – Oxygen saturation in COPD patients should be somewhere between 88%-92%. Oxygen in COPD patients is frequently administered through the use of nasal cannula or a venturi mask. Too much Oxygen in a COPD patient leads to the retention of CO2, since gas exchange is compromised due to narrowing of the airway and the destruction of the alveoli as well as lack of elastic recoil
• Alpha 1 Antitrypsin Augmentation Therapy – increases lung parenchyma protection
• Antibiotics – fight infection
• Mucolytic Agents – reduce mucus production
• Antitussive Agents – relieve cough
• Vasodilators – help reduce pulmonary hypertension
• Narcotics – act as analgesia for muscular pain due to ongoing cough and excessive accessory muscle use for breathing
• Heparin or Anti-Coagulants – if patient is bed-bound or too lethargic to move, this could help reduce the risk of pulmonary embolism and thrombosis
• Yearly Influenza Vaccine – reduces the risk of developing chronic bronchitis

COPD Exacerbation

COPD exacerbation is marked by an acute change in the individual’s baseline dyspnoea, cough or sputum production. An increase in one of these signals COPD exacerbation. It is usually triggered by infection and/or air pollution.

COPD exacerbation can be controlled by the use of Bronchodilators, Corticosteroids, Antibiotics (in the case of infection) and Oxygen therapy (to increase oxygen saturation).

If a patient doesn’t respond to initial treatment for severe dyspnoea, and exhibits additional confusion, lethargy, respiratory muscle fatigue (signals pending respiratory failure), paradoxical chest wall movement(pneumothorax) and peripheral oedema (pulmonary hypertension), hospitalisation is indicated.

In some cases, surgical management for COPD may also be indicated, namely Bullectomy (where bullae are removed), Lung Volume Reduction Surgery (where part of the affected lung is removed) or Lung Transplant (where the lung of a donor is surgically attached instead of the affected lung).

COPD Nursing Management To Promote Airway Clearance

• Bronchodilators
• Corticosteroids (oral Corticosteroids may lead to hyperglycaemia, thus the nurse should monitor for condition)
• Increase fluid intake (help in replacing fluid loss through sweating and exertion from breathing with accessory muscle use)
• Coughing Exercises (loosen and carry mucus through the airways without causing them to narrow and collapse without too much energy)
• Chest Physiotherapy (helps in removing/excreting secretions)
• Nebulised Saline (administered through the use of a nebuliser mask; helps loosen up mucus, thus enabling secretion excretion)
• Patient Education (teaching Pursed Lip Breathing, Diaphragmatic Breathing, use of walking aids to decrease physical exertion and paced exercise training throughout the day to reduce excess weight and increase breathing capacity)

COPD Nursing Management and Monitoring for Complications

• Cognitive Changes – may indicate severe hypoxia which leads to respiratory failure
• Increased Dyspnoea, Tachypnoea and Tachycardia – indicates worsening of COPD condition
• Pulse Oxymetry – monitoring patient Oxygen saturation, aiming for a value between 88-92% for COPD patients
• Infection
• Paradoxical Chest Wall Movement – to assess for pneumothorax
• Breathing Sounds – difference in auscultated sounds between both lungs may also indicate pneumothorax

Further COPD Patient Education

• Use long term inhaler treatment as prescribed
• Maintain normal temperature: temperature increase leads to an increase in oxygen requirement, while temperature decrease causes vasoconstriction which may lead to hypoxia
• Moderate activity level: helps avoid excessive coughing episodes
• Stress avoidance: promotes wellbeing
• Breathing exercises: facilitates gas exchange
• Smoking cessation: helps avoid worsening of COPD or COPD exacerbation
• Yearly influenza vaccine: helps reduce the risk of infection
• Eat healthily: to increase energy (excessive carbohydrate intake leads to an increase in carbon dioxide production, which leads to the patient feeling full even though he/she is still hungry); teach patient to eat small portions, and if not eating, encourage family members to bring in homemade meals
• Addressing the psychosocial aspect of the patient: appetite, emotional aspect, stress control, social aspect and finances (due to possible loss of work or reduced working ability)

Below you can find a collection of videos that can help provide a more visual approach to Chronic Obstructive Pulmonary Disease COPD Nursing Care.

COPD – Understanding Chronic Obstructive Pulmonary Disease: Animation

https://www.youtube.com/watch?v=2nBPqSiLg5E

Understanding COPD – Animation

COPD Animation

COPD Nursing Management – Diagnosis and Evaluation

COPD Nursing Management and Treatment

Special thanks to the creators of the featured videos on this post, specifically Youtube Channels Nucleus Medical Media, Animated COPD Patient and Alila Medical Media.

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