Obstructive Pulmonary Diseases (Chapter 28)

Asthma
Patho:
 Bronchial hyperresponsiveness with reversible expiratory air flow limitations
 Obstruction is related to (p. 544, fig. 28.3):
o Muscle spasm
o Swollen mucosa (inflammation & irritation)
o Mucus
 Remodeling:
o Chronic inflammation leading to structural changes in the bronchial wall

Risk factors / triggers

 Environmental
o Air pollution
o Allergens
o Occupational hazards (mills)
o Infections
o Meds
o Food additives
 Patient
o Genetics
o Stress
o Hormones
 Other factors
o GERD
o Cold, dry air
o Exercise (Exercise-induces asthma = EIA)
Signs & symptoms (only during an attack)
 Wheezing
 Cough
 Chest tightness
 SOB/dyspnea
 Silent chest (after displaying symptoms)
o Medical emergency! Call 911
o No air moving
  Hyperventilation (chest x-ray):
o Increased lung volume
o Air is trapped

Diagnosis
 Peak expiratory flow rate (PEFR)
o Measured with a peak flow meter
o For diagnosis & monitoring
 Spirometry (by respiratory therapist)
o FEV1 : Forced expiratory volume at 1 second
o FVC : Forced vital capacity
 Amount of air quickly and forcefully exhaled after maximum inhalation
o Ratio of FEV1 to FVC
 Chest x-ray
 Pulse oximetry (SaO2)
 Allergy testing
 ABGs
Complications
 Status asthmaticus
o Life-threatening, extreme asthma attack
Treatment
 Control & avoid risk factors/triggers
 Stepwise approach (p. 588, fig. 28.4)
o Severity determined by:
 Number of days with symptoms
 Number of times awakened at night
 Frequency of rescue inhaler use (SABA)
 Interference with ADLs
 FEV1 or PEFR
 Plan for acute attacks (p. 549, fig. 28.5)
 Meds
o SABA (inhaled)
o LABA (inhaled)
o Inhaled corticosteroids (ICS)
o Leukotriene modifying agents (oral)
 Interrupts allergic response
 Singulair (Montelukast)
o Anti-IgE (subcut)
 Decrease allergic response
Chronic obstructive pulmonary disease (COPD)
Patho:
 Progressive, persistent airflow limitation not fully reversed during forced exhalation
o Related to decrease in elastic recoil & airflow obstruction
 Bronchospasm, increased mucus production, mucosal edema
Risk factors:
 Smoking (#1)
 Infections
 Asthma
 Air pollution
 Occupation
 Age
 Genetics
o Alpha-1 antitrypsin deficiency (AATD)

Signs & symptom

 Develop slowly
 Chronic cough
 Increased sputum production
 Dyspnea
 Exposure to risk factors
 Chest breather (accessory muscles)
 Wheezing
 Chest tightness
 Fatigue
 Weight loss / anorexia
 Prolonged expiratory phase
 Decreased breath sounds (diminished)
 Tripod position
 Pursed lip breathing (prolongs exhalation)
 PaO2 < 60 & SaO2 < 88% = Hypoxemia
 PaCO2 > 45 mmHg = Hypercapnia
 Bluish/red skin color
 Polycythemia (increased RBC) & increased Hgb (> 20 g/dL)
  Asthma vs. COPD (pg. 547, tab. 28.4)

Complications
 Pulmonary HTN
 Cor pulmonale (Right-sided HF)
 Acute exacerbations
 Acute respiratory failure

Diagnosis
 Spirometry
o FEV1 to FVC ratio < 70 %
 Chest x-ray
 Echocardiogram
 ABGs
 Sputum testing

Treatment
 Teaching
o Meds (correct use, cleaning of equipment)
o O2 use (no smoking or open flames)
o Exercise
o Alternate rest & activity
 Psychiatric
o Guilt
o Depression
 Flu & pneumonia vaccinations
 Quit smoking
 Pursed lip breathing (PLB) & huff coughing
 Chest physiotherapy = percussion (done by respiratory therapist)
o Loosens secretions
 Vibration
o Loosens secretions
o Vests, flutter valves, etc.
 Nutrition
o Increase in caloric needs (work of breathing [WOB])
 o Shakes & supplements (easier to swallow than eat/chew)
 Palliative care
 Medications

Medications (asthma & COPD)

B2 adrenergic agonists = Relax smooth muscles in bronchioles (dilation of airway)
 Short acting (SABA)
o Rescue meds for acute attack and pre-exercise (EIA)
o Ex. albuterol (Proventl), levalbuterol (Xopenex)
 Long acting (LABA)
o Maintenance meds
o Ex. arformoterol (Brovana), salmeterol (Serevent)
 Side effects:
o Headache
o Tachycardia
o Restlessness
o Tremors
o Nausea
o *Caution with CAD*
Corticosteroids = anti-inflammatory (decrease mucosal edema)
 Inhaled (ICS)
o Absorbed right into lung tissue; minor systemic effects, if any
o Preferred
o Risk for oral thrush (yeast infection)
 Swish & spit after dose to prevent
 Oral & IV
o Systemic effects
o Side effects:
 Hyperglycemia
 Weakened bones
o Ex. prednisone (Oral), methylprednisolone (IV, very potent), SoluMedrol (IVP)
Anticholinergics
 Primarily for COPD
 Short acting (SAMA)
o Ex. ipratropium (Atrovent)
  Long acting (LAMA)
o Ex. tiotropium (Spiriva)
 Systemic side effects
o Can’t see
o Can’t pee
o Can’t spit
o Can’t shit

Leukotriene modifiers
 Ex. montelukast (Singulair)
Methylxanthines
 Ex. aminophylline (IV), theophylline (Oral)
 Not frequently used
Anti-IgE
 Subcut or IV
 Asthma related to allergies
Phosphodiesterase inhibitor type 4 (PDE-4)
 Ex. roflumilast (Daliresp)
o For severe COPD only
Antihistamines
 Reduce allergy symptoms by blocking histamine
 Ex. diphenhydramine (Benadryl), cetirizine (Zyrtec), loratadine (Claritin), fexofenadine
(Allegra)
 Side effects:
o Benadryl, Zyrtec, & Claritin cause drowsiness/sleepiness
o Allegra does not
Antitussives
 Cough suppressants
o Not always a good thing (need to cough up secretions)
 Ex. Tessalon pearls, dextromethorphan (Robitussin)
 Side effects:
o Drowsiness
o Constipation
o Respiratory depression

Mucolytics
 Decrease stickiness of respiratory secretions (thin)
 Ex. guaifenesin (Mucinex)
o Take with large glass of water
 Lots of fluids will work similarly
o But caution with respiratory patients due to cardiac complications
o Watch ejection fraction (EF)
 Normal = 70%
 Bad = < 30%