Introduction

Chronic obstructive pulmonary disease (COPD) is a preventable and treatable

disease with some significant extrapulmonary effects that may contribute to the
severity in individual patients. It is characterized by airflow limitation that is not fully
reversible. The airflow limitation is generally progressive and associated with an
abnormal inflammatory response of the lungs due to noxious particles or gases.
Asthma is not considered part of COPD due to its reversibility but can coexist with
asthma.

There are two types of chronic obstructive pulmonary disease (COPD), chronic
bronchitis and emphysema, which may occur together or separately. Chronic
bronchitis is diagnosed when there is a chronic cough with phlegm (sputum) for at
least 3 months over a period of 2 years. Typically, there is a chronic cough that
produces sputum. Although bronchitis may start out as an acute condition, when it
recurs repeatedly over 2 years, the diagnosis changes to chronic bronchitis. With
emphysema, there is a loss of elasticity of the lung tissue, leading to trapped air.
These air sacs lose their elasticity, swell and some even burst. The destruction is
widespread and irreversible. Both result in inflammation of the airways, trapping air in
the lung.

Both types of COPD involve changes in the lungs, but the changes in bronchitis
come and go, while those in emphysema are permanent. However, both conditions
are chronic and the symptoms will recur at regular intervals. The number one cause
both conditions, is cigarette smoking. About 75 percent of all COPD cases occur in
people with a history of smoking. When a cigarette burns, it creates more than 7,000
chemicals and many are harmful. The chemicals in cigarette smoke weaken the
lungs' defense against infections, narrow air passages, cause swelling in air tubes
and destroy air sacs—all contributing factors for COPD. Using other tobacco
products like e-cigarettes and cigars also increase the risk of developing COPD.
While there are other causes of COPD than smoking – such as air pollutants,
chemical fumes, dust, and other lung irritants – the fact that smoking is the main
cause of chronic obstructive pulmonary disease means that it is largely preventable.
 

The way the lungs are affected in each of the types of COPD accounts for the
differences in symptoms. With bronchitis, there are glands that line the larger
airways, called bronchi. These glands enlarge and produce large amounts of mucus.
The next smaller airways, called bronchioles, also become inflamed. This causes
them to spasm and swell. The result of all these changes is obstruction of the airflow
through these airways into and out of the lungs. Over time, these changes cause
permanent damage to the airways. Bronchitis's main symptom is a "wet" cough, one
that brings up thick, sticky mucus. A low-grade fever (less than 100.4 degrees
Fahrenheit) may also occur. Also, as described earlier, bronchitis symptoms tend to
come and go.

Emphysema, on the other hand, causes a collapse of the walls of the small air
sacs in the lungs called alveoli. These changes generally develop over many years
and do not cause noticeable symptoms until the damage has been done. The result
of these changes is permanent and irreversible airflow obstruction. Another
difference with emphysema is that the condition is progressive. It doesn't come and
go like bronchitis. It worsens over time. Although shortness of breath and fatigue are
two of the most common symptoms, there can be a chronic cough. This cough is not
usually as "wet" as that from chronic bronchitis, however.

An exacerbation of Chronic Obstructive Pulmonary Disease (COPD) is a

worsening or “flare up” of COPD symptoms. In many cases an exacerbation is
caused by an infection in the lungs, but in some cases, the cause is never known.
The inflammation (irritation and swelling) in the lungs during and after an
exacerbation can cause some people to be extremely ill and it often takes a month or
longer to recover completely. Exacerbations can also occur from inhaling irritating
substances from the environment like air pollution, or from severe allergies. The
lungs react to infection or irritating substances by developing inflammation that
makes the airways narrow from muscle tightness, swelling, and mucus. These
changes in the airways cause the increased signs and symptoms. Diagnosis of an
exacerbation is based upon a history of worsened signs (such as oxygen levels being
lower than normal) and symptoms and physical exam findings by a doctor or nurse,
such as difficulty of breathing, wheezing, or rapid shallow breathing. There are no
tests of the blood, sputum, or chest x-rays that have been found to diagnose an
exacerbation. Thus, the best person to help identify an exacerbation early is the
person experiencing itself.

STAGES OF COPD

To determine how difficult it is for air to move out of the lungs, the doctor may
use a test called spirometry to measure lung function. It starts with taking a deep
breath and then blowing as hard as it can into a machine called a spirometer, which
will record measurements like:

 FEV1 (forced expiratory volume in 1 second), a measure of how much air can be
breathed out in 1 second
 FVC (forced vital capacity) is the maximum amount of air one can breathe out in
one breath.
 FEV1/FVC Ratio: FEV1 expressed as a percentage of FVC; people with COPD
usually have an FEV1 that is less than 70% of the FVC, or an FEV1/FVC less
than 0.70.

Then, based on the degree of airflow limitation, it may be classified as 1 of 4

GOLD (Global Initiative for Chronic Obstructive Lung Disease) grades. This
classification of the severity of reduced airflow in COPD by GOLD is based on FEV1
after using a bronchodilator in people with FEV1 or FVC less than 0.70:
Disease Statistics

Risk Factors
Predisposing Factors
Age. COPD prevalence is 2–3 times higher in people above the age of 60 years.
The increased burden of COPD seen in the elderly population may be due to age-
associated changes in the structure and function of the lung, increasing the
pathogenetic susceptibility to COPD. The changes that occur with aging are complex,
but the main difference at a cellular level between the loss of elasticity among
elderlies, and COPD, is that there is destruction of alveolar walls and fibrosis of the
small airways in the latter. This reduces the ability of the airways to remain open in
expiration limiting airflow, which is measured using spirometry.

Gender. The number of women with COPD is increasing at a rate higher than
men. In the last several decades, COPD prevalence and mortality among women
have risen rapidly, and is now equivalent to men. COPD impacts men and women
differently. While tobacco smoke exposure remains an important risk factor for
developing COPD in both genders, worldwide smoke generated from biomass fuel
remains a major risk factor for the development of COPD in women in particular due
to greater exposure due to cooking and domestic responsibilities.

Alpha-1 Antitrypsin Deficiency (AATD). Alpha-1 antitrypsin (AAT) deficiency is

a condition that raises your risk for lung and other diseases. AAT is a protein made in
the liver to help protect the lungs. If the body does not make enough AAT, the lungs
are more easily damaged from smoking, pollution, or dust from the environment. This
can lead to COPD. AAT deficiency runs in families. Many people do not know that
they have it, but early diagnosis can help prevent COPD and other serious lung
diseases.

Allergies. Allergies can cause inflammation in the lungs. This inflammation can
result in coughing, wheezing, shortness of breath, and other symptoms. Allergies and
exposure to environmental pollutants can make COPD symptoms worse.

Childhood Asthma. Asthma triggers often include allergens such as pollen,

dust mites, cockroaches, molds, and animal dander. Allergens can make COPD
symptoms worse. And if left untreated, allergies and asthma can increase the
chances of COPD in certain individuals. While many children outgrow the symptoms
of asthma, lasting damage to their lung function could be an early marker of later
respiratory diseases such as chronic obstructive pulmonary disorder (COPD).

Precipitating Factors

Bronchopulmonary dysplasia (BPD). Babies aren't born with the condition. It

happens when a baby has been on oxygen or on a breathing machine for a long
time. This can damage the lungs, causing inflammation (swelling and irritation) and
scarring. As a result, the lungs do not develop as they should. It’s more common in
premature babies.

Cigarette smoking/ Exposure to second hand smoke. The chemicals 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. Using
other tobacco products like e-cigarettes and cigars also increase your risk of developing
COPD.

Occupational Exposures (dusts, fumes, silica and chemicals). Chronic

obstructive pulmonary disease (COPD) is caused by exposure to noxious particles
and gases. Occupational exposure to vapours, gases, dusts and fumes contributes to
the development and progression of COPD, accounting for a population attributable
fraction of 14%. The lungs react to irritating substances by developing inflammation
that makes the airways narrow from muscle tightness, swelling, and mucus. These
changes in the airways cause exacerbations of the COPD.

Air pollution (biomass fuel/ coal). When exposed to particle pollution, patients
with COPD usually have more emergency room visit, hospital admission, or even
death in some cases. Infection is one of the inducing factors of exacerbations of
COPD. In addition to these processes, pollutants also have negative effects on
mucociliary clearance, virus adhesion to respiratory mucus cells, and immune system
resistance.

Socioeconomic status. Many COPD patients live in poverty and, because of

the cost, have limited access to hospital services, which may increase their risk of
disease progression, acute exacerbations, and death. In addition, environmental
exposures (tobacco smoke, indoor and outdoor air quality, infectious agents),
psychosocial factors (family structure, stress, social support), and health system
factors can have a direct impact on a person's health.

Infectious (HIV/ TB). HIV infection causes alteration in several lines of host
defenses in the lung and respiratory tract that contribute to an increased risk for lung
complications. These alterations include abnormalities in mucociliary function and
soluble defense molecules, such as defensins within respiratory secretions. Prior
pulmonary tuberculosis (TB) can lead to long-lasting alterations in lung structure and
is linked to lung function loss, which can induce airflow obstruction, the defining
feature of chronic obstructive pulmonary disease (COPD).

Signs and Symptoms

 In the early stages of chronic obstructive pulmonary disease (COPD), many
people don't experience any symptoms. In some cases, this may be because there
aren’t any. In others, though, there are subtle early signs that might be noticed if paid
attention. The three key symptoms of COPD are shortness of breath, a cough that
doesn’t go away, and coughing up thick, often colored mucus (phlegm). According to
the American Lung Association, the following signs and symptoms can also be
reported:

Dyspnea. It is caused by airflow obstruction which is secondary to airways

inflammation, airways remodelling and sputum hypersecretion; reduced lung elastic
recoil due to emphysema and the obstruction of small airways result in incomplete air
expelling and dynamic hyperinflation ("air trapping"), hence, dyspnea occurs.

Chronic cough. Enlarged mucous glands in the lungs make excess mucus, and

damaged ciliary glands struggle to move the mucus, leading to increased coughing.
Mucus from the lungs comes up into the airways, causing irritation. A person will
cough as a means to move the mucus forward and out.

Sputum production. Healthy lungs produce a small amount of mucus every

day. The function of mucus is to keep the airways healthy by trapping particles or
germs and cleaning the passages that air moves through. When a person is sick or
breathes in irritants, it can cause the lungs to produce extra mucus. People with
COPD have increased mucus production because their lungs are always irritated.
Chronic bronchitis is one of the main conditions that make up COPD. The other is
emphysema. In chronic bronchitis, the breathing tubes in the lungs become inflamed.
This causes the overproduction of mucus.

Wheezing sounds and crackles. When exhaling and air is forced through
narrow or obstructed air passages in the lungs, a whistling or musical sound is
produced, called wheezing. In people with COPD, it's most often caused by excess
mucus obstructing the airways. This is in conjunction with muscular tightening that
further narrows the airways.
Pulmonary crackles are divided into two types, 'fine' and 'coarse' and coarse
inspiratory crackles are regarded to be typical of COPD. In COPD, these are heard at
the beginning of inspiration and may be heard over any lung region, especially those
with chronic bronchitis. The crackling noise stems from air bubbles passing through
fluid, such as mucus, in the airways.

Tachypnea. COPD is prone to alterations in oxygen and carbon dioxide levels in

the blood and/or lungs. When there is a low blood oxygen level (partial pressure of
oxygen, pO2) in the body, it may respond with rapid breathing as a way to obtain
oxygen.

Cyanosis. Cyanosis mainly occur in COPD patients with chronic bronchitis,

wherein they are referred to as “blue bloaters”. Bronchial tubes carry air into and out
of the lungs. Mucus forms when the airways are irritated and inflamed, this mucus
makes it harder to breath. The body does not take in enough oxygen, resulting in
cyanosis.

Fatigue. Fatigue is the second most common symptom in patients with chronic
obstructive pulmonary disease (COPD). People with COPD have trouble getting
oxygen into their lungs and carbon dioxide out. The shortage of oxygen and the
buildup of carbon dioxide can both make someone feel tired and low in energy.

Reoccurring lung infections. People with COPD have difficulty clearing their
lungs of bacteria, dusts and other pollutants in the air. This makes them at risk for
lung infections that may cause further damage to the lungs.

Prolonged exhalation and pursed lip breathing. Airflow limitation during the
expiratory phase in airway obstructive disease causes prolonged expiration, which is
one of the hallmarks of COPD. Patients with COPD tend to exhale with pursed-lips.
In this way, they increase expiratory airway resistance to elevate pressure inside the
small collapsible airways for pre- venting alveolar collapse or slow the breathing
frequency. Because the airways are not at risk of collapse during inspiration, many
patients, who do purse their lips, do it un- consciously only during expiration. This is
considered as a form of self-administered positive end-expiratory pressure.

Barrel chest. Some people who have chronic obstructive pulmonary disease
(COPD) — such as emphysema — develop a slight barrel chest in the later stages of
the disease. It occurs because the lungs are chronically overinflated with air, so the
rib cage stays partially expanded all the time.

Exaggerated bulging of the intercostal spaces. Normally, the intercostal

spaces bulge inward during inspiration and outward with expiration. An exaggeration
of the inspiratory retraction occurs in patients with COPD. The mechanism of this
finding is likely due to an imbalance between the ability of the respiratory muscles to
create a negative intrapleural pressure and the impaired ability of the lungs to
expand.

Muscle wasting. Patients with advanced COPD gradually lose weight and show
muscle wasting that is attributed to immobility, hypoxia, or release of systemic
inflammatory mediators, such as the tumor necrosis factor.

Weight loss. Weight loss is common in COPD because dyspnea interferes with
eating and the work of breathing is energy depleting.

Complications
COPD can cause many complications, including:

● Respiratory infections. People with COPD are more likely to catch colds, the

flu and pneumonia. Any respiratory infection can make it much more difficult to
breathe and could cause further damage to lung tissue.
● Lung cancer. People with COPD have a higher risk of developing lung cancer
because both conditions share the same risk factor: smoking cigarettes.
● Collapsed Lung (Pneumothorax). Pneumothorax happens when lung tissue
damaged by COPD allows air to leak into the space between the lungs and chest
(the pleural cavity). Because that air has nowhere to go, it accumulates and
builds up pressure between the chest wall and the lungs. As the pressure and
amount of air in this cavity increase, it can cause the lungs to be compressed or
collapse. A collapsed lung can happen suddenly and spontaneously, without any
warning, and is usually accompanied by sudden, sharp pain in the chest and
worsened shortness of breath.
● High blood pressure in lung arteries. COPD can lead to high blood pressure
in the arteries that carry blood from the heart to the lungs, a condition known as
pulmonary hypertension. Emphysema, which causes damage to the air sacs in
the lungs, can also destroy small blood vessels in the lungs, which then
increases pressure in other vessels.
● Heart problems. With pulmonary hypertension, the right side of the heart has to
work harder to move blood through the lungs. Over time, this can cause the right
side of the heart to enlarge and ultimately fail, a condition called right-sided
heart failure, or cor pulmonale.
● Secondary Polycythemia. The “polycythemia” means that the number of red
blood cells has increased. The “secondary” means that it is the result of an
underlying condition like sleep apnea, obesity hypoventilation syndrome, and
COPD. COPD lessens oxygen, which can raise levels of erythropoietin and lead
to secondary polycythemia.
● Thinning Bones (Osteoporosis). It's common for people with COPD to get
osteoporosis. They've often been smokers, they take steroids, it's hard for them
to get enough bone-strengthening exercise, and they can be low on bone-
building vitamin D. Brittle, weak bones break more easily.
● Depression. Difficulty breathing can keep a person from enjoying activities they
enjoy. And dealing with serious illness can contribute to the development of
depression.
● Weight Issues. When overweight, the lungs have to work harder. This can make
COPD worse and complications more likely. As COPD progresses, a person
might have the opposite problem: severe weight loss, sometimes because
they're too short of breath to eat enough. Being underweight can also worse
Diagnostics

Initial Evaluation.

Physical Examination. The medical team will start the assessment with a detailed
review of the symptoms and medical history. For example, factors such as
whether triggers or bouts of dyspnea occur can help distinguish COPD from similar
conditions like asthma or allergies. The healthcare provider will perform a thorough
physical examination, which can identify signs of COPD and its complications.

Vital Signs. The temperature, pulse, respiratory rate (breaths per minute), and blood
pressure will be measured. A respiratory rate above 12 to 20 breaths per minute is
considered too high for an adult and is a sign of respiratory distress or another
serious illness like anemia.

Systemic Examination. The healthcare provider will observe for signs of respiratory
distress. Struggling to breathe and loud wheezing can indicate advanced lung
disease. Advanced COPD causes right heart failure, which can result in the
prominence of the veins in the neck. The practitioner will listen to the heart and lungs
with a stethoscope. Lung sounds such as wheezing can be indications of COPD or a
lung infection. Extremities can show signs of advanced COPD. Pale or bluish fingers
or toes signal cyanosis, which is a sign of oxygen deprivation. And swelling of the
legs, ankles, or feet signals pulmonary hypertension and right heart failure (late-stage
complications of COPD).
 
Nursing Responsibilities
BEFORE
 Explain the purpose of the procedure to the patient.
DURING
 Establish rapport.
 Provide patient’s privacy.
 Position patient in a comfortable position.
AFTER
 Document pertinent findings on the patient’s chart.

Lung pulmonary function tests (Spirometry). These tests measure the amount of
air that can be inhaled and exhaled and whether the lungs deliver enough oxygen to
the blood. During the most common test, called spirometry, the patient blows into a
large tube connected to a small machine to measure how much air the lungs can
hold and how fast they can blow the air out of the lungs.
Nursing Responsibilities:
BEFORE
● Explain the purpose of the procedure to the patient.
● Position the patient comfortably (sit up straight).
● All equipment must be clean and a bacterial filter used for each patient to avoid
cross-contamination of equipment.
● Make sure that the patient does not take any bronchodilator medication for four
hours.
● Instruct patient not to smoke, drink alcohol and eat a large meal at least four
hours before the test.
● Instruct patient not to wear tight clothing that makes it difficult for them to take a
deep breath.
● Instruct patient not to exercise heavily for at least 30 minutes before the test.

DURING
● Ensure the patient is wearing nose clips to prevent air leaks from the nose. 
● Ask the patient to breathe in as fully as possible. 
● Ensure they seal lips and teeth tightly around the mouthpiece.
● Make them blow out forcibly, as hard and as fast as possible until all air is
expelled from lungs.
● Patients are advised not to lean forward during the test.
● Check that an adequate trace has been achieved. 
● Repeat the procedure at least twice until three acceptable and repeatable blows
are obtained. Maximum of 8 efforts.

AFTER
● Document the result of the procedure.

Bronchodilator Reversibility Test. This test combines spirometry with the use
of a bronchodilator, which is medicine to help open up your airways. For this test, the
patient will undergo a spirometry test to get a baseline measurement of how well the
lungs are working. Then, after about 15 minutes, the patient will take a dose of
bronchodilator medication and repeat the spirometry test. This screening is also
helpful in monitoring people already diagnosed with COPD, asthma, or both. Test
results can help a doctor determine whether the current bronchodilator therapy is
working or if it needs to be adjusted.

Nursing Responsibilities:
BEFORE
● Explain the purpose of the test to the patient.
● Inquire and record the time of last bronchodilator inhaler use. Before the test,
patient will be instructed not to take his/her normal bronchodilator medicine.
● The patient should be in a comfortable state and, ideally, should have just
emptied their bladder because the procedure can result in urinary incontinence.
● The procedure should be performed while the patient is seated because
standing increases the risk of syncope.

DURING
● Patient will be asked to take a deep breath and then blow into the spirometer as
hard as he/she can. The spirometer records the results. This is called a baseline
measurement.
● Give patient a dose of bronchodilator medicine using an inhaler or nebulizer.
● Patient will be asked to blow into the spirometer more than once. This is done to
 get the best reading.

AFTER
● Document the result of the procedure.

Chest X-ray. A chest x-ray may not show COPD until it is severe, the images
may show enlarged lungs, air pockets (bullae) or a flattened diaphragm. A chest x-
ray may also be used to determine if another condition may be causing symptoms
similar to COPD. A chest X-ray can show emphysema, one of the main causes of
COPD. An X-ray can also rule out other lung problems or heart failure. 

Nursing Responsibilities:
BEFORE
● Explain the purpose of the procedure to the patient.
● Remove all metallic objects. Items such as jewelry, pins, buttons, etc. can hinder
the visualization of the chest.
● Fasting or medication restriction is not needed unless directed by the health care
provider.
● Ensure the patient is not pregnant or suspected to be pregnant. X-rays are
usually not recommended for pregnant women unless the benefit outweighs the
risk of damage to the mother and fetus.
● Assess the patient’s ability to hold his or her breath. Holding one’s breath after
inhaling enables the lungs and heart to be seen more clearly in the x-ray.
● Provide appropriate clothing. Patients are instructed to remove clothing from the
waist up and put on an X-ray gown to wear during the procedure.
● Coordinating care between radiology and other departments.

DURING
● Instruct patient to cooperate during the procedure. The patient is asked to
remain still because any movement will affect the clarity of the image.

AFTER
● Note that no special care is required following the procedure.
● Provide comfort. If the test is facilitated at the bedside, reposition the patient
properly.
● Obtain result immediately and relay to the physician.

CT scan. Unlike a standard X-ray, which provides a flat, one-dimensional

picture, CT scans provide a series of X-ray images taken from different angles. It
gives doctors a cross-section look at the organs and other soft tissue. A CT scan
gives a more detailed view than a regular X-ray. It can be used to check for blood
clots in the lungs, which a chest X-ray can’t do. A CT scan can also pick up much
smaller detail, identifying problems, like cancer, much earlier. A CT scan of the lungs
can help detect emphysema and help determine if it might benefit from surgery for
COPD. CT scans can also be used to screen for lung cancer.

Nursing Responsibilities:
BEFORE
● Explain the purpose of the procedure to the patient.
● Obtain informed consent before the procedure.
● If the patient has a history of allergy to contrast material (such as iodine or
shellfish), the requesting physician and radiology staff should be notified.
● Check BUN and Creatinine prior to a CT scan because IV contrast can be hard
on the kidneys and can put certain people into acute renal failure.
 A creatinine below a certain level assures them that the kidneys can take the
"contrast"
● Ask the patient about any recent illnesses or other medical conditions and
current medications being taken. The specific type of CT scan determines the
need for an oral or I.V. contrast medium.
● Check for NPO status. Instruct the patient to not to eat or drink for a period
amount of time especially if a contrast material will be used because the injection
may cause stomach upset.
● Remove any metal objects, such as a belt or jewelry, which might interfere with
image results.
● Assess for the presence of implanted metal devices such as aneurysm clips or a
cardiac pacemaker/defibrillator.
● Provide information about the contrast medium. Tell the patient that a mild
transient pain from the needle puncture and a flushed sensation from an I.V.
contrast medium will be experienced.
● Instruct the patient to wear comfortable, loose-fitting clothing during the exam.
● The patient is positioned on an adjustable table inside an encircling body
scanner (gantry); straps and pillows may be used to help in maintaining the
correct position.

DURING
● Inform patients that they will be required to remain supine and still for a short
period, typically less than 30 minutes, while a body scanner surrounds them and
takes multiple images. 
● Instruct paient to hold his/her breath during the scanning.

AFTER
● Patient is assessed carefully for adverse effects to the contrast medium.
● Instruct the patient to resume the usual diet and activities unless otherwise
ordered.
● Encourage the patient to increase fluid intake (if a contrast is given). This is so to
promote excretion of the dye.

Electrocardiogram (ECG or EKG). To determine if the shortness of breath is

being caused by a heart condition as opposed to a lung problem. Over time, though,
the breathing difficulties associated with COPD can lead to cardiac complications,
including abnormal heart rhythms, heart failure, and heart attacks. An EKG measures
the electrical activity in the heart and can help diagnose a disturbance in your heart
rhythm.

Nursing Responsibilities:
BEFORE
● Verify the order for the ECG in the client's chart.
● Provide privacy and explain the procedure to the patient.
● Tell who will perform the test, where it will take place, and that it’s safe, painless,
and is noninvasive.
● Advise the patient that he doesn’t need to restrict food and fluids for the test.
● Ensure to empty the bladder. Instruct patient to void prior and to change into a
gown.
● Explain to the patient the need to lie still, relax, and breathe normally during the
procedure.
● Note current cardiac drug therapy on the test request form as well as any other
pertinent clinical information, such as chest pain or pacemaker.
● Explain that the test is painless and takes 5 to 10 minutes.
● Explain the need to darkened the examination field. 
 
DURING
● Place the patient in a supine or semi-Fowler’s position.
● Expose the chest, ankles, and wrists.
● Place electrodes on the inner aspect of the wrists, on the medical aspect of the
lower legs, and on the chest.
● After all electrodes are in place, connect the lead wires.
● Press the START button and input any required information.
● Make sure that all leads are represented in the tracing. If not, determine which
electrode has come loose, reattach it, and restart the tracing.
● All recording and other nearby electrical equipment should be properly
grounded.
● Make sure that the electrodes are firmly attached.
 
AFTER
● Disconnect the equipment, remove the electrodes, and remove the gel with a
moist cloth towel.
● If the patient is having recurrent chest pain or if serial ECG’s are ordered, leave
the electrode patches in place.
● Inform the patient that the study will be interpreted by the physician. An official
report will be sent to the requesting physician, who will discuss the findings with
the patient.
● Instruct patient to resume regular diet and activities. There is no special type of
care given following the test.

Fractional exhaled nitric oxide (FeNO) test. It measures the amount of nitric
oxide that is exhaled from a breath. Increased levels of nitric oxide are associated
with swelling of lung airways. FeNO is a marker of endogenous inflammation which
can be used to monitor inflammatory changes in the airway.

Nursing Responsibilities:
BEFORE
 Explain the purpose of the test to the patient.
 Instruct patient not to smoke, drink alcohol and eat a large meal before the
test.
 Nitrate rich food, such as green leafy vegetables and beetroot, caffeine and
alcohol can also affect the result, so instruct patient not to eat or drink these
for an hour or so before the test.
 Instruct patient to wear loose, comfortable clothing.
 Instruct patient not to perform any vigorous exercise within 30 minutes of test.
DURING
 Instruct patient to breathe into a plastic mouthpiece or a cardboard tube
attached to a monitor. The monitor shows the reading on its screen.
 Instruct patient to breathe in deeply, with mouth open, and then breathe out
little by little until lungs are empty. The breath out will normally take 10
seconds in adults (6 seconds in children).
AFTER
 Document the result of the procedure.

Sputum Examination. Analyzing the sputum can help identify the cause of breathing
difficulties and may help detect some lung cancers. If there is a bacterial infection, it
can also be identified and treated. 

Nursing Responsibilities:
BEFORE
● Explain the purpose of the procedure to the patient.
● The patient can rinse their mouth with water prior to the procedure, but avoid
mouthwash or toothpaste because these products can affect the microorganisms
in the sample.
● Collect the specimen before patient begins antibiotic therapy.

DURING
● Obtain sputum samples in the early morning because secretions accumulate
overnight.
● Instruct the client to take several deep breaths and then cough deeply to obtain
sputum.

AFTER
● Transport the specimen immediately tp the laboratory.
● Assist the client with mouth care.

Laboratory tests. Lab tests aren't used to diagnose COPD, but they may be used to
determine the cause of the symptoms or rule out other conditions.

Arterial blood gas analysis. This blood test measures how well the lungs are
bringing oxygen into the blood and removing carbon dioxide. It can also determine
the acidity (pH) of the blood. Imbalances in the amount of oxygen, carbon dioxide, or
pH can serve as a way to evaluate respiratory diseases, kidney function, and the
body’s metabolism (the process by which our body converts food into energy that can
be used right away or stored in the liver, muscles and body fat). Results of the test
can show the severity of COPD and whether a person needs oxygen therapy.
Patients with mild COPD have mild to moderate hypoxemia without hypercapnia. As
the disease progresses, hypoxemia worsens and hypercapnia may develop, with the
latter commonly being observed as the FEV1 falls below 1 L/s or 30% of the
predicted value. Lung mechanics and gas exchange worsen during acute
exacerbations.

Nursing Responsibilities:
BEFORE
● Explain the purpose of the procedure to the patient.
● Prior to arterial puncture, Allen’s test should be done.
● Explain the arterial blood gas analysis evaluates how well the lungs are
delivering the oxygen to the blood and eliminating carbon dioxide.
● Tell the patient that the test requires a blood sample.
● Explain to the patient, who will perform the arterial puncture, when it will occur,
and where the puncture site will be; radial, brachial, or femoral artery.
● Inform the patient that he/she may not need to restrict food and fluids.

DURING
● Instruct the patient to breathe normally during the test and warn him that he may
experience a brief cramping or throbbing pain at the puncture site.

AFTER
● After applying pressure to the puncture site for 3 to 5 minutes and when bleeding
 has stopped, tape a gauze pad firmly over it.
● If the puncture site is on the arm, don’t tape the entire circumference because
this may restrict circulation.
● If the patient is receiving anticoagulants or has a coagulonopathy, apply
pressure to the puncture site longer than 5 minutes if necessary.
● Monitor vital signs and observe for signs of circulatory impairment.
● Document the result of the procedure.

Complete blood count (CBC). A complete blood count (CBC) may alert the
healthcare provider if the patient has an infection. High levels of hemoglobin may
suggest the body's compensation for chronic hypoxemia related to COPD.

Nursing Responsibilities:
BEFORE
● Explain the purpose of the procedure to the patient.
● Explain that slight discomfort may be felt when the skin is punctured.
● Encourage to avoid stress if possible because altered physiologic status
influences and changes normal hematologic values.
● Explain that fasting is not necessary. However, fatty meals may alter some test
results because of lipidemia.
 
DURING
● Advise patient to feel relaxed as possible while blood is being drawn out.

AFTER
● After applying pressure to the puncture site for 3 to 5 minutes and when bleeding
has stopped, tape a gauze pad firmly over it.
● If the puncture site is on the arm, don’t tape the entire circumference because
this may restrict circulation.
● If the patient is receiving anticoagulants or has a coagulonopathy, apply
pressure to the puncture site longer than 5 minutes if necessary.
● Monitor the puncture site for oozing or hematoma formation.
● Document the result of the procedure.

Alpha-1-antitrypsin deficiency screening. AAT deficiency is a genetic

condition that can lead to COPD. This test may be done if the patient has a family
history of COPD and develops it at a young age. A patient might also have this blood
test if they are diagnosed with COPD before age 45. If the patient has a high risk of
AAT deficiency, the World Health Organization (WHO) recommends that the patient
be tested for this disorder with this simple blood test.

Nursing Responsibilities:
BEFORE
● Explain the purpose of the procedure to the patient.
● Tell the patient that the test requires a blood sample and usually takes less than
five minutes.
● Inform the patient that he/she may not need to restrict food and fluids.

DURING
● Advise patient to feel relaxed as possible while blood is being drawn out.

AFTER
● Apply pressure on the punctured site.
● Document the result of the procedure.
Treatment and Management

Lifestyle Modification

Quitting smoking. Quitting smoking is an important part of the COPD treatment

plan. The chemicals in cigarettes, e-cigarettes, and cigars can further damage the
lungs and, over time, may cause more symptoms, increase the risk of exacerbations,
and decrease lung function. Continued smoking may make it less responsive to
COPD medications.

Diet. Instead of eating three large meals, try eating five to six smaller meals
throughout the day. This will help to avoid a full stomach by giving the diaphragm and
lungs more space to move freely. Additionally, a good source of protein should be
consumed at least twice a day to help maintain strong respiratory muscles.

Breathing Techniques

Diaphragmatic breathing. Diaphragmatic breathing is a technique that aims to

breathe from the diaphragm rather than the upper chest. It’s often also called
‘breathing from the belly'. This technique helps to strengthen the muscles of the
diaphragm, which are often weaker and less functional with COPD.

Pursed lip breathing. Pursed-lip breathing is a simple and easy technique to

learn. It helps slow down breathing, making it easier for the lungs to function, and
helps keep the airways open for longer.

Medications

Several kinds of medications are used to treat the symptoms and complications
of COPD.

Bronchodilators. Bronchodilators work by relaxing the muscles in the airways.

The relaxation causes the airways to open up and the bronchial tubes to widen.
Short-acting bronchodilators are used as "quick relief" or "rescue inhalers", while
long-acting bronchodilators can be used every day to control asthma, along with an
inhaled steroid.

Oral Steroids. For people who experience periods when their COPD becomes
more severe, called moderate or severe acute exacerbation, short courses (for
example, five days) of oral corticosteroids may prevent further worsening of COPD.
However, long-term use of these medications can have serious side effects, such as
weight gain, diabetes, osteoporosis, cataracts, and an increased risk of infection.

Phosphodiesterase-4 Inhibitors. A medication approved for people with severe

COPD and symptoms of chronic bronchitis is roflumilast (Daliresp), a
phosphodiesterase-4 inhibitor. This drug decreases airway inflammation and relaxes
the airways. Common side effects include diarrhea and weight loss.
 Theophylline. This medicine works like a bronchodilator, but it's less
expensive. Theophylline can help the lungs work better, but it may not control all of
the symptoms.

Antibiotics. Respiratory infections, such as acute bronchitis, pneumonia, and

influenza, can aggravate COPD symptoms. Antibiotics help treat episodes of
worsening COPD, but they aren't generally recommended for prevention. Some
studies show that certain antibiotics, such as azithromycin (Zithromax), prevent
episodes of worsening COPD, but side effects and antibiotic resistance may limit
their use.

Mucolytics. People with COPD and chronic bronchitis may have flare-ups
(exacerbations) when their symptoms become worse. Mucolytics are medicines
taken orally that may loosen sputum, making it easier to cough it up.

Anticholinergics. Anticholinergic bronchodilators block the action of

acetylcholine. Acetylcholine is a chemical released by the nerves that can lead to
tightening of the bronchial tubes. By blocking the chemical, anticholinergic
bronchodilators cause the airways to relax and open.

Leukotriene Modifiers. Leukotriene modifiers, also called leukotriene receptor

antagonists or leukotriene synthesis inhibitors, are medications that block the effect
of leukotrienes or stop the body from producing them, thus preventing the bronchial
tubes from constricting.

Expectorants. An expectorant medication is one that increases the output of

thin respiratory tract fluid by helping to liquefy the tenacious mucus that patients with
COPD suffer from. A mucolytic medication breaks down the mucus that is present in
the lungs, which ends up thinning the respiratory secretions.

Corticosteroids. An inhaled steroid prevents and reduces swelling inside the

airways, making them less sensitive. It may also decrease mucus production. An
inhaled steroid will not provide quick relief for asthma symptoms. In addition, inhaled
steroids may help reduce symptoms associated with other chronic lung conditions.

Vaccines. The Centers for Disease Control and Prevention (CDC) recommends
people with or at risk for COPD get a yearly flu (influenza) vaccine. People with
chronic lung disease, including COPD, should also get pneumococcal vaccines; once
as an adult before 65 years old and twice at 65 years or older.

Lung Therapies

Oxygen Therapy. Supplemental oxygen, or oxygen therapy, increases the

amount of oxygen that flows into the lungs. Not everyone is a candidate for oxygen
therapy. The need for oxygen depends on the results of certain tests like oximetry,
arterial blood gas tests, or exercise tests. Depending on how much oxygen is
needed, the healthcare provider will determine the type of oxygen delivery device to
meet the patient's needs and lifestyle. Supplemental oxygen can help improve
symptoms, organ function, and the ability to stay active.
 Pulmonary Rehabilitation. Pulmonary rehabilitation is a specialized program of
exercise and education designed to help people with lung problems such as COPD.
It can help improve how much exercise a patient can do before feeling out of breath,
as well as the symptoms, self-confidence, and emotional wellbeing. Pulmonary
rehabilitation programs usually involve two or more group sessions per week for at
least six weeks.

In-Home Non-Invasive Ventilation Therapy. Non-invasive ventilation (NIV) is

the delivery of oxygen (ventilation support) via a face mask, therefore eliminating the
need for an endotracheal airway. NIV achieves comparative physiological benefits to
conventional mechanical ventilation by reducing the work of breathing and improving
gas exchange.

Surgery

Lung Volume Reduction Surgery. In this surgery, the surgeon removes small
wedges of damaged lung tissue from the upper lungs. This creates extra space in the
chest cavity so that the remaining healthier lung tissue can expand and the
diaphragm can work more efficiently. For some people, this surgery can improve their
quality of life and prolong their survival. Endoscopic lung volume reduction, a
minimally invasive procedure, has recently been approved by the U.S. Food and
Drug Administration to treat people with COPD. A tiny one-way endobronchial valve
is placed in the lung, allowing the most damaged lobe to shrink so that the healthier
part of the lung has more space to expand and function.

Bullectomy. Large air spaces (bullae) form in the lungs when the walls of the air
sacs (alveoli) are destroyed. These bullae can become very large and cause
breathing problems. In a bullectomy, doctors remove bullae from the lungs to help
improve air flow.

Lung Transplant. Lung transplantation may be an option for certain people who
meet specific criteria. Transplantation can improve the ability to breathe and be
active. However, it's a major operation that has significant risks, such as organ
rejection and the need to take lifelong immune-suppressing medications.