2017

Chronic Obstuctive
Pulmonary Disease
Case Study

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1/1/2017
Chronic Obstructive Pulmonary Disease

- also known as chronic airflow limitation is a group of disorders associated with

persistent or recurrent obstruction of airflow, which include chronic bronchitis,
emphysema and asthma. These conditions frequently overlap. Most commonly,
bronchitis and emphysema occur together. Asthma frequently occurs alone without
the triad of bronchitis, emphysema and asthma.

- Chronic obstructive pulmonary disease (COPD) is a disease state characterized by

airflow limitation that is not fully reversible. This newest definition COPD, provided
by the Global Initiative for Chrnonic Obstructive Lung Disease (GOLD), is a broad
description that better explains this disorder and its signs and symptoms (GOLD,
World Health Organization [WHO] & National Heart, Lung and Blood Institute
[NHLBI], 2004). Although previous definitions have include emphysema and chronic
bronchitis under the umbrella classification of COPD, this was often confusing
because most patient with COPD present with over lapping signs and symptoms of
these two distinct disease processes.

- COPD may include diseases that cause airflow obstruction (e.g., Emphysema, chronic
bronchitis) or any combination of these disorders. Other diseases as cystic fibrosis,
bronchiectasis, and asthma that were previously classified as types of chronic
obstructive lung disease are now classified as chronic pulmonary disorders.
However, asthma is now considered as a separate disorder and is classified as an
abnormal airway condition characterized primarily by reversible inflammation. COPD
can co-exist with asthma. Both of these diseases have the same major symptoms;
however, symptoms are generally more variable in asthma than in COPD.

- Currently, COPD is the fourth leading cause of mortality and the 12th leading cause
of disability. However, by the year 2020 it is estimated that COPD will be the third
leading cause of death and the firth leading cause of disability (Sin, McAlister, Man.
Et al., 2003). People with COPD commonly become symptomatic during the middle
adult years, and the incidence of the disease increases with age.

What Are COPD Symptoms?

Many people don't recognize the symptoms of COPD until later stages of the disease.
Sometimes people think they are short of breath or less able to go about their normal activities
because they are "just getting older." But shortness of breath is never normal. If you
experience any of these symptoms, or think you might be at risk for COPD, it is important to
discuss this with your doctor.

Chronic cough
Shortness of breath while doing everyday activities (dyspnea)
Frequent respiratory infections
Blueness of the lips or fingernail beds (cyanosis)
Fatigue
Producing a lot of mucus (also called phlegm or sputum)
Wheezing
What Causes COPD?

Over time, exposure to irritants that damage your lungs and airways can cause chronic
obstructive pulmonary disease (COPD), which includes chronic bronchitis and emphysema. The
main cause of COPD is smoking, but nonsmokers can get COPD too.

Smoking
About 85 to 90 percent of all COPD cases are caused by cigarette smoking. When a cigarette
burns, it creates more than 7,000 chemicals, many of which are harmful. The toxins in cigarette
smoke weaken your lungs' defense against infections, narrow air passages, cause swelling in air
tubes and destroy air sacsall contributing factors for COPD.

Your Environment
What you breathe every day at work, home and outside can play a role in developing COPD.
Long-term exposure to air pollution, secondhand smoke and dust, fumes and chemicals (which
are often work-related) can cause COPD.

Alpha-1 Deficiency
A small number of people have a rare form of COPD called alpha-1 deficiency-related
emphysema. This form of COPD is caused by a genetic (inherited) condition that affects the
body's ability to produce a protein (Alpha-1) that protects the lungs.

Pathophysiology of COPD
COPD is a complex syndrome comprised of airway inflammation, mucociliary dysfunction and
consequent airway structural changes.

Airway inflammation

COPD is characterized by chronic inflammation of the airways, lung tissue and pulmonary blood
vessels as a result of exposure to inhaled irritants such as tobacco smoke.

The inhaled irritants cause inflammatory cells such as neutrophils, CD8+ T-lymphocytes, B cells
and macrophages to accumulate. When activated, these cells initiate an inflammatory cascade
that triggers the release of inflammatory mediators such as tumour necrosis factor alpha (TNF-
), interferon gamma (IFN-), matrix-metalloproteinases (MMP-6, MMP-9), C-reactive protein
(CRP), interleukins (IL-1, IL-6, IL-8) and fibrinogen. These inflammatory mediators sustain the
inflammatory process and lead to tissue damage as well as a range of systemic effects. The
chronic inflammation is present from the outset of the disease and leads to various structural
changes in the lung which further perpetuate airflow limitation. The chronic inflammatory
cascade for COPD is illustrated in Figure 1.

Structural changes

Airway remodeling in COPD is a direct result of the inflammatory response associated with
COPD and leads to narrowing of the airways. Three main factors contribute to this:
peribronchial fibrosis, build-up of scar tissue from damage to the airways and over-
multiplication of the epithelial cells lining the airways.

Parenchymal destruction is associated with loss of lung tissue elasticity, which occurs as a result
of destruction of the structures supporting and feeding the alveoli (emphysema). This means
that the small airways collapse during exhalation, impeding airflow, trapping air in the lungs
and reducing lung capacity (Figure 2).
Figure 1: Inflammatory and immune cells involved in COPD.2
Adapted from Barnes, PJ. Nat Rev Immunol 2008;8:183-92

Figure 2: Airflow limitation in COPD.

Mucociliary dysfunction

Smoking and inflammation enlarge the mucous glands that line airway walls in the lungs,
causing goblet cell metaplasia and leading to healthy cells being replaced by more mucus-
secreting cells. Additionally, inflammation associated with COPD causes damage to the
mucociliary transport system which is responsible for clearing mucus from the airways. Both
these factors contribute to excess mucus in the airways which eventually accumulates, blocking
them and worsening airflow (Figure 3).
Figure 3: Mucociliary effects in the COPD airway.
Patients Profile

Diane, a 52-year old, postmenopausal white woman seeks medical treatment because she is
in her wordshaving that bronchitis thing again. She reports having these episodes 1 to 3
times per year during the past 5 years. She denies any fever with this episode. Diane speaks in
full sentences and does not appear to be in acute respiratory distress. She is currently a social
smoker but previously smoked a pack per day for approximately 10 years. She has a brother
with asthma and a grandfather who died of emphysema at the age of 68. She is allergic to
shellfish. Diane describes her symptoms as being worse in the morning with lots of coughing
and heavy phlegm production. She is also awakened by cough a few times during the night. She
is concerned because the illness is recurring more frequently. In the past, she has been treated
with a variety of medications, including inhaled corticosteroids (ICS), long-acting beta 2
adrenergic agonists (LABA), oral corticosteroids, and antibiotics. When asked about any
changes in her symptoms over time she mentions that they used to be seasonal but now they
occur sporadically, year-round. When asked about exercise, she reports that she used to walk 3
times a week with a friend but can no longer keep up because of breathing difficulties; instead,
she walks with an older neighbor about once a week. Diane attributes the change to old age.

Physical Examination

Height 5 ft 6 in
Weight 152 lb
BMI 24.5 kg/m2
BP 128/74 mm Hg
HR 74 bpm
RR 18/min
Temperature 98.4F
HEENT Normal
Neck No jugular venous distention
Lungs Decreased breath sounds, scattered end-expiratory wheeze
Heart Regular rate and rhythm, no murmurs or gallops
BMI = body mass index; BP = blood pressure; HR = heart rate; RR = respiration rate;
HEENT = head, ears, eyes, nose, and throat.

Clinical Manifestation

Diane has intermittent symptoms that are worse at night and in early morning, she has a close
relative with asthma, and she has a history of allergy. As might be expected with COPD, Diane
was in her late forties at onset of symptoms, her symptoms are progressive in that they now
occur year-round, and she has modified her lifestyle to accommodate reduced exercise
tolerance. Dianes smoking history is not definitive for either disorder. She smokes socially and
has a 10 pack per year history, but does not have the 20 pack-year history that is more clearly
associated with COPD.
Similarly, cough and wheezing are symptoms of both disorders, although a cough producing
large amounts of phlegm is more suggestive of COPD. Spirometry is the best tool for
differentiating asthma from COPD. Diane is not in acute distress; therefore pulse oximetry is
not warranted.

Allergy testing or a chest X-ray may be desirable to obtain after a diagnosis is made but will not
benefit the diagnosis itself. Because these tests are all available in primary care practice, there
is no need to refer Diane to a specialist.

Physical Manifestations

Signs of emphysema include pursed-lipped breathing, central cyanosis and finger clubbing. The
chest has hyper resonant percussion notes, particularly just above the liver, and a difficult to
palpate apex beat, both due to hyperinflation. There may be decreased breath sounds and
audible expiratory wheeze. In advanced disease, there are signs of fluid overload such as pitting
peripheral edema. The face has a ruddy complexion if there is a secondary polycythemia.
Sufferers who retain carbon dioxide have asterixis (metabolic flap) at the wrist.

Diagnostic Evaluation

1. PFTs demonstrative airflow obstruction reduced forced vital capacity (FVC), FEV1,
FEV1 to FVC ration; increased residual volume to total lung capacity (TLC) ratio, possibly
increased TLC.
2. ABG levels- decreased PaO2, pH, and increased CO2.
3. Chest X-ray in late stages, hyperinflation, flattened diaphragm, increased rettrosternal
space, decreased vascular markings, possible bullae.

Alpa1-antitrypsin assay useful in identifying genetically determined deficiency in emphysema.

Nursing Management

Monitoring

1. Monitor for adverse effects of bronchodilators tremulousness, tachycardia, cardiac

arrhythmias, central nervous system stimulation, hypertension.
2. Monitor condition after administration of aerosol bronchodilators to assess for
improved aeration, reduced adventitious sounds, reduced dyspnea.
3. Monitor serum theophylline level, as ordered, to ensure therapeutic level and prevent
toxicity.
4. Monitor oxygen saturation at rest and with activity.

Supportive Care

1. Eliminate all pulmonary irritants, particularly cigarette smoke. Smoking cessation usually
reduces pulmonary irritation, sputum production, and cough. Keep the patients room
as dust-free as possible.
2. Use postural drainage positions to help clear secretions responsible for airway
obstructions.
3. Teach controlled coughing.
4. Encourage high level of fluid intake ( 8 to 10 glasses; 2 to 2.5 liters daily) within level of
cardiac reserve.
 5. Give inhalations of nebulized saline to humidify bronchial tree and liquefy sputum. Add
moisture (humidifier, vaporizer) to indoor air.
6. Avoid dairy products if these increases sputum production.
7. Encourage the patient to assume comfortable position to decrease dyspnea.
8. Instruct and supervise patients breathing retraining exercises.
9. Use pursed lip breathing at intervals and during periods of dyspnea to control rate and
depth of respiration and improve respiratory muscle coordination.
10. Discuss and demonstrate relaxation exercises to reduce stress, tension, and anxiety.
11. Maintain the patients nutritional status.
12. Reemphasize the importance of graded exercise and physical conditioning programs.
13. Encourage use of portable oxygen system for ambulation for patients with hypoxemia
and marked disability.
14. Train the patient in energy conservation technique.
15. Assess the patient for reactive-behaviors such as anger, depression and acceptance.

Education and health maintenance

1. Review with the patient the objectives of treatment and nursing management.
2. Advise the patient to avoid respiratory irritants. Suggest that high efficiency particulate
air filter may have some benefit.
3. Warn patient to stay out of extremely hot or cold weather and to avoid aggravating
bronchial obstruction and sputum obstruction.
4. Warn patient to avoid persons with respiratory infections, and to avoid crowds and
areas with poor ventilation.
5. Teach the patient how to recognize and report evidence of respiratory infection
promptly such as chest pain, changes in character of sputum (amount, color and
consistency), increasing difficulty in raising sputum, increasing coughing and wheezing,
increasing of shortness of breath.

Medical Management

Lung therapies

Doctors often use these additional therapies for people with moderate or severe COPD:

Oxygen therapy.
If there isn't enough oxygen in your blood, you may need supplemental oxygen. There
are several devices to deliver oxygen to your lungs, including lightweight, portable units that
you can take with you to run errands and get around town.
Some people with COPD use oxygen only during activities or while sleeping. Others use
oxygen all the time. Oxygen therapy can improve quality of life and is the only COPD therapy
proven to extend life. Talk to your doctor about your needs and options.

Pulmonary rehabilitation program.

These programs generally combine education, exercise training, nutrition advice and
counseling. You'll work with a variety of specialists, who can tailor your rehabilitation program
to meet your needs. Pulmonary rehabilitation may shorten hospitalizations, increase your
ability to participate in everyday activities and improve your quality of life. Talk to your doctor
about referral to a program.

Managing exacerbations
Even with ongoing treatment, you may experience times when symptoms become worse for
days or weeks. This is called an acute exacerbation, and it may lead to lung failure if you don't
receive prompt treatment.
Exacerbations may be caused by a respiratory infection, air pollution or other triggers of
inflammation. Whatever the cause, it's important to seek prompt medical help if you notice a
sustained increase in coughing, a change in your mucus or if you have a harder time breathing.
When exacerbations occur, you may need additional medications (such as antibiotics, steroids
or both), supplemental oxygen or treatment in the hospital. Once symptoms improve, your
doctor will talk with you about measures to prevent future exacerbations, such as quitting
smoking, taking inhaled steroids, long-acting bronchodilators or other medications, getting your
annual flu vaccine, and avoiding air pollution whenever possible.

Pharmachological Interventions

Short-acting bronchodilators

Bronchodilators help open your airways to make breathing easier. Your doctor may prescribe
short-acting bronchodilators for an emergency situation or for quick relief use as needed. You
take them using an inhaler or nebulizer.

Examples of short-acting bronchodilators include:

albuterol (Vospire ER)

levalbuterol (Xopenex)
ipratropium (Atrovent)
albuterol/ipratropium (Combivent)

Short-acting bronchodilators can cause side effects such as dry mouth, blurry vision, or cough.
These effects should go away over time. Other side effects include tremors (shaking) and a fast
heartbeat. If you have a heart condition, tell your doctor before taking a short-acting
bronchodilator.

Corticosteroids

With COPD, your airways can be inflamed (swollen and irritated). Inflammation makes it harder
to breathe. Corticosteroids are a type of medication that reduces inflammation in the body,
making air flow easier in the lungs.

Several types of corticosteroids are available. Some are inhalable and should be used every day
as directed. Other corticosteroids are injected or taken by mouth. These forms are used when
your COPD suddenly gets worse.

The corticosteroids doctors most often prescribe for COPD are:

Fluticasone (Flovent), which comes as an inhaler that you use once or twice daily. Side
effects can include headache, sore throat, voice changes, and allergic reaction.
Budesonide (Pulmicort), which comes as a powder, liquid, or in an inhaler. Side effects
can include colds or thrush, which is an infection in the mouth.
Prednisolone, which comes as a pill, liquid, or as a shot and is usually given for
emergency rescue treatment. Side effects can include muscle weakness, upset stomach,
and weight gain.
Methylxanthines

Warnings For COPD Medications

Whatever medication your doctor prescribes, be sure to take it according to your doctors
instructions. If you have serious side effects, such as an allergic reaction with rash or swelling,
call your doctor right away. Because some COPD medications can affect your cardiovascular
system, be sure to tell your doctor if you have an irregular heartbeat or cardiovascular
problems.
For some people with severe COPD, the typical first-line treatments, such as fast-acting
bronchodilators and corticosteroids, dont seem to help when used on their own. When this
happens, some doctors prescribe a drug called theophylline along with a bronchodilator.
Theophylline works as an anti-inflammatory drug and relaxes the muscles in the airways.
Theophylline comes as a pill or liquid you take daily.

Side effects of theophylline can include nausea or vomiting, tremors, and trouble sleeping.

Long-acting bronchodilators

Long-acting bronchodilators are medications that are used to treat COPD over a longer period
of time. They are usually taken once or twice daily using inhalers or nebulizers. Because these
drugs work gradually to help ease breathing, they dont work well as rescue medication.

The long-acting bronchodilators available today are:

aclidinium (Tudorza)
arformoterol (Brovana)
formoterol (Foradil, Perforomist)
glycopyrrolate (Seebri Neohaler)
indacaterol (Arcapta)
olodaterol (Striverdi Respimat)
salmeterol (Serevent)
tiotropium (Spiriva)
umeclidinium (Incruse Ellipta)

Side effects of long-acting bronchodilators can include:

dry mouth
dizziness
tremors
runny nose
irritated or scratchy throat

More serious side effects include blurry vision, rapid heart rate, and an allergic reaction with
rash or swelling.

Combination drugs

Several COPD drugs come as combination medications. These are mainly combinations either of
two long-acting bronchodilators or of an inhaled corticosteroid and a long-acting
bronchodilator.

Combinations of two long-acting bronchodilators include:

 glycopyrrolate/formoterol (Bevespi Aerosphere)
glycopyrrolate/indacaterol (Utibron Neohaler)
tiotropium/olodaterol (Stiolto Respimat)
umeclidinium/vilanterol (Anoro Ellipta)

Combinations of an inhaled corticosteroid and a long-acting bronchodilator include:

budesonide/formoterol (Symbicort)
fluticasone/salmeterol (Advair)
fluticasone/vilanterol (Breo Ellipta)

Roflumilast

Roflumilast (Daliresp) is a type of drug called a phosphodiesterase-4 inhibitor. Roflumilast

comes as a pill you take once per day. It helps relieve inflammation, which can improve air flow
to your lungs. Your doctor will likely prescribe this drug along with a long-acting bronchodilator.

Side effects of roflumilast can include:

weight loss
diarrhea
cramps
tremors

You should also tell your doctor if you have liver problems before taking this medication.

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
HFA, Flonase, others) and budesonide (Pulmicort Flexhaler, Uceris, others) are examples of
inhaled steroids.

Oral steroids

For people who have a moderate or severe acute exacerbation, short courses (for example, five
days) of oral corticosteroids prevent further worsening of COPD. However, long-term use of
these medications can have serious side effects, such as weight gain, diabetes, osteoporosis,
cataracts and an increased risk of infection.

Theophylline

This very inexpensive medication may help improve breathing and prevent exacerbations. Side
effects may include nausea, headache, fast heartbeat and tremor. Side effects are dose related,
and low doses are recommended.

Antibiotics

Respiratory infections, such as acute bronchitis, pneumonia and influenza, can

aggravate COPD symptoms. Antibiotics help treat acute exacerbations, but they aren't generally
recommended for prevention. However, a recent study shows that the antibiotic azithromycin
prevents exacerbations, but it isn't clear whether this is due to its antibiotic effect or its anti-
inflammatory properties.

Surgical Management

Surgery is an option for some people with some forms of severe emphysema who aren't helped
sufficiently by medications alone. Surgical options include:

Lung volume reduction surgery.

In this surgery, your surgeon removes small wedges of damaged lung tissue from the upper
lungs. This creates extra space in your chest cavity so that the remaining healthier lung tissue
can expand and the diaphragm can work more efficiently. In some people, this surgery can
improve quality of life and prolong survival.

Lung transplant.

Lung transplantation may be an option for certain people who meet specific criteria.
Transplantation can improve your ability to breathe and to be active. However, it's a major
operation that has significant risks, such as organ rejection, and it's necessary to take lifelong
immune-suppressing medications.

Bullectomy.

Large air spaces (bullae) form in the lungs when the walls of the air sacs are destroyed. These
bullae can become very large and cause breathing problems. In a bullectomy, doctors remove
bullae from the lungs to help improve air flow.