Lesson 3 Chronic Obstructive
Pulmonary Disease (COPD)
CHRONIC OBSTRUCTIVE
PULMONARY DISEASE
Individuals with COPD are at risk for ARF
due to progressive airflow limitation with
chronic inflammatory airway and lung
response. Altered host defenses, increased
secretion volume and viscosity, impaired
secretion clearance and airway changes, and
common pathophysiologic changes predispose
the patient with COPD to acute exacerbations
or episodes of ARF. The etiology, clinical
presentation, and management of ARF in
COPD patients vary somewhat from ARF
without chronic underlying pulmonary
dysfunction. This section of the chapter
highlights differences in ARF management in
the patient with underlying COPD.
Cristobal, Rocelyn P.
Any systemic or pulmonary illness can
precipitate ARF in patients with COPD. In
addition to the etiologies of ARF diseases or
situations that decrease ventilatory drive,
muscle strength, chest wall
elasticity, or gas exchange capacity,
or increase airway resistance or
metabolic oxygen requirements can
easily lead to ARF in patients with
COPD. The most common
precipitating events include.
> Respiratory infection
(pneumonia, bronchitis): This is the
most frequent trigger of COPD
exacerbations. Respiratory
infections can be caused by virus or bacteria.
Common pathogens in patients with COPD
include Haemophilus influenza, Streptococcus
pneumoniae, Moraxella catarrhalis, and
Pseudomonas aeruginosa
> Environmental factors: Pollution or smoking,
including second hand smoke is an additional
common cause of ARF.
>Pulmonary embolus: The high incidence of
right ventricular failure in COPD increases the
risk of pulmonary embolus from right
ventricular mural thrombi. PE in patients with
COPD exacerbations may contribute to
respiratory compromise or it may be an
incidental finding in these patients.
> Pulmonary hypertension (PH): The presence
of secondary PH typically due to chronic
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hypoxemia, left heart failure, or sleep apnea
may also be an additional risk factor for ARF.

> Patient factors: Other medical conditions

such as heart disease or diabetes along with
advanced age, previous hospitalizations,
duration of COPD, productive cough, and
history of antibiotic use are associated with
the increased risk the development of ARF in
COPD patients places a tremendous burden
on the pulmonary system. The chronic disease
process leads to impaired ventilation, poor gas
exchange, and airway obstruction. The
additional burden of an acute disease process,
even a relatively minor one, further impairs
ventilation and gas exchange and increases
airway obstruction. Compensatory
mechanisms can easily be overwhelmed, with
lethal consequences.

Signs and symptoms are similar to ARF, but

usually more pronounced.

Management of ARF in Patients

with COPD
The presence of chronic respiratory
dysfunction and an acute respiratory
problem leads to some changes in the
typical management of ARF. Treatment is
directed at both the acute precipitating
Cristobal, Rocelyn P. 2
event and the chronic airflow obstruction
problems associated with COPD.
Treating the Underlying Disease
State
1. Increase airway diameter with
bronchodilators and reduce airway edema
with corticosteroids. Short-acting
beta2-agonists (SABA) with or without
anticholinergic agents are recommended
as the initial treatment. Higher than usual
doses may be necessary until the
precipitating event is resolved. Systemic
corticosteroids are used to decrease airway
inflammation and thus bronchospasm.
The steroids may also enhance secretion
clearance.
2. Treat pulmonary infections with
appropriate antibiotics.
3. Improve secretion removal. Strategies to
improve secretion removal include
adequate hydration, coughing, heated
moist aerosolization, and mobilization.
The routine use of chest physiotherapy is
not supported by the literature and is not
recommended. Secretions may be thick
and tenacious. Monitor response to these
therapies and discontinue them if no
additional benefits are observed.
Cristobal, Rocelyn P.
Improving Oxygenation and
Ventilation
1. Correct hypoxemia with small increases
in Fio2 levels, preferably with a controlled
02 delivery device such as a Venturi mask,
biphasic intermittent positive airway
pressure (BiPAP), or continuous positive
airway pressure (CPAP). The goal is to
maintain adequate arterial oxygenation
(Pao2 of55-60 mm Hg or the patient's
baseline values during nonacute
situations) without significantly increasing
Paco2 levels. The administration of oxygen
to COPD patients was once believed to
eliminate the "hypoxic drive to breathe,"
creating a risk for hypercarbia, acidosis,
and death. The hypoxic drive is
responsible for approximately 10% of the
total drive to breathe. Supplemental
oxygen is usually necessary to prevent the
deleterious effects of hypoxia and
potential organ failure. Higher than
necessary Fio2 levels are avoided. Oxygen
administration in COPD patients is
necessary to prevent hypoxia and organ
failure and are never withheld. Titration
and considerations for mechanical
ventilation in the COPD patient with C02
retention (Paco2 > 50 mm Hg) are guided
by the pH and Paco2.
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Nutritional Support
1. Initiate enteral or oral feeding as soon as
possible, once hemodynamic stability is
achieved.
2. In patients who are unable to eat, use
enteral feeding rather than parenteral
nutrition to decrease risk of infectious
complications
3. If used, noninvasive positive pressure
ventilation makes oral feeding difficult,
and the insertion of a small bore
nasoenteric tube may be necessary
1. Position the patient to maximize
ventilatory efforts and relaxation/rest
during spontaneous breathing. A high
Fowler position and leaning on an overbed
table may be a position of comfort prior to
intubation and mechanical ventilation.
Cristobal, Rocelyn P.
2. Teach relaxation techniques and
diaphragmatic, pursed-lip
breathing to decrease anxiety and
improve ventilatory patterns.
Anxiolytics and other sedatives are
used cautiously to avoid decreasing
MV.
3. Assist with implementing
noninvasive ventilation if needed.
The use of noninvasive ventilation
in COPD patients with ARF is
preferred.
4. Monitor patients managed with
supplemental oxygen or noninvasive
ventilation for the need for intubation.
Deterioration of mental status,
hemodynamic instability, and inadequate
response to initial therapy are all
indications that intubation and
mechanical ventilation are warranted. The
patient's baseline pulmonary function and
functional status, and the reversibility of
the condition causing ARF are also factors
in the decision to intubate. Weaning from
mechanical ventilation is frequently more
difficult, and in some cases not possible, in
the presence of COPD. Informed
discussions with the patient and family
regarding intubation are essential. The
presence of an advanced directive and
designation of a power of attorney for
healthcare decisions can help in guiding
clinician's actions when patients are
unable to make treatment decisions
themselves.
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5. Close monitoring of COPD patients is
also required following intubation and
initiation of mechanical ventilation.

Cristobal, Rocelyn P. 5