Chronic obstructive pulmonary disease
Chronic obstructive pulmonary disease (COPD) is chronic airway obstruction that results from emphysema, chronic bronchitis, asthma, or any combination of these disorders. (See Types of chronic obstructive pulmonary disease, pages 554 to 557. Also see Three types of emphysema, page 558.) Usually, more than one of these underlying conditions coexist; in most cases, bronchitis and emphysema occur together. It doesn’t always produce symptoms and causes only minimal disability in many patients. However, COPD tends to worsen with time.
Causes and incidence
Predisposing factors include cigarette smoking, recurrent or chronic respiratory infections, air pollution, occupational exposure to chemicals, and allergies. Smoking is by far the most important of these factors — it impairs ciliary action and macrophage function, inflames airways, increases mucus production, destroys alveolar septae, and causes peribronchiolar fibrosis. Early inflammatory changes may reverse if the patient stops smoking before lung destruction is extensive. Familial and hereditary factors (such as deficiency of alpha1-antitrypsin) may also predispose a person to COPD.
The most common chronic lung disease, COPD (also known as chronic obstructive lung disease) affects an estimated 17 million Americans, and its incidence is rising. It affects more males than females, probably because until recently men were more likely to smoke heavily. COPD occurs mostly in people older than age 40.
Signs and symptoms
The typical patient, a long-term cigarette smoker, has no symptoms until middle age. His ability to exercise or do strenuous work gradually starts to decline and he begins to develop a productive cough. These signs are subtle at first, but become more pronounced as the patient gets older and the disease progresses. Eventually the patient may develop dyspnea on minimal exertion, frequent respiratory infections, intermittent or continuous hypoxemia, and grossly abnormal pulmonary function studies. Advanced COPD may cause severe dyspnea, overwhelming disability, cor pulmonale, severe respiratory failure, and death.
Diagnosis
For specific diagnostic tests used to determine COPD, see Types of chronic obstructive pulmonary disease.
Treatment
Treatment is designed to relieve symptoms and prevent complications. Because most patients with COPD receive outpatient treatment, they need comprehensive teaching to help them comply with therapy and understand the nature of this chronic, progressive disease. If programs in pulmonary rehabilitation are available, encourage patients to enroll.
Urge the patient to stop smoking. Provide smoking cessation counseling or refer him to a program. Avoid other respiratory irritants, such as secondhand smoke, aerosol spray products, and outdoor air pollution. An air conditioner with an air filter in his home may be helpful.
The patient is usually treated with beta-agonist bronchodilators (albuterol or salmeterol), anticholinergic bronchodilators (ipratropium), and corticosteroids (beclomethasone or triamcinolone). These are usually given by metered-dose inhaler, requiring that the patient be taught the correct administration technique.
Antibiotics are used to treat respiratory infections. Stress the need to complete the prescribed course of antibiotic therapy.
Special considerations
❑ Teach the patient and his family how to recognize early signs of infection; warn the patient to avoid contact with people with respiratory infections. Encourage good oral hygiene to help prevent infection. Pneumococcal vaccination and annual influenza vaccinations are important preventive measures.
❑ To promote ventilation and reduce air trapping, teach the patient to breathe slowly, prolong expirations to two to three times the duration of inspiration, and to exhale through pursed lips.
❑ To help mobilize secretions, teach the patient how to cough effectively. If the patient with copious secretions has difficulty mobilizing secretions, teach his family how to perform postural drainage and chest physiotherapy. If secretions are thick, urge the patient to drink 12 to 15 glasses of fluid per day. A home humidifier may be beneficial, particularly in the winter.
❑ Administer low concentrations of oxygen as ordered. Perform blood gas analysis to determine the patient’s oxygen needs and to avoid carbon dioxide narcosis. If the patient is to continue oxygen therapy at home, teach him how to use the equipment correctly. The patient with COPD rarely requires more than 2 to 3 L/minute to maintain adequate oxygenation. Higher flow rates will further increase the partial pressure of arterial oxygen, but the patient whose ventilatory drive is largely based on hypoxemia commonly develops markedly increased partial pressure of arterial carbon dioxide tensions. In these cases, chemoreceptors in the brain are relatively insensitive to the increase in carbon dioxide. Teach the patient and his family that excessive oxygen therapy may eliminate the hypoxic respiratory drive, causing confusion and drowsiness, signs of carbon dioxide narcosis.
❑ Emphasize the importance of a balanced diet. Because the patient may tire easily when eating, suggest that he eat frequent, small meals and consider using oxygen, administered by nasal cannula, during meals.
❑ Help the patient and his family adjust their lifestyles to accommodate the limitations imposed by this debilitating chronic disease. Instruct the patient to allow for daily rest periods and to exercise daily as his physician directs.
❑ As COPD progresses, encourage the patient to discuss his fears.
❑ To help prevent COPD, advise all patients, especially those with a family history of COPD or those in its early stages, not to smoke.
❑ Assist in the early detection of COPD by urging persons to have periodic physical examinations, including spirometry and medical evaluation of a chronic cough, and to seek treatment for recurring respiratory infections promptly.
❑ Lung volume reduction surgery is a new procedure for carefully selected patients with primarily emphysema. Nonfunctional parts of the lung (tissue filled with disease and providing little ventilation or perfusion) are surgically removed. Removal allows more functional lung tissue to expand and the diaphragm to return to its normally elevated position.
Pictures
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2008 Williams & Wilkins.
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