SL CONTENT PAGE

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1 INTRODUCTION 2

2 DEFINITION 2

3 INCIDENCE 2

4 RELATED ANATOMY AND PHYSIOLOGY 3-4

5 TYPES 4

6 RISK FACTORS 5

7 ETIOLOGY 5

8 PATHOPHYSIOLOGY 6

9 CLINICAL MANIFESTATIONS 6-7

10 DIAGNOSTIC STUDIES 7-8

11 MANAGEMENT 8-10

12 COMPLICATIONS 11

13 CONCLUSION 11

14 BIBLIOGRAPHY 12

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 CHRONIC OBSTRUCTIVE PULMONARY DISEASE

INTRODUCTION
Chronic obstructive pulmonary disease refers to chronic bronchitis or emphysema, a pair of
two commonly co-existing diseases of the lungs in which the airway becomes narrowed. This
leads to a limitation of the flow of air to and from the lungs causing shortness of breath.
Chronic obstructive pulmonary disease (COPD) is a disease state characterized by airflow
limitation that is not fully reversible. COPD may include diseases that cause airflow
obstruction (e.g., emphysema, chronic bronchitis) or a combination of these disorders.

DEFINITION

According to GOLD 2011,

“Chronic Obstructive Pulmonary Disease, a common
preventable and treatable disease, is characterized by persistent airflow limitation that is
usually progressive and associated with an enhanced chronic inflammatory response in the
airways and the lung to noxious particles or gases”.

According to GOLD 2017,

“Chronic Obstructive Pulmonary Disease is a common,
preventable and treatable disease that is characterized by persistent respiratory symptoms and
airflow limitation that is due to airway and/or alveolar abnormalities usually caused by
significant exposure to noxious particles or gases”.

INCIDENCE
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 It is the 3 leading cause of mortality and 12 leading cause of disability.
 In 2020 COPD is the 3rd leading cause of death.
 It is commonly seen in males and in smokers.
 It is the third ranked cause of death in the United States, killing more than 120,000
individuals each year.

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RELATED ANATOMY AND PHYSIOLOGY

Fig: Anatomy and physiology of the respiratory system

STRUCTURES:

 The anatomy of a typical respiratory system is the respiratory tract. The tract is

divided into an upper and a lower respiratory tract.
1. The upper tract includes the nose, nasal cavities, sinuses, pharynx and the part
of the larynx above the vocal folds.
2. The lower tract includes the lower part of the larynx,
the trachea, bronchi, bronchioles and the alveoli

FUNCTIONS:

1. Breathing or ventilation -as air moves along the respiratory tract it is warmed,
moistened and filtered.
2. External respiration, which is the exchange of gases (oxygen and carbon dioxide)
between inhaled air and the blood.
3. Internal respiration, which is the exchange of gases between the blood and the tissue
fluids.

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 4. Cellular Respiration, the main processes serves for:
 Regulation of blood pH, which occurs in coordination with the kidneys, and as
a Defence against microbes.
 Control of body temperature due to loss of evaporate during expiration

MECHANICS OF BREATHING:
 Inhalation at rest is primarily due to the contraction of the diaphragm As the
diaphragm contracts, the rib cage is simultaneously enlarged by the ribs being pulled
upwards by the intercostal muscles . The enlargement of the thoracic cavity's vertical
dimension by the contraction of the diaphragm, and its two horizontal dimensions by
the lifting of the front and sides of the ribs, causes the intrathoracic pressure to fall.
The lungs' interiors are open to the outside air, and being elastic, therefore expand to
fill the increased space. The inflow of air into the lungs occurs via the respiratory
airways. During exhalation the diaphragm and intercostal muscles relax. This returns
the chest and abdomen to a position determined by their anatomical elasticity.

TYPES
The term chronic obstructive pulmonary disease encompasses two types of obstructive
airway diseases. COPD includes chronic bronchitis and emphysema. Asthma is not
considered part of COPD due its reversibility.

1. Chronic Bronchitis: It is a condition in which the bronchial tubes becomes inflamed.

It is a chronic inflammation of lower respiratory tract characterized by excessive
mucous secretion, cough & dyspnea associated with recurrent infections of the lower
respiratory tract.
2. Emphysema: It is an abnormal permanent enlargement of the air space distal to the
terminal bronchioles, accompanied by destruction of their walls and without obvious
fibrosis. It is a complex lung disease characterized by damage to the gas-exchanging
surfaces of the lungs (alveoli). Only about 10% of patients with COPD have pure
emphysema.
CLASSIFICATION OF SEVERITY OF COPD
STAGE SYMPTOMSPULMONARY
FUNCTION TESTS
STAGE 0: AT RISK CHRONIC SYMPTOMS NORMAL SPIROMETRY
STAGE I: MILD COPD WITH OR WITHOUT <80 %
CHRONIC SYMPTOMS
STAGE II: MODERATE WITH OR WITHOUT 50-80%
COPD CHRONIC SYMPTOMS
STAGE III: SEVERE WITH OR WITHOUT 30-50%
COPD CHRONIC SYMPTOMS
STAGE IV: VERY WITH OR WITHOUT <30% OR <50% AND
SEVERE COPD CHRONIC SYMPTOMS CHRONIC RESPIRATORY
FAILURE

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RISK FACTORS
 Cigarette Smoking
 Occupational dust and chemicals
 Environmental tobacco smoke
 Indoor and outdoor pollution
 Nutrition
 Infections
 Socio-economic status
 Aging population

ETIOLOGY FOR COPD

1. Exposure to tobacco smoke accounts for an estimated 80% to 90% of COPD cases.
2. 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 sacs—all
contributing factors for COPD.
3. Passive smoking: Passive smoking is the inhalation of tobacco smoke, called second
hand smoke (SHS), or environmental tobacco smoke (ETS), by persons other than the
intended "active" smoker. It occurs when tobacco smoke enters an environment,
causing its inhalation by people within that environment.
4. Occupational exposure: Exposure to workplace of dusts found in coal mining, gold
mining, and the cotton textile industry and chemicals such as cadmium, isocynates
and fumes from wielding have been implicated in the development of COPD.
5. Ambient air pollution: Ambient air pollution is a broader term used to describe air
pollution in outdoor environments. Poor ambient air quality occurs when pollutants
reach high enough concentrations to affect human health and/or the environment.
6. Sudden airway constriction in response to inhaled irritant.
7. Bronchial hype-responsiveness, is a characteristic of asthma.
8. Genetic abnormalities: alpha 1-antitrypsin deficiency is a genetic condition that is
responsible for about 2% of cases of COPD. In this case the body does not make
enough of the protein to protect the lungs from damaged caused by an inflammatory
response due to tobacco use.

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PATHOPHYSIOLOGY

Abnormal inflammatory response of the lungs due to the toxic gases

Response occurs in the airways, parenchyma and the pulmonary vasculature

Narrowing of the airway takes place

Destruction of parenchyma leads to emphysema

Imbalance of proteinases/antiproteinases

Pulmonary vascular changes (thickening of vessels, collagen deposits, destruction of capillary

beds)

Mucus hypersecretion (cilia dysfunction, airflow limitation, corpulmonale)

Chronic cough and sputum production

CLINICAL MANIFESTATIONS
 COPD is characterized by three primary symptoms:
1. Cough
2. Sputum production and
3. Dyspnea on exertion (DOE): Dyspnea may be severe and often interferes with the
patient’s activities. Weight loss is common because dyspnea interferes with eating.
 ACUTE SYMPTOMS
 Sore throat
 Fatigue (tiredness), weight loss
 Fever and bodyache
 Stuffy nose or runny nose
 Vomiting and diarrhea
 Persistent cough
 Cough may produce clear mucus
 Shortness of breath

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  CHRONIC SYMPTOMS
 Coughing
 Wheezing
 Chest discomfort
 The coughing may produce a large amounts of mucus. This type of cough
often is called a smoker’s cough.

DIAGNOSTIC EVALUATION
1. History collection (The nurse should obtain a thorough health history for a patient
with known or potential COPD).

Key factors to assess in the COPD Patient’s Health History

 Exposure to risk factors- types, intensity, duration.
 Past medical history-respirator diseases/problems, including asthma, allergy, sinusitis,
nasal polyps, history of respiratory infections.
 Family history of COPD or other chronic respiratory diseases.
 Pattern of symptom development.
 History of exacerbations or previous hospitalizations for respiratory problems.
 Presence of comorbidities.
 Appropriateness of current medical treatments.
 Impact of the disease on quality of life.
 Available social and family support for patient
 Potential for reducing risk factors (e.g., smoking cessation).

2. Pulmonary function tests: Pulmonary function tests are useful in diagnosing and
assessing the severity of COPD. Usually spirometry is ordered before and after
bronchodilation. The most significant findings are related to increased resistance to
expiratory airway.

3. Spirometry: It is used to evaluate airflow obstruction.

4. Arterial blood gas (ABGs) measurements may also be obtained to access baseline
oxygenation and gas exchange. It is usually assessed in the severe stages and
monitored in patients hospitalized with acute exacerbations.

5. Alpha-1antitrypsin deficiency screening may be performed for patients under age

45 or for those with a strong family history of COPD.

6. Chest X-Ray: Chest X-ray Abnormal chest X-ray findings are usually not seen until
COPD is severe. In this case, the X-ray may show:

 Flattening of the diaphragm, the large muscle that separates the lungs and
heart from the abdominal cavity.
 Increased size of the chest, as measured from front to back.
 A long narrow heart.

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  Abnormal air collections within the lung (focal bullae). A normal chest X-ray
does not mean you do not have COPD. It may be most useful for ruling out
other conditions that might be causing your breathing problems, such as lung
cancer, heart failure, pneumonia, or tuberculosis.

MANAGEMENT
The main objective of COPD management are following:
1. Relieve symptoms
2. Prevent disease progression
3. Reduce mortality & improve exercise tolerance
4. Prevent and treat complications.

MEDICAL MANAGEMENT
1. RISK REDUCTION

 Smoking cessation is the single most effective intervention to prevent COPD

or slow its progression. (smoking cessation is major essential to reduce disease
progression and improve survival rate)
 Nurses play a key role in promoting smoking cessation and educating patients
about ways to do so. Patients diagnosed with COPD who continue to smoke
must be encouraged and assisted to quit.

2. PHARMOCOLOGICAL THERAPY

 Bronchodilators: Bronchodilators relieve bronchospasm and reduce airway

obstruction by allowing increased oxygen distribution throughout the lungs
and improving alveolar ventilation.
 These medications, which are central in the management of COPD are
delivered through a metered-dose inhaler (MDI) by nebulization, or via the
oral route in pill or liquid form.

3. CORTICOSTEROIDS

 Corticosteroids. Inhaled and systemic corticosteroids (oral or intravenous)

may also be used in COPD but are used more frequently in asthma.
 Although it has been shown that corticosteroids do not slow the decline in
lung function, these medications may improve symptoms.
 Other Medications including Patients should receive a yearly influenza
vaccine and the pneumococcal vaccine every 5 to 7 years as preventive
measures.

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 4. MANAGEMENT EXACERBATION


An exacerbation of COPD is difficult to diagnose, but signs and symptoms
may include increased dyspnea, increased sputum production and purulence,
respiratory failure, changes in mental status, or worsening blood gas
abnormalities.
 Primary causes for an acute exacerbation include tracheobronchial infection
and air pollution.
5. OXYGEN THERAPY
 Oxygen therapy can be administered as long-term continuous therapy, during
exercise, or to prevent acute dyspnea.
 Long-term oxygen therapy has been shown to improve the patient’s quality of
life and survival.

SURGICAL MANAGEMENT
 Bullectomy: Bullae are enlarged airspaces that do not contribute to ventilation but
occupy space in the thorax, these areas may be surgically excised.
 Lung volume reduction surgery: It involves the removal of a portion of the diseased
lung parenchyma. this allows the functional tissue to exposed.
 Lung transplantation

PULMONARY REHABILITATION
 The primary goal of rehabilitation is to restore patients to the highest level of
independent function possible and to improve their quality of life.
 A successful rehabilitation program is individualized for each patient, is
multidisciplinary, and attends to both the physiologic and emotional needs of the
patient.

NURSING MANAGEMENT
NURSING DIAGNOSIS
1. Ineffective breathing pattern related to chronic airflow limitation.
2. Ineffective airway clearance related to bronchoconstriction, increased mucus
production, ineffective cough, possible bronchopulmonary infection.
3. Risk for infection related to compromised pulmonary function, retained secretions and
compromised defense mechanisms.
4. Imbalanced nutrition: less than body requirements related to increased work of
breasting, presenting dyspnea & drug effects.
5. Deficient knowledge of self-care strategies to be performed at home.

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ASSESSMENT
 Assess the client status ask detail about smoking (pack per year history, occupational
exposure history, positive family history of respiratory disease etc.)
 Note amount, color and consistency of sputum.
 The nurse should be inspect for use of accessory muscles during respiration and use of
abdominal muscles during expirations.
 The nurse plays a key role in identifying potential candidates for pulmonary
rehabilitation and in facilitating and reinforcing the material learned in the
rehabilitation program.

NURSING INTERVENTIONS
 The nurse should teach to patient and family as well as facilitating specific services
for the patient (e.g., respiratory therapy education, physical therapy for exercise and
breathing retraining, occupational therapy, medications using e.g. MDI, Nebulization
for conserving energy during activities of daily living, and nutritional counselling).
 BREATHING EXERCISE:
 Inspiratory muscle training is defined as a course of therapy consisting of a
series of breathing exercises that aim to strengthen the bodies’ respiratory
muscles making it easier for people to breathe. Inspiratory muscle training is
normally aimed at people who suffer from asthma, bronchitis, emphysema and
COPD.
 Diagphragmatic breathing: It reduces respiratory rate, increases alveolar
ventilation, and sometimes helps expel as much air as possible during
expiration.
 Pursed lip breathing: It is a technique that helps in shortness of breath. To
practice pursed lip breathing one has to breathe in slowly through the nose
keeping the mouth closed. Pucker or Purse the lips as if to whistle and breathe
out.
 Self-care activities: As gas exchange, airway clearance, & the breathing pattern
improve, the patient is encouraged to assume increasing participation in self-care
activities.
 Oxygen Therapy: Oxygen supplied to the home comes in compressed gas, liquid, or
concentrator systems. Portable oxygen systems allow the patient to exercise, work,
and travel.
 Nutritional Therapy: Nutritional assessment and counseling are important aspects in
the rehabilitation process for the patient with COPD.

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COMPLICATIONS
1. Respiratory insufficiency and Respiratory failure are major life-threatening
complications of COPD.
2. Pneumonia & respiratory infection.
3. Right-sided heart failure
4. Pulmonary hypertension
5. Pneumothorax
6. Skeletal muscle dysfunction
7. Depression and anxiety disorders

CONCLUSION
Earlier COPD was closely associated with smoking tobacco. But, today only 20% of the
cases are related to smoking -remaining part of the population is getting COPD due to other
factors. We believe that over half of the cases are caused by air pollution.COPD makes
breathing difficult for the 16 million Americans who have this disease. Millions more suffer
from COPD , but have not been diagnosed and are not being treated. Although there is no
cure for COPD, it can be treated.

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BIBLIOGRAPHY

1. Grant A.W. Anne. Ross and Wilson Anatomy and Physiology. 10th Edition. China:
Elsevier Publishers(P) Ltd:2008. P:
2. Chintumani. Lewis Medical Surgical Nursing. New Delhi, India: Elsevier India (P)
Ltd:2015. P:
3. Brunner and Siddarth’s. Textbook of Medical-Surgical Nursing. 14th Edition.
Philadelphia:Wolters Kluwer, 2018. P:634-47
4. Mahler.A.Donald. Chronic Obstructive Pulmonary disease. 1st
Edition.Minneapolis:Hillcrest Media Group,2015.

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