COPD & asthma.ppt
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COPD is a chronic lung disease characterized by airflow obstruction. It includes emphysema and chronic bronchitis. Cigarette smoking is the leading cause of COPD. Symptoms include dyspnea, cough, sputum production, and wheezing. Diagnosis is confirmed by pulmonary function tests showing reduced FEV1 and FEV1/FVC ratio. Treatment involves smoking cessation, bronchodilators, corticosteroids, oxygen therapy, pulmonary rehabilitation, and surgery for severe cases.
COPD & asthma.ppt
- 1. COPD
- 2. Definition A disease state characterized by the presence of airflow obstruction due to chronic bronchitis or emphysema; the airflow obstruction is generally progressive, may be accompanied by airflow hyperactivity, and may be viewed as partially reversible. Includes emphysema and chronic bronchitis
- 3. Definition COPD is an umbrella term used to describe chronic lung diseases in which air flow is obstructed by emphysema, chronic bronchitis, refractory (irreversible) asthma, and severe bronchiectasis.
- 4. Prevalence COPD occurs in 4-6% of white males, and 1-3% of adult white females The 4th most common cause of death in the United States 14.2 million people in U.S. have COPD Highest mortality rate is in white men, and the lowest is in hispanic women.
- 5. Types of COPD Emphysema Permanent and destructive enlargement of airspaces distal to the terminal bronchioles without obvious fibrosis and with loss of normal architecture Always involves clinically significant airflow limitation. “pink puffer” Chronic Bronchitis Presence of a cough productive of sputum not attributable to other causes on most days for at least 3 months over 2 consecutive years May be present in the absence of airflow limitation. “blue bloater”
- 6. COPD
- 8. Pathogenesis of COPD Increased number of activated polymorphonuclear cells and macrophages produce elastases (such as human leukocyte elastase), resulting in lung destruction. Increased oxidative stress caused by free radicals in cigarette smoke, the oxidants released by phagocytes, and polymorphonuclear leukocytes all may lead to apoptosis or necrosis of exposed cells
- 9. Pathogenesis of COPD (cont.) Emphysema 3 morphologic patterns: Centricacinar: focal destruction limited to the respiratory bronchioles and the central portions of acinus associated with cigarette smoking most severe in the upper lobes Panacinar: involves the entire alveolus distal to the terminal bronchiole develops in patients with homozygous alpha1-antitrypsin (AAT) deficiency most severe in the lower lung zones Distal acinar: Also called paraseptal least common form involves distal airway structures, alveolar ducts, and sacs localized to fibrous septa or to the pleura and leads to formation of bullae (can result in pneumothorax) Chronic Bronchitis Mucus gland enlargement Airway atrophy, focal squamous metaplasia, ciliary abnormalities, variable amounts of airway smooth muscle hyperplasia, inflammation, and bronchial wall thickening Respiratory bronchioles display a mononuclear inflammatory process, lumen occlusion by mucous plugging, goblet cell metaplasia, smooth muscle hyperplasia, and distortion due to fibrosis Airway walls to deform and narrow the airway lumen
- 10. Risk Factors SMOKING! 48 million smokers in the U.S. 3000 new people take up smoking daily Nearly all patients with symptomatic COPD are current or former smokers 10-20% of smokers will develop symptomatic COPD. In men who smoke one pack/day, the drop in FEV1 per year was 9 mL more than in non-smokers Occupational Exposures Dusts, gases, fumes Alpha1-antitrypsin deficiency Alpha1-antitrypsin is an important protease inhibitor that usually presents elastases from causing lung destruction
- 11. Risk Factors Occupations exposure Air pollution Genetic abnormality Deficiency Alpha-antitripsin Family history Passive smoking Cigarette smoking Risk factors
- 12. Pathophysiology Due to causes & risk factors of the COPD Affect ciliary cleaning mechanism of respiratory tract Airflow is obstructed & air becomes trapped behind the obstruction Alveoli greatly distend & lung capacity decreased Increased accumulation of the mucus from mucus glands Produce more irritation, infection Damage to lung
- 13. Stages of COPD Stage FEV1/FV C Ratio FEV1 % Clinical Findings At Risk >0.7 Patients who smoke, patients exposed to high pollutants, and patients with recurrent respiratory symptoms/infections. Give influenza and pneumonia vaccines. Mild < 0.7 >80 Add short-acting bronchodilator as needed Moderate <0.7 50-80 Add regular treatment with one or more long-acting bronchodilator and add Pulmonary rehabilitation Severe <0.7 30-50 Add inhaled corticosteroids if repeated exacerbations Very Severe < 0.7 <30 Add long-term oxygen if chronic respiratory failure; Consider surgical treatments
- 14. Symptoms Dyspnea Cough (usually worse in morning, sputum production) Wheezing Cyanosis Right heart failure Weight loss, anorexia Frequent respiratory infections Production of purulent (cloudy and discolored) sputum Enlarged A-P diameter of chest Acute and chronic respiratory failure Weight loss Increased work of breathing Tightness of chest Tachypnea Prolonged expirations Pitting peripheral edema fatigue
- 15. Physical Exam RR, HR, O2 saturation Gen: Barrel-chest, accessory muscle use CV: Quiet heart sounds Resp: Decreased breath sounds, wheezing, rhonchi, crackles
- 16. Labs CBC: Hgb/Hct ABG: pH, pCO2 Chemistry: HCO3
- 17. Diagnostic evaluation Lung function test (PFT): LFT measures how much air person can breath in and out, how fast he/she can breathe air out, and how well lung deliver oxygen to blood. Components of LFT: 1. Spirometry, post bronchodilator spirometry , lung volumes and diffusion capacity CXR/ CTSCAN: These tests create pictures of the structures inside the chest, such as heart, lungs and blood vessels. The picture can show the signs of COPD ABG PULSE OXIMETRY Alpha 1 antitrypsine level: it can also cause liver diseases in children
- 18. Emphysema
- 19. Diagnosis of COPD Look for secondary polycythemia: Hct >52% in males, Hct>47% in females Measure alpha1-antitrypsin levels in all patients 40 years or younger, or in those with family history. Hyperinflation see on chest x-ray Bullae seen on Chest x-ray or CT scan
- 21. Diagnosis of COPD – Pulmonary Function Tests Forced Expiratory Volume for 1 second (FEV1) FEV1/FVC (Forced Vital Capacity) ratio Total Lung Capacity (TLC) Forced Residual Capacity (FRC) Residual Volume (RV) Vital Capacity (VC)
- 23. COPD Exacerbation Typically manifest as increased sputum production, more purulent sputum and worsening of dyspnea. Although infectious etiologies account for most exacerbations, exposure to allergens, pollutants or inhaled irritants may also play a role. Bacterial infection is a factor in 70 to 75 percent of exacerbations, with up to 60 percent caused by Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis Antibiotic therapy has a small but important effect on clinical recovery and outcome. Respiratory fluoroquinolone (Levofloxacin, Moxifloxacin) Ceftriaxone + azithromycin Short courses of systemic corticosteroids may provide important benefits in patients with exacerbations of COPD. Oxygen therapy to keep saturation Between 90-93% Non-invasive ventilation such as BiPAP can be helpful in avoiding intubation/mechanical ventilation.
- 24. Treatment of COPD SMOKING CESSATION! Short-acting bronchodilators Albuterol, theophylline Long-acting bronchodilator salmeterol Combination of anti-cholinergic and -agonist bronchodilator Ipratropium + albuterol (combivent) Tiotropium (spiriva) Methylxanthines (Theophylline) Has anti-inflammatory affect, and improves respiratory muscle function, stimulates the respiratory center, and promotes bronchodilation Adverse effects include anxiety, tremors, insomnia, nausea, cardiac arrhythmia, and seizures Inhaled corticosteroids Fluticasone (Flovent), budesonide (Pulmicort) Combination of Inhaled corticosteroid and long-acting -agonist Fluticasone + salmeterol (Advair) Oral Corticosteroids
- 25. Medical management Nicotine replacement therapy: Nicotine polacrilex is a chewing gum chewing pieces come in 2 strengths(2mg ,4mg) if person smoke 1 pack per day, he should use 4mg pieces. If person smoke less than 1 pack per day he should use 2mg pieces. He should chew hourly and also chew when needed. The person should reduce the amount chewed over the next 3 months. Mucolytics: it not only reduce sputum but also improve sputum clearance. Ex, guaifenesin, potassium iodide are taken orally , N- acetycysteine is commonly taken through a nebulizer. Antibiotics: in people with COPD, chronic infection of lower airways is common. Ex, amoxicilline, cefaclor or trimethoprim/sulfamethoxazole. II line treatment: ex, azithromycin, clarithromycin, fluoroquinolones Immunization: patient with COPD should discuss influenza, pneumococcal immunization.
- 26. Treatment of A-1 antitrypsin deficiency: replacement of missing or inactive AAT by injection can help prevent progression of associated emphysema. Non pharmacologic therapy: 1. Nebulization Oxygen therapy Removing bronchial secretions Exercises
- 27. Treatment of COPD (cont.) Oxygen Therapy Continous oxygen has been shown to cut mortality in half or decrease morbidity when compared with non-continous oxygen Continuous (24 hours/day) Resting Pa02 of 55 mm HG, or Resting oxygen saturation < 88% Resting Pa02 of 56-59 mmHg or Oxygen Sat. <89% in presence of dependent edema (suggestive of CHF), P pulmonale on ECG (P wave more than 3 mm in inferior leads) or cor pulmonale, or erythrocytosis (Hct > 56) Noncontinuous During exercise – when PaO2 is < 55 mmHg or Oxygen sat. < 88% with low level of exercise. During sleep if Pa02 is < 55 mmHg or Sa02 less than 88% with associated complications such as pulmonary hypertension, daytime somnolence, cardiac arrythmias.
- 28. Treatment of COPD (cont.) Pulmonary Rehabilitation Aimed at keeping patient conditioned with exercise, perception of dyspnea, quality of life and self-efficacy. Surgery Bullectomy Resection of large bullae compressing normal lung Lung volume reduction surgery Pneumonectomy of nonuniform emphysematous lung Double lung transplantation Can be life-saving, but is costly, can be lack of donor availability and requires lifelong immunosuppression.
- 29. Take Home Points Smoking is the number one cause of COPD! If smoking is stopped once COPD diagnosed, the progression of disease can slow down. Treat COPD exacerbations with antibiotics and possibly with steroids. Continuous oxygen is shown to decrease morbidity and mortality in COPD
- 30. COMPLICATIONS Respiratory insufficiency Respiratory failure Pneumonia Atelectasis Pneumothorax Hypoxemia Respiratory acidosis Cardiac failure Status asthmaticus
- 31. Nursing diagnosis Ineffective airway clearance r/t bronchoconstriction, increased mucus production Impaired gas exchange r/t decreased ventilations Ineffective breathing pattern r/t shortness of breath Imbalanced nutrition less than body requirement r/t increased work of breathing, air swallowing Activity intolrence r/t fatigue, inadequate oxygenation & dyspnea Anxiety r/t acute breathing difficulties and fear of suffocation Deficient knowledge r/t regarding condition, treatment, self care and discharged needs lack of information's.
- 32. BRONCHIAL ASTHMA It is a chronic (long term) lung diseases that inflames and narrow the airways. Asthma is reversible, obstractive airway diseases. There is a narrowing of bronchial lumen characterized by wheezing & diffculty in breathing.
- 33. Types of asthma /causes 1. Allergic asthma (extrinsic asthma): triggered by allergens, such as pet dander, house dust, feathers, food , pollen ---------inhalation of specific allergens-------- hyper immune response (type 1 hypersensitivity)------- IgE bind to mast cells in the bronchial mucosa------ -- bronchospasm ----- airway obstruction -- --- mucus secretions
- 34. 2.Non-allergic asthma This type of asthma is triggered by irritants in the air that are not related to allergens. Example- air pollution, cold, heat, weather changes, fumes, wood , cigarette smoke, room deodorants, household cleaning product, perfumes, RTI, change in temp. Stress, physical exertion, drugs- aspirin NSAIDs
- 35. 3. Mixed asthma It has both allergic and non allergic asthma. Cough variant asthma 4. Cough-variant asthma: CVA is a characterized by one symptom, a persistent dry cough 5. Exercise induced asthma: it effects people during or after physical activity.
- 36. 6. Nocturnal asthma: It is characterized by asthma symptoms that worsen at night. However, certain triggers- such as heartburn, pet dander, dust & mites can cause those symptoms to worsen at night while sleeping. 7. Occupational asthma: It is induced by triggers that exist in a person’s workplace. Irritants & allergens include dusts, dyes, gases, fumes, animal proteins, & rubber latex, industries- manufacturing, textiles, farming & woodworking.
- 37. Due to etiological factors Reversible and diffuse airway inflammation Hyper responsiveness of airways Air flow limitation Swelling of membranes that line the airways (mucosal edema) Contraction of the bronchial smooth muscles (bronchospasms ) Bronchial muscles and mucus glands enlarges Production of thick, tenacious sputum Alveoli hyper inflate Wheezing, cough, Dyspnea, chest tightness
- 38. CLINICAL FEATURES Coughing: A persistent cough, the cough may be dry or wet and might worsen, early in the morning Wheezing: wheezing is a whistling noise heard during breathing Chest tightness: this may feel like something is squeezing or sitting on chest. As muscles surrounding the airways constrict, patient may experience a feeling of tightness in the chest. Shortness of breath: shortness of breath id the feeling that a barely finished before another is needed. Mucus production : many people with asthma produce excessive, thick mucus that obstructs the airways, which can lead to coughing.
- 39. Other clinical features Restlessness prolonged expiratory phase Dry, hacking & non-productive Hypoxemia cough widened pulse pressure Fever of 100 degree fatigue Chest & abdominal pain difficulty talking and walking Headache status asthmaticus: Diaphoresis Central cyanosis Nasal flaring Mental confusion ARF Irritable Vomiting
- 40. Diagnostic evaluation Spirometer Peak Expiratory Flow (PEF): it measures the ability to push air out of the lungs or how fast air can be exhaled Pulse oxymetry Methacholine challenge: methacholine will cause mild constriction of airway Nitric oxide test: it measures the amount of a gas called nitrous oxide in breath. If airways are inflamed- a sign of asthma –may have higher than normal nitric oxide level CXR Allergy blood testing ABG CBC Sputum culture Sputum cytology
- 41. Asthma zone -NHLBI Green zone: “ Doing well” Yellow zone: “asthma is getting worse” Red zone: “ medical alert”
- 42. MANAGEMNT A voidance of triggers: The patient is instructed to identify and avoid asthma triggers, the patient can use bronchodilator or mast cell inhibitors MDI Using vinyl matters Maintenance in door humidity Smoking and secondary smoke discouraged
- 43. These drugs should be avoided -Asprin, NSAIDs, Beta blockers- propranolol, metoprolol PHARMACOLOGIC THERAPY: Long term control medications: Inhaled corticosteroid: to relieve airway inflammation and swelling ex: fluticasone, budesonide, mometasone, beclomethsone, Patients may need to use these medications for several days to weeks Leukotriene modifiers: It reduce inflammation, these are 2nd line of defence against astrhma ex; ZILEUTON(Zyflo), Zafirlukast, montelukast(Singulair) Long acting beta agonists(LABA’s): This class of drugs is chemically related to adrenaline. Inhaled LABA’s work to keep breathing passages open for 12h or lonnger. they relax the muscles of breathing passgage. They may also reduce the inflammation
- 44. Ex: LABA’s Salmeterol( serevent), formoterol( Foradil) Methylxanthines: These are the another group of controller medications useful in the treatment of asthma This group of medications is chemically related to caffeine. It works as a long acting bronchodilators ex: Theophylline, aminopahylline Combination inhalers: ex: fluticasone+ salmeterol and Formoterol + Budesonide these medications contain a LABA along with corticosteroid Cromolyn sodium: Cromolyn sodium is prevent the release of chemicals that cause asthma related inflammation. Omalizumab: it belongs to a newer class of agents that works with the bodys immune system. Asthma who have an elevated level of immnogloblines E (IgE) an allergy antibodys the drug is given by injections. This agents inhibits IgE binding to cells that release chemicals, this binding prevents relase of these mediators
- 45. Short acting Beta agonists: It is used for rescue medications, inhaled work rapidly., within a minutes, to open the breathing passages, and effects usually lasts for four hours. Ex: albuterol, levalbuterol, pirbuterol,(Maxair Auto inhaler) ANTICHOLINRGICS: This drugs used for rescue medications during asthma attacks. Inhaled drugs open the airway passage. Ex, Ipratropium bromide(Atrovent) Oral & IV corticosteroids: ex, Prednisone and methylprednisolone Bronchial thermoplasty Breathing techniques Relaxation techniques Acupuncture:
- 46. Self care at home A void trigger Use air conditioner Reduce pet dander Clean regularly Get regular exercises Maintain a health weight Eat fruits and vegetables Do not take cough medicines
- 47. Nursing Diagnosis Impaired gas exchange r/t altered O2 supply, obstruction of airway Ineffective airway clearance r/t bronchospasm Ineffective breathing pattern r/t bronchospasm Imbalanced nutrition less than body requirement r/t dyspnea, sputum production Risk for increasing attack of respiratory distress r/t exposures allergens