Chronic Obstructive Pulmonary disease Definition

C- Shaped pieces of cartilage in the wall keep the trachea open. They also provide support so that the tracheal wall does not collapse inward and obstruct the air passageway. BRONCHI

Chronic obstructive lung disease, also known as chronic obstructive pulmonary disease (COPD), is a general term for a group of conditions in which there is persistent difficulty in expelling (or exhaling) air from the lungs. COPD commonly refers to two related, progressive diseases of the respiratory system, chronic bronchitis and emphysema. Because smoking is the major cause of both diseases, chronic bronchitis and emphysema often occur together in the same patient. COPD can cause coughing that produces large amounts of mucus (a slimy substance), wheezing, shortness of breath, chest tightness, and other symptoms. Cigarette smoking is the leading cause of COPD. Most people who have COPD smoke or used to smoke. Long-term exposure to other lung irritants, such as air pollution, chemical fumes, or dust, also may contribute to COPD. In emphysema, the walls between many of the air sacs are damaged, causing them to lose their shape and become floppy. This damage also can destroy the walls of the air sacs, leading to fewer and larger air sacs instead of many tiny ones. If this happens, the amount of gas exchange in the lungs is reduced. In chronic bronchitis, the lining of the airways is constantly irritated and inflamed. This causes the lining to thicken. Lots of thick mucus forms in the airways, making it hard to breathe. Most people who have COPD have both emphysema and chronic obstructive bronchitis. Thus, the general term "COPD" is more accurate.

At the superior border of the fifth thoracic vertebra, the trachea divides into a right primary bronchus, which goes into the right lung, and a left primary bronchus, which goes into the left lung. The right primary bronchus is more vertical, shorter, and wider than the left. At the point where the trachea divides into right and left primary bronchi an internal ridge called the carina, is formed by a posterior and somewhat inferior projection of the last tracheal cartilage. On entering the lungs, the primary bronchi divide to form smaller bronchi- the secondary bronchi, one for each lobe of the lung. The secondary bronchi continue to branch, forming still smaller bronchi, called tertiary bronchi, that divide into bronchioles. Bronchioles, in turn, branch repeatedly, and the smallest ones branch into even smaller tubes called terminal bronchioles. This extensive branching from the trachea resembles an inverted tree and is commonly referred to as the bronchial tree. LUNGS Are paired cone-shaped organs in the thoracic cavity. The lungs occupy the chest cavity on either side if the heart. Extending from the clavicles to the diaphragm. On the medial surface of each lung is an indentation called the hilus, where the primary bronchus and the pulmonary artery and veins enter the lungs. Two layers of serous membrane are called the pleural membrane which encloses and protects the lungs. The superficial layer is called the parietal pleura which line the thoracic cavity; the deep layer is called the visceral pleura, which then covers the lungs themselves. Between the visceral and parietal pleurae is a small space called the pleural cavity which contains a small amount of lubricating fluid secreted by the membranes. This fluid reduces friction between the membranes, allowing them to slide easily to one another during breathing. Inflammation of the pleural membrane is called pleurisy or pleuritis. The functional units of the lung are the milllions of alveoli, the air sacs that are the site of gas exchange. Both the alveoli and the surrounding alveolar capillaries are made of simple squamous epithelium; that is, their walls are only one cell in thickness to permit diffusion of gases. Each alveolus is lined with a thin layer of tissue fluid that is essential for the diffusion of gases, but the surface tension of the fluid tends to make the walls of an alveolus stick together internally. Certain alveolar cells secrete pulmonary surfactant, a lipoprotein that mixes with the tissue fluid and decreases surface tension to permit inflation. Also in the alveoli are the alveolar macrophages, which phagocytize pathogens or fine dust particles and debris that have not been trapped and swept out by the cilia. BLOOD SUPPLY IN THE LUNGS The lungs receive blood via two sets of arteries: the pulmonary arteries and the bronchial arteries. Deoxygenated blood passes through the pulmonary artery that enters the left lung and a right pulmonary artery that enters the right lung. The pulmonary arteries are the only arteries that carry deoxygenated blood. Return of the oxygenated blood to the heart occurs by way of the four pulmonary veins, which drain to the left atrium. Bronchial arteries, which branch from the aorta, deliver oxygenated blood to the lungs. This blood mainly perfuses the walls of the bronchi and bronchioles. Connections exist between branches of the bronchial arteries and branches of the pulmonary arteries however, and most blood returns to the heart via pulmonary veins. Some blood, however, drains into bronchial veins, branches of the azygos system, and returns to the heart via the superior vena cava. GAS EXCHANGE

Anatomy and Physiology Respiratory System The respiratory system consists of the nose, pharynx (throat), larynx (voice box), trachea (windpipe), bronchi and lungs. Its parts can be classified according to either structure or function. Structurally, the respiratory system consists of two parts: 1) structures. 2) lungs. The UPPER RESPIRATORY SYSTEM includes the nose, pharynx and associated

The LOWER RESPIRATORY SYSTEM includes the larynx, trachea, bronchi, and

NOSE - The uppermost portion of the human respiratory system, the nose is a hollow air passage that functions in breathing and in the sense of smell. The nasal cavities moisten and warm incoming air, while small hairs and mucus filter out harmful particles and microorganisms. PHARYNX

Gas exchange in the body is called RESPIRATION, it has three basic steps: Also known as the throat, it is a funnel- shaped tube about 13cm (5inches) long that starts at the internal nares and extends to the level of the cricoids cartilage, the most inferior cartilage of the larynx. The pharynx functions as a passageway for air and food, provides a resonating chamber for speech sounds, and houses the tonsils, which participate in immunological reactions against foreign invaders. The pharynx can be divided into three anatomical regions: 1. Pulmonary Ventilation- also known as breathing, is the inhalation and exhalation of air between the atmosphere and the alveoli of the lungs. 2. External Respiration- it is the exchange of gases between the alveoli of the lungs and the blood in pulmonary capillaries across the respiratory membrane. In this process, pulmonary capillary gains oxygen and loses carbon dioxide. 3. Internal Respiration- is the exchange of gases between blood in systemic capillaries and tissue cells. In this step the blood loses oxygen and gains carbon dioxide. Within cells, the metabolic reactions that consume oxygen and give off carbon dioxide during the production of ATP are termed cellular respiration.

1) Nasopharynx- superior portion of the pharynx, lies posterior to the nasal cavity and extends to the soft palate. Eustachian tubes from the middle ear cavities open into the nasopharynx. 2) Orophraynx- the intermediate portion of the pharynx, lies posterior to the oral cavity and extends from the soft palate inferiorly to the level of the hyoid bone. It has one opening called the fauces. Fauces has both respiratory and digestive functions, it serves as common passageway for air, food and drink. Two pairs of tonsils, the palatine and lingual tonsils are found in the oropharynx. 3) Laryngopharynx- also known as hypopharynx, is the inferior portion of the pharynx and begins at the level of the hyoid bone. It opens into the esophagus posteriorly and the larynx anteriorly. LARYNX Also known as the voice box, it is a short passageway that connects the laryngopharynx with the trachea. It lies in the midline of the neck anterior to the esophagus and the fourth through sixth cervical vertebrae. Larynx is made of nine pieces of cartilage, yielding a firm yet flexible tissue that keeps the airway open. It is lined with ciliated epithelium. The thyroid cartilage, commonly known as Adams apple, is the largest of these cartilage pieces and is palpable on the front of the neck. The epiglottis s the uppermost cartilage and covers the larynx, like a flap when the larynx is elevated during swallowing. The vocal cord are on either side if the rima glottidis (airway opening). When pulled together across the rima glottidis and vibrated by exhaled air, the vocal cords produce sounds that may be turned into speech. TRACHEA Or windpipe, is a tubular passageway for air that is about 12 cm (5 inches) long and 2.5 cm (1 inch) in diameter. It is located anterior to the esophagus and extends from the larynx to the superior border of the fifth thoracic vertebra, where it divided into right and left primary bronchi. The nine cartilage of the larynx are:

Etiology: Age- COPD is rarely found below the age of 40). Lung function deteriorates with age. Ageing may therefore increase the susceptibility for the development of COPD and its exacerbations. As previously stated, COPD prevalence is higher in elderly people; it is not the physiological decline of the function which predispose to COPD. Gender-Male Genetic factors- A rare inherited condition and the only currently known genetic risk factor for COPD, alpha1-antitrypsin (AAT) deficiency is due to the inability to produce enough of the lung-protective protein AAT in the liver. Severe AAT-deficiency leads to emphysema at an early age Smoking - Smoking impairs cilliary action and macrophage function causing inflammation in the airway. Increased mucus production, alveolar destruction and peribronchiolar fibrosis. Occupation pollution exposure - Exposure to harmful particles, chemicals, vapors or gases while at work organic materials (animal dander, grain dust), chemicals (beryllium), and asbestos particles. Environmental air pollution - Research conducted by NIEHS scientists has shown that long-term exposure to air pollutants increases the risk of respiratory illnesses such as allergies, asthma, chronic obstructive pulmonary disease, and lung cancer. Children and the elderly are particularly vulnerable to the health effects of ozone, fine particles, and other airborne toxicants.

a. Monitor respirations and breath sounds. Laboratory Tests: Arterial blood gases - are measured to determine the amount of oxygen dissolved in the blood (pO2), the percentage of hemoglobin saturated with oxygen (O2 sat), the amount of carbon dioxide dissolved in the blood (pCO2), and the amount of acid in the blood pH. The oxygen measure may be used to determine whether a patient needs oxygen therapy. Spirometry The most reliable way to determine reversible airway obstruction is with spirometry, a procedure that measures the amount of air entering and leaving the lungs. This simple test can be performed in most physicians' offices, with the patient sitting comfortably in front of the spirometry machine. The machine measures airflow that passes through the inhalation port attached to the machine. The inhalation device is usually a disposable cardboard tube or a reusable tube that can be sterilized after use. The patient inhales as deeply as possible and forms a seal around the tube with their mouth. Then the patient exhales, as forcefully and rapidly as they can, until they can exhale no more. To be an adequate test, the patient must exhale all the air they possibly can continue exhaling for at least another 6 seconds. Usually, three separate attempts are made and the best result is used for evaluation. Oximetry- This noninvasive method determines the oxygenation of the blood (O2 sat; normal is greater than 90%) by measuring the amount of light transmitted through an area of skin. The device must be able to read pulsatile flow, so it must pick up a pulse to be accurate. Chest X-Ray- Findings characteristic of COPD in chest x-ray are hyperinflated lungs with flattened diaphragm, hyperlucent lungs (chest film shows greater than normal film blackening from increased transmission of x-rays), and central pulmonary artery enlargement. Bullae, areas of destroyed lung tissue that create large dilated air sacs, may be seen as well. Management: Bronchodilators (beta2 agonists, anticholinergics, and theophylline) beta2 agonists relax the smooth muscle thereby decreasing bronchoconstriction and airflow obstruction Anti-inflammatory drugs (corticosteroids). These are most effective when inhaled. There are several delivery methods for inhaled medications, including metered-dose inhalers, breath-actuated inhalers, dry powder inhalers, and nebulizers Mucolytics- guaifenesin, potassium iodide, and N-acetylcysteine. i. Lung Volume Reduction Surgery & COPD In lung volume reduction surgery (LVRS), the upper portions of the diseased lungs are removed 4. nutrients. a. 1. a. b. c. d. e. f. g. h. i. Impaired gas exchange r/t altered O2 delivery Elevate head of bed/position client appropriately. Encourage frequent position changes and deep breathing/coughing exercise Provide supplemental oxygen at lowest concentration as indicated Maintain adequate I&O for mobilization of secretions but avoid fluid overload Avoid use of facemask in elderly emaciated client. Administer medications as indicated Encourage adequate rest and limit activities within client tolerance Promote calm/restful environmentnote character and effectveiness of cough mechanism Monitor/adjust ventilator settings 5. a. b. c. d. e. f. g. 2. Ineffective Airway Clearance r/t bronchospasms h. Risk for infection r/t decreased ciliary action. Monitor clients visitors/caregiveers for respiratory illnesses Provide for isolation as indicated Fill bubbling humidifiers/nebulizers with sterile water Encourage deep breathing Provide positional changes Maintain adequate hydration Administer medications as indicated Discuss role of smoking in contributing to the illness b. c. Imbalanced Nutrition: less than body requirements r/t inability to ingest adequate Promote comfort measures and provide for relief of pain b. elevate head of bed/change position every 2hours and prn c. Insert oral airway d. give expetorants/bronchodilators as ordered e. support reduction/cessation of smoking f. position appropriately g. increase OFI to at least 2000ml/day within cardiac tolerance h.keep environment allergen free. i. Perform/assist client with postural drainage and percussion as indicated if not contraindicated by condition such as asthma

3. a. b. c. d. e. f. g. h.

Activity Intolerance r/t imbalance between O2 supply and demand Report client signs of weakkness Adjust activities ot prevent overexertion Provide/monitor response to supplemental oxygen as indicated Increase exercise/activitiy levels gradually; teach methods to conserve energy Plan care to carefilly balance rest periods with activities Provide positive atmosphere Encourage expression of feelings contributing to/resulting from condition Assist with activities and provide/monitor clients use of assistive devices

Identify client risk for malnutrition Assess weight Provide diet modification

Pathophsyiology
Predisposing Factors Age Sex Genetic Factor Precipitating Factors Smoking Occupational Exposure Air Pollution

Inhalation of irritants and irritation of airway lining

Production of neutrophils, macrophage and lymphocytes Inflammation of epithelium of the central airway and mucous producing glands

Production of excess smooth muscles and connective tissues

Destruction of Elastase

Fibrotic scars in the airway

Ineffective breakdown of Elastin

S/Sx: Productive Cough Dyspnea Body Malaise Production of thick sputum

Blockage/ Narrowing of the airway Chronic Bronchitis

Hyperinflation of the lungs

Emphysema

S/Sx: Barrel Chest Weight Loss Fatigue

Laboratory Tests Arterial blood gas

S/Sx Chronic Cough Wheezing Chest Tightness Clubbing of Fingers Hemoptysis Cyanosis

Diagnostic Test Spirometry Chest X-Ray Oximetry

Chronic Obstructive Pulmonary Disease

Medical Management Bronchodilators Anti-Inflammatory Drugs Corticosteroids Mucolytics Oxygen

Surgical Management Lung Volume Reduction Surgery Lung Transplantation

Nursing management Impaired Gas Exchange related to altered oxygen delivery Ineffective airway clearance related to bronchospasms Activity intolerance related to imbalanced oxygen supply and demand Imbalanced nutrition:Less than body requirements related to inability to ingest adequate nutrients Risk for infection related to decreased ciliary action

Prognosis

If Treated

If not treated
Exacerbations will contionue Respiratory Insufficiency and Failure Respiratory Infection Pneumothorax Death

Strict compliance to treatment regimen and total abstinence of smoking will lead to a good prognosis