What You Need To Know: Chronic Obstructive Pulmonary Disease (COPD)

Tuesday I had a patient admitted to the ICU for an exacerbation of COPD. They had a respiratory rate of 40, pulse oximetry of 89 and pulse of 140. They were dyspneic, in pain and just not in good shape.

For those of you that know about COPD, you may not learn much from this article, but for those of you that don't know what COPD is, what it does and what it can do to you, please read on.

What Is COPD?

COPD is an acronym for Chronic Obstructive Pulmonary Disorder. COPD is a disease characterized by airflow limitation. COPD is preventable and treatable, though not reversible.

What Causes COPD?

The airflow limitation is progressive and is due to an abnormal inflammatory response to noxious particles or gases. A primary cause is cigarette smoking. The lungs become irritated and inflamed when the smoke is inhaled.

Other causes include occupational chemicals and dusts, air pollution and severe, recurring respiratory infections.

What Is COPD? Part II

There are two types of COPD, Chronic Bronchitis and Emphysema. Chronic bronchitis is characterized by a productive cough that is present for 3 months in each of 2 consecutive years and all other causes of chronic cough have been ruled out. Emphysema is an abnormal and permanent enlargement of airspace's, accompanied by wall destruction without fibrosis. It is rare for a patient to be diagnosed strictly with chronic bronchitis or emphysema. The conditions usually coexist.

Who Gets COPD?

According the the Medical Surgical Nursing Assessment and Management of Clinical Problems text, an estimated 10.7 million Americans over the age of 18 have COPD.

COPD is more common in men, although the number of women affected is on the rise due to an increase of women smokers.

What Happens To You When You Get COPD?

COPD isn't something that happens over night-you don't wake up one morning and say "oh, I'm havin' a hard time breathing. Must be that COPD stuff." Instead, COPD is gradual and can take awhile for a person to realize they're having trouble breathing.

Clinically speaking, the pathophysiology of COPD includes inflammation of the airways, lung parenchyma (gas-exchanging surfaces) and pulmonary vasculature.

The inflammation results in increased mucous production and recurrent cycle of injury and repair to the airway walls, which results in scar tissue and collagen formation. All of this combined results in narrowing of the airways.

In the lungs themselves, the alveoli and respiratory bronchioles are the gas-exchanging surfaces. In a person with COPD, these become damaged and less functional. This means that when oxygen is inhaled, the alveoli are less able to exchange the oxygen for CO2 to be blown off.

Another area damaged is the supporting structures of the lungs- these are necessary to pull, or put traction on the bronchioles, allowing CO2 and air to exit the lungs (be blown off). This can be likened to blowing into a paper bag: oxygen enters easily, but is unable to come out, thus remaining in the lung. During this time, the bronchioles become further damaged and collapse (esepecially on expiration). Oxygen remaining in the lung becomes trapped and results in hyperinflation and over distention of the alveoli. The trapped air eventually leads to the signature "Barrel Chest" appearance of COPD patients.

Simply put: In COPD, the lungs are easily inflated, but can only partially deflate.

Symptoms:

Manifestations usually begin to develop around 50 years of age after smoking 20-packs per year. Consider seeking a medical diagnoses/ medical help if you have the following:

cough

sputum production

dyspnea (shortness of breath)

and/or a history of exposure to risks factors for the disease

A red flag is often an intermittent cough that occurs most often in the morning with expectoration of small amounts of sticky mucous.

Dyspnea is shortness of breath, and in COPD is progressive and usually occurs with exertion. Eventually as the disease progresses dyspnea will occur at rest as the alveoli become overdistended and larger amounts of air is trapped.

What Happens In The Long Run? Prognosis:

Although COPD is not curable or reversible, it can be treated.

The number one, most important thing to do is STOP SMOKING! Smoking is only going to further irritate the airway and cause problems. Other options for treatment include respiratory and physical therapy.

Respiratory therapy will help a patient with breathing retraining. It will teach the patient to Pursed Lip Breathe: Inhale slowly through the nose and then exhale (very) slowly through pursed lips (almost like whistling). The intent is for exhalation to be 3 times as long as inhalation. This should be done before and after any activity that causes dyspnea and tachypnea (increased/fast respirations).

Physical therapy will help the patient learn ways to go about daily and physical activities that will help decrease dyspnea and tachypnea and help the client maintain a better quality of life.

Drug therapy is also usually prescribed. Drugs of choice include: Albuterol, Atrovent, and Serevent. Other drugs that may be prescribed are Spiriva and sometimes corticosteroids. Oxygen therapy is also widely prescribed to help treat COPD and hypoxemia (low blood-oxygen level).

Unfortunately, the later COPD is diagnosed and treatment started, the worse off the patient is. Quality of life depends largely on the stage of disease at diagnoses and compliance with the medical regimen.

So What Happened To The Patient?

When my shift was over Tuesday, my patient was satting in the low 90's thanks to 4 Liters of oxygen per nasal cannula and respirations were in the 20's. Normal oxygen saturation is 98-100 and respirations are 11-20. This patient was beginning to enter the late stages of COPD. The effects were evident in all of the body systems: legs were a purple/blue color due to a lack of oxygen reaching the lower extremities, urine was a deep amber color due to renal dysfunction and the patient had diminished lung sounds throughout due to a lack of airflow within the lungs. The patient had to sleep sitting up as being on their back caused an extreme increase in respiratory rate and effort and a decrease in O2 sats. The patient became winded with simple tasks such as combing hair and brushing teeth. Unfortunately, this patient also refused treatment that could have helped ease respiratory effort. This patient also chose to continue smoking 1-2 packs/day. At 65 years old, this patient was living the life of someone 40 years their senior. Their quality of life was minimal: 25 medications multiple times a day, amputations with un-healing incisions and completely dependent on others for bathing and toileting because they didn't have enough energy to complete the tasks.

As I left it was expected for this patient to be moved to the regular unit for a few more days and then be discharged home, most likely to get another infection and be re-admitted to the ICU. This patients life will play out in this circle until the lungs become too damaged function at all.