COPD Case Study
1. What clinical findings are likely in R.S. as a consequence of his COPD?
R.S. has chronic bronchitis. According to the UC San Francisco Medical Center “Chronic bronchitis is a common type of chronic obstructive pulmonary disease (COPD) in which the air passages in the lungs — the bronchi — are repeatedly inflamed, leading to scarring of the bronchi walls. As a result, excessive amounts of sticky mucus are produced and fill the bronchial tubes, which become thickened, impeding normal airflow through the lungs.” (Chronic Bronchitis 2015) There are many things that can be observed as clinical findings. R.S. will have a chronic cough that has lasted from 3 months to two years or more, and a lot of sputum. The sputum is due to
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an overproduction of goblet cells that make mucous. The mucous will block the airways. He will also have a shortness of breath, a blue and bloated appearance, and have signs of other sequela such as pulmonary hypertension, edema and cardiovascular effects. Features of the chronic bronchitis can be seen in diagnostic tests such as PFTs, ABG levels, and chest x-ray. His PFTs will show that he has a hard time breathing because of a higher residual volume, meaning that he will have a harder time inhaling and exhaling. His TLC will be normal. His ABG levels with show that he does not have enough oxygen and has too much carbon dioxide. A chest X-ray will see any other abnormalities such as lesions or thickened lung walls. 2. How would the consequences of the COPD of R.S. (identified in question 1) differ from those of emphysematous COPD? Characteristics associated with chronic bronchitis (Type B COPD) are: Being overweight, 30-40, cyanosis in late stages, and high mucous production. These patients are known as “blue bloaters” because of their swelled up appearance, bloating, and bluishness due to having less oxygen. They have a chronic cough with plenty of mucous production. Characteristics associated with emphysema (Type A COPD) are: Thinness due to having a difficult time consuming food, decreased lung elasticity, a high RV, increased TLC, decreased FEV, and decreased FVC. People with emphysema are known as “pink puffers” because They are thin, have barrel chest, and breathe with pursed lips. They are also likely to be above age 50. Emphysema can be caused by many things but is likely caused by heavy smoking. People younger than fifty with emphysema may have a deficiency of alpha-1 antitrypsin. They also may have worked in a dangerous setting such as mining or construction. People with emphysema will also have less abnormal ABG values that those with chronic bronchitis. The textbook states that “By sustaining high ventilatory effort, a patient can have blood oxygen levels that are generally maintained near normal. Carbon dioxide levels may be normal or low as a result of hyperventilation until late in the disease.” (Copstead 2013) 3. Interpret R.S.’s laboratory results. How would his acid-base disorder be classified? What is the most likely cause of his polycythemia? The lab results given are R.S. ABG values which are not at normal levels. His blood pH is 7.32, which is lower than normal. This means that is it slightly acidic. His PaCO2 level is 60 mm Hg, which is high. His bicarbonate level is also high. This would explain why his carbon dioxide is high. This is also why his oxygen level is low. His baselines are not normal so his position on the Davenport diagram will be on the side of respiratory acidosis. He would need to decrease his bicarbonate level in order to get to a normal value pH. This is shown in the following diagram: Another part of R.S. lab test is his hematocrit level. Hematocrit indicates how much red blood cells a person had. R.S. has a hematocrit that is higher than normal (it is 52%), which means that his body is trying to produce more erythropoietin in order to compensate for the low oxygen due to chronic bronchitis. This has negative effects. When there are too much red blood cells, blood viscosity increases. This is very dangerous for someone with chronic bronchitis and pulmonary hypertension because it can lead to clots and heart failure. 4. What is the rationale for treating R.S. with Theophylline and a ß2 agonist? One of the main causes of chronic bronchitis is the inhalation of irritants into the lungs.
Most of the time, it is from smoking. The tissue in the lungs will become inflame and produce mucous because of exposure to these chemicals. Theophylline and ß2 agonist will act to relax and dilate the airways and allow more oxygen to enter. They will also decrease the lungs sensitivity so that they do not react so much to inhaled chemicals.
In the article "The Effect of Theophylline and ß2 agonists on Airway Reactivity" it says that more airway responsiveness occurs in asthma, chronic bronchitis, cystic fibrosis, and other diseases. Theophylline and ß2 agonists are used commonly for maintenance therapy for symptoms associated with the increased responsiveness. Both can reduce airway responsiveness to a variety of chemical irritants.. (Ahrens 15S)
They are both used because they do the same thing in different ways and using two of them will make the treatment more effective since they are not acting on the same way. Theophylline will block the receptors on lung tissue that receive signals from things that increase heart rate or cause vasoconstriction. ß2 agonists will help the beta receptors to bronchodilate.
5. What effects would his respiratory disease have on his cardiovascular
function? With chronic bronchitis it is very hard to breathe and since the body isn't getting enough oxygen it has to work much harder. This overworks the heart muscles and leads to hypertrophy and maybe even right sided heart failure if it is severe enough. In order to understand how chronic bronchitis can affect the cardiovascular system, it would be important to know about how it works. In the textbook it is said that “Pathologic changes in the airway include chronic inflammation and swelling of the bronchial mucosa resulting in scarring, increased fibrosis of the mucous membrane, hyperplasia of bronchial mucous glands and goblet cells, hypertrophy of bronchial glands and goblet cells, and increased bronchial wall thickness, which potentiates obstruction to airflow.” (Copstead 2013)These things lead to cardiovascular sequela. Things like increased bronchial wall thickness and hardening of the mucous membrane leads to pulmonary hypertension, which can eventually lead to right-sided heart failure. The prompt also mentions that R.S. has pneumonia. This important because chronic bronchitis is associated with having airway infections. This is why there is something on his lower right lobe. The pneumonia will make the cardiovascular health worse because breathing is already obstructed. This will increase pulmonary hypertension, and heart failure is more likely. Bacterial infections can also lead to myocardial infarction by attacking the cardiac tissue.
The risk factors that Jessica presented with are a history that is positive for smoking, bronchitis and living in a large urban area with decreased air quality. The symptoms that suggest a pulmonary disorder include a productive cough with discolored sputum, elevated respiratory rate, use of the accessory respiratory muscles during quite breathing, exertional dyspnea, tachycardia and pedal edema. The discolored sputum is indicative of a respiratory infection. The changes in respiratory rate, use of respiratory muscles and exertional dyspnea indicate a pulmonary disorder since there is an increased amount of work required for normal breathing. Tachycardia may arise due to the lack of oxygenated blood available to the tissue stimulating an increase in heart rate. The pedal edema most probably results from decreased systemic blood flow.
Ransley reports frequent nasal congestion that has been more problematic in the last couple of weeks and I note you have commenced him on some oral antibiotics and prednisolone which seems to be helping.
R.S. has been using the recommended treatment for his condition, which inlcude inhaled short-acting Beta-2 agonist and Theophylline, a bronchodilator, to control his respiratory disease.
Asthma is a chronic inflammatory disease of the airways. It is a reversible airway obstruction, occurring 8 to 10% of the population worldwide. According to a study in 2005, asthma affects over 15 million Americans, with more than 2 million annual emergency room visits. Asthma patients have a hyper-responsiveness in their airways and generally and increase in their airway smooth muscle cell mass. This hyperplasia is due to the normal response to the injury and repair to the airway caused by exacerbations. The main choice of therapy for asthma patients is β2- adrenergic agonists. Racemic albuterol has been the drug of choice for a short acting bronchodilator for a long time, but since the development of levalbuterol, there is the question of which drug is a better choice for therapy. Efficacy and cost of treatment must both be taken into consideration in each study of these therapies to determine which is best for the treatment of asthma.
There are two forms of bronchodilators, a short acting and a long acting form. Short acting relieves or stops asthma symptoms and is very helpful during an attack. They are also called ‘rescue’ medications because they are best for treating sudden or severe asthma symptoms. Long acting bronchodilators are used to control asthma, they take longer to work but they also last longer, up to 12 hours, whereas a short acting would only last for about 4-5 hours. Ventolin is a short acting form, it is the recommended medication to use 15-20 mins before exercising.
Mrs. Jones, An elderly woman, presented severely short of breath. She required two rest periods in order to ambulate across the room, but refused the use of a wheel chair. She was alert and oriented, but was unable to speak in full sentences. Her skin was pale and dry. Her vital signs were as follows: Temperature 97.3°F, pulse 83, respirations 27, blood pressure 142/86, O2 saturation was 84% on room air. Auscultation of the lungs revealed crackles in the lower lobes and expiratory wheezing. Use of accessory muscles was present. She was put on 2 liters of oxygen via nasal canal. With the oxygen, her O2 saturation increased to 90%. With exertion her O2 saturation dropped to the 80's. Mrs. Jones began coughing and she produced large amounts of milky sputum.
The purpose of this essay is to explore nursing care priorities for a patient with a common health condition. A common health condition is a disease or condition which occurs most often within a population. The author has chosen scenario 3 for this essay and will describe the nursing assessment and care planning provided to a patient with Chronic Obstructive Pulmonary Disease (COPD). The WHO definition of COPD is a lung disease which has a chronic obstruction of the airways that impedes normal breathing and is not fully reversible (). According to), there are estimated to be over 3 million people in the UK with COPD. It is common in later life and there are approximately 25,000 deaths each year, with 15% of COPD being work related (The identity of the patient will remain anonymous in adherence with the Nursing and Midwifery Council, Code of Conduct on patient confidentiality (). However, the patient will be referred to as Mr B in this essay. The author has chosen the priority of eating and drinking for Mr B. Patients with COPD are at increased risk of malnutrition and nurses must make certain they screen patients and offer advice or refer as necessary (). If this priority is managed well it will have a positive effect on the other priorities (, 2012). In accordance with NICE Guideline 101 (), the treatment and care provided should consider each persons’ individual requirements and preference. Care and treatment should take into account people’s individual needs and choices. To allow people to reach informed decisions there must be good communication, supported by evidence-based practice (). This essay will provide an evidence based discussion on how care will be implemented in relation to Mr B and his eating and drin...
...a are bronchodilators like anticholinergic, beta agonists, theophylline and oxygen, which are for the advance cases of the disease. In addition, the best treatment for people whom have emphysema is for them to stop smoking.
Chronic Obstructive Pulmonary Disease (COPD) is a lung disease that affects breathing. This disease is one that blocks or obstructs air flow which then affects the way that one breathes. It diminishes the capability of airflow in and out of the lungs. COPD is the term used for a group of different diseases that affect the lungs. The two most common types of COPD are emphysema and chronic bronchitis. Emphysema is a destruction of the small bronchioles in the lungs and chronic bronchitis is an inflammation of the lining of the bronchial tubes. Both emphysema and chronic bronchitis are obstructive diseases that impact breathing in a negative manner. (COPD, 2014)
Chronic obstructive pulmonary disease (COPD) is preventable disease that has a detrimental effects on both the airway and lung parenchyma (Nazir & Erbland, 2009). COPD categorises emphysema and chronic bronchitis, both of which are characterised by a reduced maximum expiratory flow and slow but forced emptying of the lungs (Jeffery 1998). The disease has the one of the highest number of fatalities in the developed world due to the ever increasing amount of tobacco smokers and is associated with significant morbidity and mortality (Marx, Hockberger & Walls, 2014). Signs and symptoms that indicate the presence of the disease include a productive cough, wheezing, dyspnoea and predisposing risk factors (Edelman et al., 1992). The diagnosis of COPD is predominantly based on the results of a lung function assessment (Larsson, 2007). Chronic bronchitis is differentiated from emphysema by it's presentation of a productive cough present for a minimum of three months in two consecutive years that cannot be attributed to other pulmonary or cardiac causes (Marx, Hockberger & Walls, 2014) (Viegi et al., 2007). Whereas emphysema is defined pathologically as as the irreversible destruction without obvious fibrosis of the lung alveoli (Marx, Hockberger & Walls, 2014) (Veigi et al., 2007).It is common for emphysema and chronic bronchitis to be diagnosed concurrently owing to the similarities between the diseases (Marx, Hockberger & Walls, 2014).
Chronic bronchitis is a disorder that causes inflammation to the airway, mainly the bronchial tubules. It produces a chronic cough that lasts three consecutive months for more than two successive years (Vijayan,2013). Chronic Bronchitis is a member of the COPD family and is prominently seen in cigarette smokers. Other factors such as air pollutants, Asbestos, and working in coal mines contributes to inflammation. Once the irritant comes in contact with the mucosa of the bronchi it alters the composition causing hyperplasia of the glands and producing excessive sputum (Viayan,2013). Goblet cells also enlarge to contribute to the excessive secretion of sputum. This effects the cilia that carry out the mechanism of trapping foreign bodies to allow it to be expelled in the sputum, which are now damaged by the irritant making it impossible for the person to clear their airway. Since the mechanism of airway clearance is ineffective, the secretion builds up a thickened wall of the bronchioles causing constriction and increasing the work of breathing. The excessive build up of mucous could set up pneumonia. The alveoli are also damaged enabling the macrophages to eliminate bacteria putting the patient at risk for acquiring an infection.
His positive result of nasopharyngeal aspirate for Respiratory Syncytial Virus (RSV) indicates that Liam has acute bronchiolitis, which is a viral infection (Glasper & Richardson, 2010). “Bronchiolitis is the most common reason for admission to hospital in the first 6 months of life. It describes a clinical syndrome of cough tachypnoea, feeding difficulties and respiratory crackles in chest auscultation” (Fitzgerald, 2011, p.160). Bronchiolitis can cause respiratory distress and desaturation (91% in the room air) due to airway blockage; therefore the infant appears to have nasal flaring, intercostal and subcostal retractions, and tachypnoea (54 breathes/min) during breathing (Glasper & Richardson, 2010). Tachycardia (152 beats/min) could occur due to hypoxemia and compensatory mechanism for low blood pressure (74/46mmHg) (Fitzgerald, 2011; Glasper & Richardson, 2010).
The causes of Pulmonary Fibrosis vary from a patient’s occupation to their medical conditions. Pulmonary Fibrosis is caused by environmental factors along with genetic factors. Genetics plays a role in the contraction by determining a person’s vulnerability. A person being in an environment with asbestos fibers, silica dust, grain dust, and bird or animal droppings is at risk for this disease. Patients who also have gone through radiation could be at risk depending on how much the lung was exposed and how long it was exposed to the radiation. Medications can also factor in to the cause of the disease. Chemotherapy drugs, heart medications, and some antibiotics have been linked to Pulmonary Fibrosis. A patient’s previous medical conditions can aid in the formation of this disease such as pneumonia, tuberculosis, scleroderma, and systemic lupus erythematosus. Some other known causes are smoking and lung infection.
Mary was seen today following her redo bronchoscopy. Unfortunately, there was not much mucus seen and as such I suspect that the right middle lobe collapse and the lingular collapse are going to be a chronic change. Despite this though, Mary does seem to be coping well with this and up until ten days ago was only coughing very occasionally and was not describing any issues with breathlessness. Ten days ago though, she had a viral infection that progressed to a green cough and she did start seven days of doxycycline that completely cleared things up. She stopped this three days ago and has started to have a return of the green sputum, but without any other significant symptoms. I have suggested she complete another seven days. It is likely
Today there are various treatment options for those that suffer from mild, moderate, and severe chronic obstructive pulmonary disease (COPD). Staging COPD is the first step in treatment and in order to make a proper diagnosis physicians use the GOLD standard. GOLD stands for Global Initiative for Chronic Obstructive Lung Disease and this staging method uses forced expiratory volume in one second (FEV1) to classify the varying severities of COPD. FEV1 greater than 80% of their total exhaled breath or forced vital capacity (FVC) is considered to be mild, between 50% and 80% is moderate, between 30% and 50% is severe, and less than 30% is very severe. These are also signified by stages, stage I being the best and stage IV being the worst (Spencer and Hanania 2013). Once the severity of COPD has been discussed and tested for, treatment options can then be assessed.