Chronic obstructive pulmonary disease (COPD) is estimated to affect 32 million persons in the United States and is the third leading cause of death in this country (Mosenifar & Oppenheimer, 2022). It is primarily present in smokers and those greater than the age of 40. However, its prevalence is likely to be underestimated due to the underdiagnosis of COPD (Agarwal, 2022).
Definition
COPD is a common and treatable disease characterized by progressive airflow limitation and tissue destruction. It is associated with structural lung changes due to chronic inflammation from prolonged exposure to noxious particles or gases most commonly cigarette smoke. Chronic inflammation causes airway narrowing and decreased lung recoil (Agarwal, 2022). Clients typically have symptoms of chronic bronchitis and emphysema, but the classic triad also includes asthma (Mosenifar & Oppenheimer, 2022).
Chronic bronchitis is defined clinically as the presence of chronic productive cough for three months during each of two consecutive years (other causes of cough being excluded). Emphysema is defined pathologically as an abnormal, permanent enlargement of the air spaces distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis (Mosenifar & Oppenheimer, 2022).
Pathophysiology
COPD is an inflammatory condition involving the airways, lung parenchyma, and pulmonary vasculature. The process is thought to involve oxidative stress and protease-antiprotease imbalances. Emphysema describes one of the changes seen in COPD where there is the destruction of the alveolar air sacs leading to obstructive physiology. An irritant, such as smoking, causes an inflammatory response. Neutrophils and macrophages are recruited and release multiple inflammatory mediators. Oxidants and excess proteases lead to the destruction of the air sacs. The protease-mediated destruction of elastin leads to a loss of elastic recoil and results in airway collapse during exhalation (Agarwal, 2022).
Etiology
COPD is caused by prolonged exposure to harmful particles or gases. Cigarette smoking is the most common cause of COPD worldwide. Other causes may include second-hand smoke, environmental and occupational exposures, and alpha-1 antitrypsin deficiency (AATD).
- Cigarette smoking. Overall, tobacco smoking accounts for as much as 90% of COPD risk. Cigarette smoking introduces macrophages to release neutrophil chemotactic factors and elastases, which lead to tissue destruction (Mosenifar & Oppenheimer, 2022).
- Second-hand smoke. Secondhand smoke, or environmental tobacco smoke, increases the risk of respiratory infections, augments asthma symptoms, and causes a measurable reduction in pulmonary function (Mosenifar & Oppenheimer, 2022).
- Environmental factors. Although the role of air pollution in the etiology of COPD is unclear, the effect is small when compared with that of cigarette smoking. In developing countries, the use of biomass fuels for indoor cooking and heating is likely to be a major contributor to the worldwide prevalence of COPD. Long-term exposure to traffic-related air pollution may be a factor in COPD in clients diagnosed with diabetes and asthma (Mosenifar & Oppenheimer, 2022).
- Alpha-1 antitrypsin deficiency (AATD). Alpha-1 antitrypsin (AAT) is a glycoprotein member of the serine protease inhibitor family that is synthesized in the liver and secreted into the bloodstream. AATD is the only known genetic risk factor for developing COPD and accounts for less than 1% of all cases in the United States. Severe AAT deficiency leads to premature emphysema at an average age of 53 years for nonsmokers and 40 years for smokers (Mosenifar & Oppenheimer, 2022).
Epidemiology
The National Health Interview Survey reports the prevalence of emphysema at 18 cases per 10000 persons and chronic bronchitis at 34 cases per 1000 persons. Another study estimates a prevalence of 10.1% in the United States. The exact burden of COPD worldwide is largely unknown, but estimates have varied from 7-19%. The Burden of Obstructive Lung Disease (BOLD) study found a global prevalence of 10.1%. Although current rates of COPD in men are higher than the rates in women, the rates in women have been increasing. COPD occurs predominantly in individuals older than age 40 years (Mosenifar & Oppenheimer, 2022).
Presentation
Most clients with COPD seek medical attention late in the course of their disease. These clients typically present with a combination of signs and symptoms of chronic bronchitis, emphysema, and reactive airway disease. Symptoms include the following:
- Productive cough. A productive cough or acute chest illness is common. The cough is usually worse in the mornings and produces a small amount of colorless sputum.
- Breathlessness. Breathlessness is the most significant symptom, but it usually does not occur until the sixth decade of life (although it may occur much earlier). By the time the FEV1 has fallen to 50% of predicted, the client is usually breathless upon minimal exertion.
- Wheezing. Wheezing may occur in some clients, particularly during exertion and exacerbations.
Chronic bronchitis characteristics include the following:
- Obesity
- Frequent cough and expectoration are typical
- Use of accessory muscles for respiration
- Coarse rhonchi and wheezing
- Signs of right heart failure such as edema and cyanosis
Emphysema characteristics include the following:
- Client may be very thin with a barrel chest
- Little or no cough or expectoration
- Breathing may be assisted by pursed lips and the use of accessory respiratory muscles
- Tripod sitting position
- Hyperresonant chest with wheezing
- Distant heart sounds
Interventions
The primary goals of treatment are to control symptoms, improve the quality of life, and reduce exacerbations and mortality.
- Bronchodilators. Bronchodilators are the backbone of any COPD treatment regimen. They work by dilating airways, thereby decreasing airflow resistance. This increases airflow ad decreases dynamic hyperinflation. These drugs provide symptomatic relief but do not alter disease progression or decrease mortality.
- Diet. The inadequate nutritional status associated with low body weight in clients diagnosed with COPD is associated with impaired pulmonary status, reduced diaphragmatic mass, lower exercise capacity, and higher mortality rates.
- Smoking cessation. Smoking cessation continues to be the most important therapeutic intervention for COPD. Most clients with COPD have a history of smoking or are currently smoking tobacco products. A smoking cessation plan is an essential part of a comprehensive management plan. Smoking intervention programs include self-help, group, healthcare provider delivered, workplace, and community programs.
- Corticosteroids. Systemic and inhaled corticosteroids attempt to temper the inflammation and positively alter the course of the disease. The use of systemic steroids in the treatment of acute exacerbations is widely accepted and recommended, given their high efficacy.
- Antibiotics. Empiric antimicrobial therapy is recommended in clients with an acute exacerbation (as evidenced by an increase in baseline dyspnea and/or a change in the quantity or quality of cough) and evidence of an infectious process, such as fever, leukocytosis, or an infiltrate on chest radiograph.
- Oxygen therapy. Oxygen administration reduces mortality rates in clients diagnosed with advanced COPD because of the favorable effects on pulmonary hemodynamics.
Nursing Diagnosis for COPD
Nursing Diagnosis
Ineffective Airway Clearance
Assessment
Verbalization of difficulty breathing / changes in depth and rate of respirations / use of accessory muscles / abnormal breath sounds / persistent cough with or without sputum
Problem
Bronchospasm
Increased production of secretions
Decreased energy or fatigue
Nursing Diagnosis
Impaired Gas Exchange
Assessment
Dyspnea / confusion / restlessness / inability to moblize secretions / abnormal ABGs / hypoxia / hypercapnia / changes in vital signs / reduced tolerance for activity
Problem
Obstruction of airways by secretions
Bronchospasm
Alveoli destruction
Nursing Diagnosis
Imbalanced Nutrition: Less than Body Requirements
Assessment
Weight loss / loss of muscle mass / poor muscle tone / altered taste sensation / aversion to eating / lack of interest in food
Problem
Dyspnea
Increased sputum production
Medication side effects
Fatigue
Nursing Diagnosis
Deficient Knowledge
Assessment
Request for information / statement of concerns and misconceptions / inaccurate follow-through of instructions / development of preventable complications
Problem
Lack of information
Unfamiliarity with information resources
Information misinterpretation
Lack of recall
Cognitive limitation
Nursing Diagnosis
Self-Care Deficit
Assessment
Intolerance to activity / decreased strength and endurance / inability to ingest sufficient food / inability to get in and out of bathroom / inability to maintain appearance at a satisfactory level / inability to get to toilet or commode
Problem
Depression
Weakness
Impaired mobility status
Nursing Diagnosis
Ineffective Home Maintenance
Assessment
Intolerance to activity / inadequate support system / insufficient finances / unfamiliarity with resources / reported lack of equipment / inability to take responsibility for meeting basic health practices / lack of adaptive behaviors to internal/external environmental changes /
Problem
Significant alteration in communication skills
Unachieved tasks
Lack of ability to make deliberate judgments
Ineffective individual coping
Lack of material resources
Nursing Diagnosis
Risk for Infection
Assessment
Stasis of secretions / defective alveolar macrophages / increased neutrophils / persistent bacterial colonization / dyspnea / productive cough / shortness of breath / fever / sputum purulence / increased sputum production
Problem
Decreased ciliary action
Tissue destruction
Increased environmental exposure
Chronic disease process
Malnutrition
Nursing Diagnosis
Activity Intolerance
Assessment
Reported fatigue or weakness / Exertional discomfort / dyspnea / verbalization of lack of interest in activity / tachycardia in response to activity / pallor / cyanosis / tachypnea
Problem
Restricted mobility
Imbalance between oxygen supply and demand
Exhaustion associated with interruption in usual sleep pattern due to coughing or dyspnea
References
- Agarwal, A. (2022, July 17). Chronic Obstructive Pulmonary Disease – StatPearls. NCBI. Retrieved September 27, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK559281/
- Mosenifar, Z., & Oppenheimer, J. J. (2022, June 3). Chronic Obstructive Pulmonary Disease (COPD): Practice Essentials, Background, Pathophysiology. Medscape Reference. Retrieved September 27, 2022, from https://emedicine.medscape.com/article/297664-overview
- Wackerhausen, L.-M. H., & Hansen, J. G. (2012). Risk of Infectious Diseases in Patients with COPD. The Open Infectious Diseases Journal, 6(Suppl 1), 52-59.
