COPD Case Study
Breathing new life into
COPD management
16 Nursing made Incredibly Easy! July/August 2011
www.NursingMadeIncrediblyEasy.com
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) promotes awareness, education, and care for patients with chronic obstructive pulmonary disease (COPD). The committee annually reviews evidence-based guidelines for prevention, diagnosis, and treatment of COPD. We give you an overview of these guidelines.
By Brenda L. Smith, MSN, RN, CMSRN Nursing Instructor • UPMC Shadyside School of Nursing • Pittsburgh, Pa. Frederick J. Tasota, MSN, RN Critical Care Clinical Specialist • UPMC Presbyterian Hospital • Pittsburgh, Pa. …show more content…
The authors have disclosed that they have no significant relationships with or financial interest in any commercial companies that pertain to this educational activity.
2.3
ANCC CONTACT HOURS
GOLD is a consortium of international experts whose objective is to improve worldwide awareness, education, and care for COPD patients. Formed in 1997 in collaboration with the World Health Organization (WHO) and the National Heart, Lung and Blood Institute, the consortium published its initial report in 2001, following a comprehensive review of existing guidelines for COPD. After reviewing the world’s literature each year, committee members continue to develop evidence-based guidelines for preventing, diagnosing, and treating COPD. Annual updates are available online at http://www.goldcopd.org. In this article, we give you an overview of these important guidelines to promote their use in the clinical setting.
Coming to terms
The term COPD doesn’t describe one disease process; rather, it encompasses pathology from different disease states that ultimately produce chronic and irreversible limitations in airflow. The GOLD report www.NursingMadeIncrediblyEasy.com defines COPD as a preventable and treatable disease characterized by airflow limitation that also has some extrapulmonary (outside of the lung) effects that may contribute to other comorbidities in certain patients. The airflow limitation is progressive in nature and is associated with an abnormal lung inflammatory response. Chronic bronchitis and emphysema have long been identified as the two categories beneath the umbrella term COPD. Interestingly, the 2010 GOLD report includes neither of these disease entities in its definition of COPD. Bronchitis isn’t always associated with airflow obstruction, and the alveolar destruction that’s indicative of emphysema is only one of multiple lung abnormalities present in COPD. However, the 2010 report does describe the characteristic airflow limitation of COPD developing from small airway disease (obstructive bronchiolitis) and lung tissue destruction (emphysema). Chronic bronchitis is diagnosed by the presence of a cough with sputum production for 3 months a year for 2 consecutive
July/August 2011 Nursing made Incredibly Easy! 17
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
years. Although this is a disease of the small airways, its definition doesn’t include reference to airflow limitation, and many patients who don’t have a chronic cough and sputum production may develop airflow limitation. However, the presence of a cough and sputum production doesn’t exclude a diagnosis of COPD. Obstructive bronchiolitis involves narrowing of the small airways that may result from various pathologic states. This broader term better reflects the airflow limitation of COPD as defined by the GOLD report. Emphysema is associated with alveolar destruction, which reduces the surface area available for gas exchange. This structural change decreases elastic recoil— the ease with which the lung
relaxes during expiration—and results in alveolar hyperinflation and air trapping. There are two commonly recognized types of emphysema: centriacinar or cerntrilobular, and panacinar (see Lung changes in emphysema).
Deep impact
Although 16 million patients in the United States may already be diagnosed with COPD, another 14 million may be undiagnosed. In the United States, COPD accounted for 1.5 million emergency visits and more than 725,000 hospitalizations in 2000, and more than $32 billion in costs in 2002. According to the WHO, the incidence of COPD is on the rise. Currently ranked as the fourth leading cause of morbidity and mortality in the United States, COPD is predicted to become number three by the year 2020. Not only does this chronic disease present a significant health burden, it also has costly economic and social ramifications. The direct healthcare costs to treat, diagnose, and manage the disease are burdensome not only to patients but also to the U.S. healthcare system. This debilitating disease prevents many patients from earning a living, leading them to rely on family, other caregivers, and indirectly on society as a whole for financial support.
Lung changes in emphysema
Alveolus Smooth muscle Dilation and destruction of bronchial walls
Structural changes
Exposure to irritating, inhaled substances such as cigarette smoke normally causes an inflammatory response in the airways and lungs. In COPD, an exaggerated response to noxious stimuli disrupts the body’s normal defense mechanisms. This abnormal response results in chronic inflammation and structural changes in the trachea and bronchi, bronchioles, respiratory bronchioles and alveoli, and the pulmonary vessels. The airways narrow due to the body’s attempts to adapt to injurious stimuli and chronic inflammatory changes. The inflammatory response causes an increase in the number of macrophages and CD8+ www.NursingMadeIncrediblyEasy.com Loss of lung tissue
Source: Pathophysiology Made Incredibly Visual! Philadelphia, PA: Lippincott Williams & Wilkins; 2008:52.
18 Nursing made Incredibly Easy! July/August 2011
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
lymphocytes, which combine to destroy tissue throughout the lungs. In the trachea and bronchi, an increase in goblet cells and enlarged submucosal glands increase mucus secretion and further narrow the airways. Bronchioles narrow from thickening of airway walls and from increased exudate. Chronic airway inflammation may also lead to pulmonary vasoconstriction secondary to chronic hypoxemia. This leads to pulmonary hypertension, which in turn may cause right-sided heart failure (cor pulmonale). Continued exposure to noxious irritants and inflammatory changes cause fibrotic changes in the small airways, obstructing airflow during expiration. As the alveoli become further damaged, hyperinflation results from loss of elasticity. As COPD progresses, alveolar hyperinflation makes inspiration more difficult, reduces gas exchange, and leads to reduced oxygen uptake and carbon dioxide retention.
Risk factors for developing COPD
• Genetic factors • Exposure to particles • Tobacco smoke • Occupational dusts (organic and inorganic) • Indoor air pollution from heating and cooking with biomass fuels such as wood and dung in poorly vented dwellings • Outdoor air pollution • Lung growth and development problems • Oxidative stress • Respiratory infections • Lower socioeconomic status • Poor nutrition • Comorbidities
Source: Bauldoff GS. When breathing is a burden: how to help patients with COPD. Am Nurse Today. 2009;4(9):17-23.
Where there’s smoke, there’s fire
One of your important roles in the prevention and treatment of COPD is to identify patient risk factors for this disease. Risk factors include genetics and environmental exposures. Of every two people with the same smoking history, one may develop COPD; of every six people diagnosed with COPD, one has never smoked. A genetic predisposition is thought to be the reason these nonsmokers develop COPD. Genetic risk factors for COPD aren’t clearly understood and require further research, but the most studied and documented genetic risk factor is alpha1 antitrypsin deficiency. Alpha1 antitrypsin is an enzyme produced mostly in the liver that primarily protects the lungs from injury. A deficiency of this enzyme predisposes adults to the early development of emphysema. www.NursingMadeIncrediblyEasy.com An estimated 100,000 people in the United States have this enzyme deficiency, but only about 10% of them have been diagnosed. Although both smokers and nonsmokers with the deficiency experience a decline in lung function, smokers have an increased risk of rapid disease progression. Cigarette smoking is by far the most common cause for the development and progression of COPD. In addition, exposure to secondhand smoke (passive smoking) increases the risk of COPD in nonsmokers. Exposure to cigarette smoke initiates the inflammatory cascade in the airways and lungs, and continued exposure to noxious irritants may result in obstructive airflow limitation. Carbon monoxide, a byproduct of cigarette smoking, adds to the problem. In the body, carbon monoxide combines with hemoglobin to form carboxyhemoglobin. These hemoglobin molecules are inefficient carriers of oxygen to the body’s tissues and only worsen hypoxemia. Other environmental risk factors include exposure to occupational dusts and chemicals, and indoor and outdoor air pollution. An estimated 19% of those
July/August 2011 Nursing made Incredibly Easy! 19
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
with COPD develop the disease secondary to occupational exposure, and 31% of them are nonsmokers. The GOLD report cites several other risk factors that have been identified through research, including respiratory injuries during gestation and childhood that interfere with normal lung growth and development, asthma, lower socioeconomic status, viral and bacterial infections, and poor nutrition (see Risk factors for developing COPD). Whether gender is a risk factor is unclear. Historically, COPD has been more prevalent in men than in women, but recent studies reveal that women have almost achieved equality with men in terms of COPD. Causes for this rise are thought to be related to women having smaller airways and more women smoking cigarettes over the past few decades.
GOLD star assessment
If you suspect your patient has COPD, obtain a thorough health history and physical assessment. The health history should include risk factors, pattern of
Picturing a barrel-shaped chest
signs and symptoms (progressive, persistent dyspnea; chronic cough; and sputum production), and the presence of comorbidities.
Possible physical assessment findings include decreased breath sounds, a barrel-shaped chest, and pursed-lip breathing (see Picturing a barrel-shaped chest). The healthcare provider will confirm a diagnosis of COPD with spirometry. Considered the gold standard for diagnosing and monitoring disease progression, spirometry is the most accurate and objective means to measure airflow limitation. It also helps to differentiate COPD from other pulmonary diseases. Spirometry includes measurement of forced vital capacity (FVC), the maximal amount of air that can be rapidly and forcefully exhaled from the lungs after maximal inspiration, and forced expired volume achieved in 1 second (FEV1), the volume of air expired in the first second of FVC. The ratio of FEV1/FVC is then calculated. A normal FEV1/FVC ratio is greater than or equal to 70% of the predicted value based on height, age, and gender. A calculated ratio of less than 70% confirms airflow obstruction. COPD severity is classified as stages I through IV based on spirometry measurements (see Using GOLD staging for
COPD).
Smoking out the dangers of COPD
Annually, smoking is responsible for more than 435,000 deaths in the United States, with tobacco-related disease accounting for $96 billion in medical expenses. Approximately 20% of American adults currently smoke, and 4,000 children and adolescents will smoke their first cigarette today. Smoking cessation is the single most cost-effective strategy to reduce the risk of developing COPD or to slow its progression. More than 70% of current smokers have a desire to stop smoking. Take advantage of an opportunity to help them achieve this goal. www.NursingMadeIncrediblyEasy.com Source: Smeltzer SC, Bare BG, Hinkle JL, Cheever KH. Brunner and Suddarth’s Textbook of Medical-Surgical Nursing. 11th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:689.
20 Nursing made Incredibly Easy! July/August 2011
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Dependence on tobacco is both a chronic disease and an addiction. Stopping tobacco use is difficult and relapse is common, mainly because nicotine is highly addictive. To prevent or minimize the development of chronic disease, be proactive in assessing, educating, and intervening to help stop your patient’s tobacco use. Be sure to consistently identify and document the smoking habits of each patient. Determine the age at which the patient began smoking, current smoking status, and the desire to stop smoking. Inform the patient about effective treatment options for smoking prevention and cessation. The U.S. Public Health Service has compiled guidelines for smoking cessation entitled Treating Tobacco Use and Dependence: 2008 Update. Quick Reference Guide for Clinicians. These guidelines outline a fivestep approach known as the 5 A’s for clinicians to help their patients stop smoking (see When smokers want to quit, use the 5 A’s). Use the guidelines with every patient encounter to identify tobacco users and encourage them to quit. Once a patient has expressed the desire to quit smoking, discuss the preparatory STAR quit plan with the patient (see The STAR quit plan for smoking cessation). Also included in the guidelines are specific interventions, known as the 5 R’s, which the clinician can use to educate and enhance motivation to stop smoking for smokers who don’t want to quit (see When smokers don’t want to quit, use the 5 R’s).
Using GOLD staging for COPD
Stage I: mild COPD FEV1/ FVC FEV1
COPD management
16 Nursing made Incredibly Easy! July/August 2011
www.NursingMadeIncrediblyEasy.com
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) promotes awareness, education, and care for patients with chronic obstructive pulmonary disease (COPD). The committee annually reviews evidence-based guidelines for prevention, diagnosis, and treatment of COPD. We give you an overview of these guidelines.
By Brenda L. Smith, MSN, RN, CMSRN Nursing Instructor • UPMC Shadyside School of Nursing • Pittsburgh, Pa. Frederick J. Tasota, MSN, RN Critical Care Clinical Specialist • UPMC Presbyterian Hospital • Pittsburgh, Pa. …show more content…
The authors have disclosed that they have no significant relationships with or financial interest in any commercial companies that pertain to this educational activity.
2.3
ANCC CONTACT HOURS
GOLD is a consortium of international experts whose objective is to improve worldwide awareness, education, and care for COPD patients. Formed in 1997 in collaboration with the World Health Organization (WHO) and the National Heart, Lung and Blood Institute, the consortium published its initial report in 2001, following a comprehensive review of existing guidelines for COPD. After reviewing the world’s literature each year, committee members continue to develop evidence-based guidelines for preventing, diagnosing, and treating COPD. Annual updates are available online at http://www.goldcopd.org. In this article, we give you an overview of these important guidelines to promote their use in the clinical setting.
Coming to terms
The term COPD doesn’t describe one disease process; rather, it encompasses pathology from different disease states that ultimately produce chronic and irreversible limitations in airflow. The GOLD report www.NursingMadeIncrediblyEasy.com defines COPD as a preventable and treatable disease characterized by airflow limitation that also has some extrapulmonary (outside of the lung) effects that may contribute to other comorbidities in certain patients. The airflow limitation is progressive in nature and is associated with an abnormal lung inflammatory response. Chronic bronchitis and emphysema have long been identified as the two categories beneath the umbrella term COPD. Interestingly, the 2010 GOLD report includes neither of these disease entities in its definition of COPD. Bronchitis isn’t always associated with airflow obstruction, and the alveolar destruction that’s indicative of emphysema is only one of multiple lung abnormalities present in COPD. However, the 2010 report does describe the characteristic airflow limitation of COPD developing from small airway disease (obstructive bronchiolitis) and lung tissue destruction (emphysema). Chronic bronchitis is diagnosed by the presence of a cough with sputum production for 3 months a year for 2 consecutive
July/August 2011 Nursing made Incredibly Easy! 17
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
years. Although this is a disease of the small airways, its definition doesn’t include reference to airflow limitation, and many patients who don’t have a chronic cough and sputum production may develop airflow limitation. However, the presence of a cough and sputum production doesn’t exclude a diagnosis of COPD. Obstructive bronchiolitis involves narrowing of the small airways that may result from various pathologic states. This broader term better reflects the airflow limitation of COPD as defined by the GOLD report. Emphysema is associated with alveolar destruction, which reduces the surface area available for gas exchange. This structural change decreases elastic recoil— the ease with which the lung
relaxes during expiration—and results in alveolar hyperinflation and air trapping. There are two commonly recognized types of emphysema: centriacinar or cerntrilobular, and panacinar (see Lung changes in emphysema).
Deep impact
Although 16 million patients in the United States may already be diagnosed with COPD, another 14 million may be undiagnosed. In the United States, COPD accounted for 1.5 million emergency visits and more than 725,000 hospitalizations in 2000, and more than $32 billion in costs in 2002. According to the WHO, the incidence of COPD is on the rise. Currently ranked as the fourth leading cause of morbidity and mortality in the United States, COPD is predicted to become number three by the year 2020. Not only does this chronic disease present a significant health burden, it also has costly economic and social ramifications. The direct healthcare costs to treat, diagnose, and manage the disease are burdensome not only to patients but also to the U.S. healthcare system. This debilitating disease prevents many patients from earning a living, leading them to rely on family, other caregivers, and indirectly on society as a whole for financial support.
Lung changes in emphysema
Alveolus Smooth muscle Dilation and destruction of bronchial walls
Structural changes
Exposure to irritating, inhaled substances such as cigarette smoke normally causes an inflammatory response in the airways and lungs. In COPD, an exaggerated response to noxious stimuli disrupts the body’s normal defense mechanisms. This abnormal response results in chronic inflammation and structural changes in the trachea and bronchi, bronchioles, respiratory bronchioles and alveoli, and the pulmonary vessels. The airways narrow due to the body’s attempts to adapt to injurious stimuli and chronic inflammatory changes. The inflammatory response causes an increase in the number of macrophages and CD8+ www.NursingMadeIncrediblyEasy.com Loss of lung tissue
Source: Pathophysiology Made Incredibly Visual! Philadelphia, PA: Lippincott Williams & Wilkins; 2008:52.
18 Nursing made Incredibly Easy! July/August 2011
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
lymphocytes, which combine to destroy tissue throughout the lungs. In the trachea and bronchi, an increase in goblet cells and enlarged submucosal glands increase mucus secretion and further narrow the airways. Bronchioles narrow from thickening of airway walls and from increased exudate. Chronic airway inflammation may also lead to pulmonary vasoconstriction secondary to chronic hypoxemia. This leads to pulmonary hypertension, which in turn may cause right-sided heart failure (cor pulmonale). Continued exposure to noxious irritants and inflammatory changes cause fibrotic changes in the small airways, obstructing airflow during expiration. As the alveoli become further damaged, hyperinflation results from loss of elasticity. As COPD progresses, alveolar hyperinflation makes inspiration more difficult, reduces gas exchange, and leads to reduced oxygen uptake and carbon dioxide retention.
Risk factors for developing COPD
• Genetic factors • Exposure to particles • Tobacco smoke • Occupational dusts (organic and inorganic) • Indoor air pollution from heating and cooking with biomass fuels such as wood and dung in poorly vented dwellings • Outdoor air pollution • Lung growth and development problems • Oxidative stress • Respiratory infections • Lower socioeconomic status • Poor nutrition • Comorbidities
Source: Bauldoff GS. When breathing is a burden: how to help patients with COPD. Am Nurse Today. 2009;4(9):17-23.
Where there’s smoke, there’s fire
One of your important roles in the prevention and treatment of COPD is to identify patient risk factors for this disease. Risk factors include genetics and environmental exposures. Of every two people with the same smoking history, one may develop COPD; of every six people diagnosed with COPD, one has never smoked. A genetic predisposition is thought to be the reason these nonsmokers develop COPD. Genetic risk factors for COPD aren’t clearly understood and require further research, but the most studied and documented genetic risk factor is alpha1 antitrypsin deficiency. Alpha1 antitrypsin is an enzyme produced mostly in the liver that primarily protects the lungs from injury. A deficiency of this enzyme predisposes adults to the early development of emphysema. www.NursingMadeIncrediblyEasy.com An estimated 100,000 people in the United States have this enzyme deficiency, but only about 10% of them have been diagnosed. Although both smokers and nonsmokers with the deficiency experience a decline in lung function, smokers have an increased risk of rapid disease progression. Cigarette smoking is by far the most common cause for the development and progression of COPD. In addition, exposure to secondhand smoke (passive smoking) increases the risk of COPD in nonsmokers. Exposure to cigarette smoke initiates the inflammatory cascade in the airways and lungs, and continued exposure to noxious irritants may result in obstructive airflow limitation. Carbon monoxide, a byproduct of cigarette smoking, adds to the problem. In the body, carbon monoxide combines with hemoglobin to form carboxyhemoglobin. These hemoglobin molecules are inefficient carriers of oxygen to the body’s tissues and only worsen hypoxemia. Other environmental risk factors include exposure to occupational dusts and chemicals, and indoor and outdoor air pollution. An estimated 19% of those
July/August 2011 Nursing made Incredibly Easy! 19
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
with COPD develop the disease secondary to occupational exposure, and 31% of them are nonsmokers. The GOLD report cites several other risk factors that have been identified through research, including respiratory injuries during gestation and childhood that interfere with normal lung growth and development, asthma, lower socioeconomic status, viral and bacterial infections, and poor nutrition (see Risk factors for developing COPD). Whether gender is a risk factor is unclear. Historically, COPD has been more prevalent in men than in women, but recent studies reveal that women have almost achieved equality with men in terms of COPD. Causes for this rise are thought to be related to women having smaller airways and more women smoking cigarettes over the past few decades.
GOLD star assessment
If you suspect your patient has COPD, obtain a thorough health history and physical assessment. The health history should include risk factors, pattern of
Picturing a barrel-shaped chest
signs and symptoms (progressive, persistent dyspnea; chronic cough; and sputum production), and the presence of comorbidities.
Possible physical assessment findings include decreased breath sounds, a barrel-shaped chest, and pursed-lip breathing (see Picturing a barrel-shaped chest). The healthcare provider will confirm a diagnosis of COPD with spirometry. Considered the gold standard for diagnosing and monitoring disease progression, spirometry is the most accurate and objective means to measure airflow limitation. It also helps to differentiate COPD from other pulmonary diseases. Spirometry includes measurement of forced vital capacity (FVC), the maximal amount of air that can be rapidly and forcefully exhaled from the lungs after maximal inspiration, and forced expired volume achieved in 1 second (FEV1), the volume of air expired in the first second of FVC. The ratio of FEV1/FVC is then calculated. A normal FEV1/FVC ratio is greater than or equal to 70% of the predicted value based on height, age, and gender. A calculated ratio of less than 70% confirms airflow obstruction. COPD severity is classified as stages I through IV based on spirometry measurements (see Using GOLD staging for
COPD).
Smoking out the dangers of COPD
Annually, smoking is responsible for more than 435,000 deaths in the United States, with tobacco-related disease accounting for $96 billion in medical expenses. Approximately 20% of American adults currently smoke, and 4,000 children and adolescents will smoke their first cigarette today. Smoking cessation is the single most cost-effective strategy to reduce the risk of developing COPD or to slow its progression. More than 70% of current smokers have a desire to stop smoking. Take advantage of an opportunity to help them achieve this goal. www.NursingMadeIncrediblyEasy.com Source: Smeltzer SC, Bare BG, Hinkle JL, Cheever KH. Brunner and Suddarth’s Textbook of Medical-Surgical Nursing. 11th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:689.
20 Nursing made Incredibly Easy! July/August 2011
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Dependence on tobacco is both a chronic disease and an addiction. Stopping tobacco use is difficult and relapse is common, mainly because nicotine is highly addictive. To prevent or minimize the development of chronic disease, be proactive in assessing, educating, and intervening to help stop your patient’s tobacco use. Be sure to consistently identify and document the smoking habits of each patient. Determine the age at which the patient began smoking, current smoking status, and the desire to stop smoking. Inform the patient about effective treatment options for smoking prevention and cessation. The U.S. Public Health Service has compiled guidelines for smoking cessation entitled Treating Tobacco Use and Dependence: 2008 Update. Quick Reference Guide for Clinicians. These guidelines outline a fivestep approach known as the 5 A’s for clinicians to help their patients stop smoking (see When smokers want to quit, use the 5 A’s). Use the guidelines with every patient encounter to identify tobacco users and encourage them to quit. Once a patient has expressed the desire to quit smoking, discuss the preparatory STAR quit plan with the patient (see The STAR quit plan for smoking cessation). Also included in the guidelines are specific interventions, known as the 5 R’s, which the clinician can use to educate and enhance motivation to stop smoking for smokers who don’t want to quit (see When smokers don’t want to quit, use the 5 R’s).
Using GOLD staging for COPD
Stage I: mild COPD FEV1/ FVC FEV1