Learning Objectives
By the end of this section, you will be able to:
- Discuss the pathophysiology, risk factors, and clinical manifestations for chronic obstructive pulmonary disease
- Describe the diagnostics and laboratory values in the disease of chronic obstructive pulmonary disease
- Apply nursing concepts and plan associated nursing care for the patient with chronic obstructive pulmonary disease
- Evaluate the efficacy of nursing care for the patient with chronic obstructive pulmonary disease
- Describe the medical therapies that apply to the care of chronic obstructive pulmonary disease
One widely prevalent obstructive respiratory disease is chronic obstructive pulmonary disease (COPD). Thirteen percent of American adults (age forty to seventy-nine) have COPD. Most cases are linked to cigarette smoking, though COPD can occur in people who have never smoked. Some studies suggest that exposure to secondhand smoke increases the risk of COPD. It can cause chronic illness, hospitalization, and death. Annually, the United States sees 120,000–140,000 deaths attributable to COPD. COPD is more common in Black Americans than in other groups. There is a slightly higher prevalence of cases in males compared with females (Avital & Oji, 2021).
Pathophysiology
COPD is a chronic condition characterized by inflammation of the airways, blood vessels, and lung tissues that obstruct gas exchange. Most commonly, an irritant (e.g., smoking) causes dangerous levels of inflammation. This results in changes to the airways, including narrowing, smooth muscle hypertrophy, and increased mucous production. Over time, scar tissue can form and cause further narrowing of the airways. When alveolar walls become damaged and lose elasticity, resulting in problems with exhalation and CO2 trapping, emphysema occurs (Figure 11.19).
In rare cases, alpha-1 antitrypsin deficiency causes COPD. This genetic disorder results in misfolded, mutated proteins that build up in the liver. A lack of alpha-1 antitrypsin means that the body is unable to neutralize an enzyme that, when unchecked, can overwork and increase the risk of lung damage. Unlike smoking-related COPD, COPD caused by alpha-1 antitrypsin deficiency typically only affects the lower lobes of the lungs (Agarwal et al., 2023).
Risk Factors
Cigarette smoking is the most significant risk factor for COPD. Typically, a smoking history of more than ten to fifteen pack-years is seen with COPD. Occupational or environmental exposures to dust and fumes account for the approximately 20 percent of COPD patients who are nonsmokers (Han et al., 2023). Secondhand smoke and alpha-1 antitrypsin deficiency are additional risk factors for developing COPD (Agarwal et al., 2023).
Clinical Manifestations
COPD generally presents in adults, with the initial onset of problematic symptoms occurring more often during winter months due to irritation from cold air. Patients will report a cough, progressive shortness of breath, and mucous production.
Physical assessment may reveal wheezing. Patients with COPD may demonstrate a prolonged expiratory phase. Because exhalation becomes difficult in COPD, air becomes trapped in the lungs. The anterior-posterior chest wall diameter can increase and become barrel shaped from the chronic air trapping. Because of the increased effort required to breathe, patients with chronic COPD can develop muscle wasting and cachexia, a disorder that causes loss of muscle and adipose tissue (Figure 11.20). Clubbing of the fingers can occur due to chronic hypoxia. In severe cases and during acute exacerbations, patients may experience noticeable respiratory distress. Manifestations can include accessory muscle usage, pursed lip breathing, and cyanosis. In advanced cases, right-sided heart failure can occur, causing lower extremity edema (Agarwal et al., 2023).
Assessment and Diagnostics
COPD is assessed during initial diagnosis, ongoing treatment, and during acute exacerbations. Precise testing can provide important information about lung function. Other than diagnostic findings, the nurse might notice clues, such as tripod positioning, pursed lip breathing, and lower oxygenation saturation with exacerbation.
COPD is diagnosed and staged with pulmonary function tests using spirometry. Lung function may be evaluated before and after administration of an inhaled bronchodilator. The maximum exhaled volume in one second (forced expiratory volume [FEV1]) is compared with the overall maximum volume that can be exhaled (forced vital capacity [FVC]). If the ratio of forced expiratory volume in one second to forced vital capacity (FEV1/FVC) is under 0.7, or 70 percent of predicted, COPD is present. After a diagnosis of COPD is confirmed, severity is identified using the Global Initiative for Chronic Obstructive Lung Disease (GOLD) classification system, which is the gold standard for diagnosis. This compares the patient’s actual FEV1 to the expected FEV1. A higher FEV1 indicates that the disease is mild, and the patient is closer to normal lung function. A lower FEV1 indicates diminished lung function and increased disease severity.
- GOLD 1: mild disease; the FEV1 is >/= 80 percent of the predicted value.
- GOLD 2: moderate disease; the FEV1 is 50–79 percent of the predicted value.
- GOLD 3: severe disease; the FEV1 is 30–49 percent of the predicted value.
- GOLD 4: very severe disease; the FEV1 is < 30 percent of the predicted value.
Laboratory testing may be performed. A complete blood test is used to evaluate anemia, infection, and polycythemia. If alpha-1 antitrypsin deficiency is suspected, these levels can be evaluated with a blood test. Diagnostic imaging, such as chest x-rays and computed tomography (CT scans), may be used to evaluate disease progression and acute infections.
An acute exacerbation usually presents with increased dyspnea, increased sputum volume, and purulent sputum. In a mild exacerbation, at least one of those assessment findings will be present, plus one of the following additional symptoms:
- increased wheezing
- increased cough
- fever without another cause
- recent upper respiratory infection (within five days)
- increased heart rate compared with baseline
- increased respiratory rate compared with baseline
Moderate and severe exacerbations will have two or three of the following: worsening shortness of breath, increased volume of sputum, and/or purulence.
When a low oxygen level is present or suspected, pulse oximetry and arterial blood gas analysis can provide helpful information that can guide therapy, including oxygen administration. Arterial blood gas analysis can also be used to assess elevated levels of carbon dioxide (> 45 mmHg) (Agarwal et al., 2023). Patients with mild or moderate COPD will often have arterial blood gas results that demonstrate mildly low oxygen levels without elevated CO2 levels. Over time, as COPD becomes more severe, oxygen levels drop, and elevated CO2 can occur. Respiratory acidosis is the most common blood gas abnormality in COPD. Adequate CO2 clearance is not possible due to lung damage. CO2 levels rise, decreasing the pH to an acidotic level (Han et al., 2023).
Nursing Care of the Patient with COPD
Nursing care of the patient with COPD takes place during initial diagnosis or ongoing treatment. When interviewing a patient, careful listening can provide important clues about respiratory and functional status.
Interdisciplinary Plan of Care
Interdisciplinary Plan of Care for a Patient with COPD
The interdisciplinary plan of care includes a variety of health-care professionals who work together to coordinate care for a patient with COPD. Their goal is to provide continued care, management, and preventative measures to reduce readmission to the hospital for acute episodes of exacerbation. The interdisciplinary team includes the following:
- Diagnostic imaging team to perform CXRs, and blood sampling collection
- Pharmacists to manage medications and verify compatibility
- Nutritionists to provide disease specific meal plans and supplements
- Social workers to collaborate post-discharge resources and referrals
- Therapists, including occupational, physical, recreational, and speech language
- Providers: pulmonologist/primary care to oversee the patient’s plan of care
- COPD educators to provide best practices to prevent acute episodes and improve quality of life at home
- Cardiopulmonary team to perform cardiopulmonary rehab in an outpatient setting
- Home care providers to arrange services in the home post discharge
Recognizing Cues and Analyzing Cues
The nurse caring for a patient with COPD integrates objective data with the patient’s subjective observations. The patient may report subjective symptoms, including a cough, worsening shortness of breath, and mucous production. Additionally, many patients will have a history of smoking or exposure to environmental irritants. Inquire about the frequency and duration of exposure to cigarette smoke and other irritants. Because preventable respiratory illnesses can cause serious infections in patients with COPD, ask patients about their immunization status.
Objectively, vital signs are evaluated with a focus on respiratory rate and oxygen saturation. Lung auscultation may reveal wheezing. Patients with COPD may demonstrate a prolonged expiratory phase. Physical assessment can also reveal a barrel-shaped chest, with increased anterior-posterior diameter. In patients with long-standing disease, muscle wasting, cachexia, and digital clubbing may be present. Physiological causation of clubbing is not entirely understood (Burcovschii & Aboeed, 2022). When evaluating for a COPD exacerbation, the nurse observes one or more of the key assessment findings to diagnose COPD.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
In patients with COPD, signs of inadequate oxygenation and respiratory distress are a high priority. The nurse may assist with spirometry testing and review results with the patient, and administer medications, such as bronchodilators and glucocorticoids. Educational topics include smoking cessation, infection prevention, vaccination, and how to use inhaled medications. Because steroid inhalers can increase the risk of oral candida infections, rinsing the mouth after use is an important teaching point. Educate also on the correct usage of spacers to decrease infection. Dyspnea can limit a patient’s activity tolerance, meaning energy conservation strategies (e.g., activity pacing) can be helpful. In patients who struggle with activities of daily living due to dyspnea, nutritional coaching and interventions can be helpful. High-calorie foods can be a good choice when dyspnea makes eating challenging. When chronic oxygen therapy is utilized, patient teaching also addresses oxygen safety.
In acute exacerbations, nursing interventions may include monitoring oxygen saturation and applying supplemental oxygen. The nurse collaborates with respiratory therapy and the provider to identify SpO2 targets and optimize oxygenation. Because of the risk of CO2 retention, the nurse should assess for signs of elevated CO2 levels thirty to sixty minutes after oxygen therapy is initiated (Han et al., 2023). Pulmonary rehabilitation may be indicated. In pulmonary rehabilitation, a supervised coaching program helps people with chronic lung disease optimize their respiratory status through various breathing techniques and exercises. Pulmonary rehabilitation assists patients to increase exercise with less symptom burden (Terry & Dhand, 2023).
Evaluation of Nursing Care for the Patient with COPD
Nursing care for patients with COPD involves assessing both respiratory and functional status. As disease progresses, and during acute exacerbations, pulmonary status can worsen and difficulties with ADLs can occur. The most important outcomes related to COPD focus on symptom management, oxygen level, activity tolerance, and prevention of exacerbations. The nurse evaluates symptom severity and how it affects the patient’s ability to perform activities of daily living. Spirometry testing is used to identify changes in lung function. In acute exacerbations, signs of infection, oxygen saturation, and oxygen requirement are monitored.
Medical Therapies and Related Care
COPD treatment focuses on controlling current symptoms and decreasing the risk of exacerbations. The interprofessional team includes nurses as well as respiratory therapists, providers, physical therapists, occupational therapists, dietitians, and pharmacists. Pulmonary rehabilitation therapy can help patients improve endurance and activity tolerance.
Many of the strategies used to treat COPD are like those used to treat asthma. Smoking cessation is a cornerstone of treatment. Infection prevention, including influenza and pneumococcal vaccines, can provide important prevention against serious illness. Several types of bronchodilators are used in treatment and maintenance. Beta-2 agonists work by dilating the smooth muscles in the airway; they can be short-acting or long-acting. Short-acting beta-2 agonists are used for acute treatment, while long-acting beta-2 agonists are used for long-term therapy. Antimuscarinics keep airways open by preventing bronchoconstriction. Like beta-2 agonists, antimuscarinic agents can be short-acting or long-acting. Methylxanthines are a long-acting therapy; they cause bronchodilation by relaxing smooth muscle. Some studies support the use of prophylactic azithromycin to decrease the number of exacerbations in COPD patients (Agarwal et al., 2023).
Inhaled corticosteroids are commonly used to decrease airway swelling and are used as long-term therapy. Phosphodiesterase-4 inhibitors, such as Roflumilast, reduce inflammation and are used in patients with severe disease. In some patients, long-term use of azithromycin can decrease the likelihood of exacerbations. Despite medication and pulmonary rehabilitation, most patients with COPD will eventually have low oxygen levels, even at rest. Chronic oxygen therapy is a common treatment that can improve symptoms and lengthen survival. Surgery is sometimes used to treat severe cases. Surgical options include removal of damaged lung areas, surgery to decrease overall lung volume, and lung transplantation.
Acute exacerbations of COPD can require additional therapy. Oral and parenteral glucocorticoids are utilized for short-term treatment of acute exacerbations. Antibiotics may be necessary if there is a confirmed or suspected bacterial infection. The GOLD strategy supports starting antibiotics empirically when sputum is increasing in purulence or volume, dyspnea is increasing, or ventilatory support is needed (Terry & Dhand, 2023). Supplemental oxygen, up to and including ventilator support, may be necessary (Agarwal et al., 2023). Pulmonary rehabilitation can be a valuable intervention to improve quality of life.