RESPIRATORY SYSTEM

MS SEENA RACHEL GEORGE

IMSC NURSING

BHCON

THE HUMAN RESPIRATORY SYSTEM

It is the system consisting of tubes and is responsible for the exchange of gases in Humans by filtering incoming air and transporting it into the microscopic alveoli where gases are exchanged

Your respiratory system provides the energy needed by cells of the body to funtion according to their designated tasks

The organs of the ldquoRespiratory Tractrdquo

can be divided into two groupsldquoSTRUCTURALLYrdquo

The Upper Respiratory Tract

Nose

Nasal cavity

Sinuses

Pharynx

The Lower Respiratory Tract

Larynx

Trachea

Bronchial Tree

Lungs

CONDUCTING PASSAGES

bull NOSE - NASAL CAVITY amp

PARANASAL SINUSES

bull PHARYNX

bull LARYNX ndash EPIGLOTTIS amp VOCAL CORDS

bull TRACHEA

bull BRONCHI ndash BRONCHIAL TREE

bull LUNGS ndashLOBES OF THE LUNGS

PLUERAL CAVITIES AND ALVEOLI

Nose (nasal cavity)

bull Both olfactory and respiratory functions

bull Inspired air is warmed or cooled

bull Brought close to body temperature

bull Also moistened by fluid derived from

transudation through epithelium and

secretions of glands and goblet cells

Warming and

humidification of inspired air

bull Moist air is necessary

for integrity and proper

functioning of

ciliated epithelium

bull Secretions have

bactericidal actions

bull Stiff hairs trap dust and

foreign particles

bull Resonator in voice and speech

Pharynxbull Nasal cavity opens posteriorly into

nasopharynx

bull During swallowing respiration is

Temporarily inhibited permitting

food to enter oropharynx

bull Elevation of larynx and

closure of vocal cords

prevents entry of food into larynx

THE HUMAN RESPIRATORY SYSTEM

It is the system consisting of tubes and is responsible for the exchange of gases in Humans by filtering incoming air and transporting it into the microscopic alveoli where gases are exchanged

Your respiratory system provides the energy needed by cells of the body to funtion according to their designated tasks

The organs of the ldquoRespiratory Tractrdquo

can be divided into two groupsldquoSTRUCTURALLYrdquo

The Upper Respiratory Tract

Nose

Nasal cavity

Sinuses

Pharynx

The Lower Respiratory Tract

Larynx

Trachea

Bronchial Tree

Lungs

CONDUCTING PASSAGES

bull NOSE - NASAL CAVITY amp

PARANASAL SINUSES

bull PHARYNX

bull LARYNX ndash EPIGLOTTIS amp VOCAL CORDS

bull TRACHEA

bull BRONCHI ndash BRONCHIAL TREE

bull LUNGS ndashLOBES OF THE LUNGS

PLUERAL CAVITIES AND ALVEOLI

Nose (nasal cavity)

bull Both olfactory and respiratory functions

bull Inspired air is warmed or cooled

bull Brought close to body temperature

bull Also moistened by fluid derived from

transudation through epithelium and

secretions of glands and goblet cells

Warming and

humidification of inspired air

bull Moist air is necessary

for integrity and proper

functioning of

ciliated epithelium

bull Secretions have

bactericidal actions

bull Stiff hairs trap dust and

foreign particles

bull Resonator in voice and speech

Pharynxbull Nasal cavity opens posteriorly into

nasopharynx

bull During swallowing respiration is

Temporarily inhibited permitting

food to enter oropharynx

bull Elevation of larynx and

closure of vocal cords

prevents entry of food into larynx

The organs of the ldquoRespiratory Tractrdquo

can be divided into two groupsldquoSTRUCTURALLYrdquo

The Upper Respiratory Tract

Nose

Nasal cavity

Sinuses

Pharynx

The Lower Respiratory Tract

Larynx

Trachea

Bronchial Tree

Lungs

CONDUCTING PASSAGES

bull NOSE - NASAL CAVITY amp

PARANASAL SINUSES

bull PHARYNX

bull LARYNX ndash EPIGLOTTIS amp VOCAL CORDS

bull TRACHEA

bull BRONCHI ndash BRONCHIAL TREE

bull LUNGS ndashLOBES OF THE LUNGS

PLUERAL CAVITIES AND ALVEOLI

Nose (nasal cavity)

bull Both olfactory and respiratory functions

bull Inspired air is warmed or cooled

bull Brought close to body temperature

bull Also moistened by fluid derived from

transudation through epithelium and

secretions of glands and goblet cells

Warming and

humidification of inspired air

bull Moist air is necessary

for integrity and proper

functioning of

ciliated epithelium

bull Secretions have

bactericidal actions

bull Stiff hairs trap dust and

foreign particles

bull Resonator in voice and speech

Pharynxbull Nasal cavity opens posteriorly into

nasopharynx

bull During swallowing respiration is

Temporarily inhibited permitting

food to enter oropharynx

bull Elevation of larynx and

closure of vocal cords

prevents entry of food into larynx

CONDUCTING PASSAGES

bull NOSE - NASAL CAVITY amp

PARANASAL SINUSES

bull PHARYNX

bull LARYNX ndash EPIGLOTTIS amp VOCAL CORDS

bull TRACHEA

bull BRONCHI ndash BRONCHIAL TREE

bull LUNGS ndashLOBES OF THE LUNGS

PLUERAL CAVITIES AND ALVEOLI

Nose (nasal cavity)

bull Both olfactory and respiratory functions

bull Inspired air is warmed or cooled

bull Brought close to body temperature

bull Also moistened by fluid derived from

transudation through epithelium and

secretions of glands and goblet cells

Warming and

humidification of inspired air

bull Moist air is necessary

for integrity and proper

functioning of

ciliated epithelium

bull Secretions have

bactericidal actions

bull Stiff hairs trap dust and

foreign particles

bull Resonator in voice and speech

Pharynxbull Nasal cavity opens posteriorly into

nasopharynx

bull During swallowing respiration is

Temporarily inhibited permitting

food to enter oropharynx

bull Elevation of larynx and

closure of vocal cords

prevents entry of food into larynx

Nose (nasal cavity)

bull Both olfactory and respiratory functions

bull Inspired air is warmed or cooled

bull Brought close to body temperature

bull Also moistened by fluid derived from

transudation through epithelium and

secretions of glands and goblet cells

Warming and

humidification of inspired air

bull Moist air is necessary

for integrity and proper

functioning of

ciliated epithelium

bull Secretions have

bactericidal actions

bull Stiff hairs trap dust and

foreign particles

bull Resonator in voice and speech

Pharynxbull Nasal cavity opens posteriorly into

nasopharynx

bull During swallowing respiration is

Temporarily inhibited permitting

food to enter oropharynx

bull Elevation of larynx and

closure of vocal cords

prevents entry of food into larynx

Warming and

humidification of inspired air

bull Moist air is necessary

for integrity and proper

functioning of

ciliated epithelium

bull Secretions have

bactericidal actions

bull Stiff hairs trap dust and

foreign particles

bull Resonator in voice and speech

Pharynxbull Nasal cavity opens posteriorly into

nasopharynx

bull During swallowing respiration is

Temporarily inhibited permitting

food to enter oropharynx

bull Elevation of larynx and

closure of vocal cords

prevents entry of food into larynx

Pharynxbull Nasal cavity opens posteriorly into

nasopharynx

bull During swallowing respiration is

Temporarily inhibited permitting

food to enter oropharynx

bull Elevation of larynx and

closure of vocal cords

prevents entry of food into larynx

Larynx

bull Lower part of pharynx and at upper end of

trachea

bull Cartilagenous cartilages being held

together ligaments

bull Production of voice

bull Achieved by forcible expulsion of air from

lungs causing production of sound

bull Contraction of adductor muscles and glottis

It is an enlargement in the airway

superior to the trachea and inferior to the pharynx

bull It helps keep particles from entering the

trachea and also houses the vocal cords

It is composed of a framework of muscles

and cartilage bound by elastic tissue

The Epiglottis

It is a large leaf-shaped piece of cartilage

A flap of cartilage that prevents food from

entering the trachea (or windpipe)

During swallowing there is elevation of the larynx

The Vocal Cords Inside the larynx 2 pairs of folds of muscle and

connective tissues covered with mucous membrane make up the vocal cords

a The upper pair is the false vocal cords

b The lower pair is the true vocal cords

c Changing tension on the vocal cords controls pitch while increasing the loudness depends upon increasing the force of air vibrating the vocal cords

During normal breathing the vocal cords are relaxed and the

glottis is a triangular slit

bull During swallowing the false vocal cords and epiglottis close off the glottis

THE TRACHEA

bull It is a tubular passage way for airlocated anterior to the esophagus

bull It extends from the larynx to the 5th thoracic vertebra where it divides into the

right and left bronchi

bull The inner wall of the trachea is lined with

ciliated mucous membrane

with many goblet cells

that serve to trap incoming

particles

bull The tracheal wall is

supported by 20 incomplete

cartilaginous rings

BRONCHI The Bronchi are the two main air passages

into the lungs

They are composed of the

ldquoRight Primary Bronchusrdquo- leading to the right lung

ldquoLeft Primary Bronchusrdquo - leading to the left lung

The Bronchial Tree

The bronchial tree consists of branched tubes leading from the trachea to the alveoli

The bronchial tree begins with the two primary bronchi each leading to a lung

The branches of the bronchial tree from the trachea are right and left primary bronchi

these further subdivide until bronchioles give rise to alveolar ducts which terminate in alveoli

LUNGS

bull One on either side

bull Large cone-shaped spongy structures

which occupy most of thoracic cavity

bull Left lung is divided into 2 lobes and right

into 3

bull Lined by pleura (visceral and parietal)

It is an enlargement in the airway

superior to the trachea and inferior to the pharynx

bull It helps keep particles from entering the

trachea and also houses the vocal cords

It is composed of a framework of muscles

and cartilage bound by elastic tissue

The Epiglottis

It is a large leaf-shaped piece of cartilage

A flap of cartilage that prevents food from

entering the trachea (or windpipe)

During swallowing there is elevation of the larynx

The Vocal Cords Inside the larynx 2 pairs of folds of muscle and

connective tissues covered with mucous membrane make up the vocal cords

a The upper pair is the false vocal cords

b The lower pair is the true vocal cords

c Changing tension on the vocal cords controls pitch while increasing the loudness depends upon increasing the force of air vibrating the vocal cords

During normal breathing the vocal cords are relaxed and the

glottis is a triangular slit

bull During swallowing the false vocal cords and epiglottis close off the glottis

THE TRACHEA

bull It is a tubular passage way for airlocated anterior to the esophagus

bull It extends from the larynx to the 5th thoracic vertebra where it divides into the

right and left bronchi

bull The inner wall of the trachea is lined with

ciliated mucous membrane

with many goblet cells

that serve to trap incoming

particles

bull The tracheal wall is

supported by 20 incomplete

cartilaginous rings

BRONCHI The Bronchi are the two main air passages

into the lungs

They are composed of the

ldquoRight Primary Bronchusrdquo- leading to the right lung

ldquoLeft Primary Bronchusrdquo - leading to the left lung

The Bronchial Tree

The bronchial tree consists of branched tubes leading from the trachea to the alveoli

The bronchial tree begins with the two primary bronchi each leading to a lung

The branches of the bronchial tree from the trachea are right and left primary bronchi

these further subdivide until bronchioles give rise to alveolar ducts which terminate in alveoli

LUNGS

bull One on either side

bull Large cone-shaped spongy structures

which occupy most of thoracic cavity

bull Left lung is divided into 2 lobes and right

into 3

bull Lined by pleura (visceral and parietal)

The Epiglottis

It is a large leaf-shaped piece of cartilage

A flap of cartilage that prevents food from

entering the trachea (or windpipe)

During swallowing there is elevation of the larynx

The Vocal Cords Inside the larynx 2 pairs of folds of muscle and

connective tissues covered with mucous membrane make up the vocal cords

a The upper pair is the false vocal cords

b The lower pair is the true vocal cords

c Changing tension on the vocal cords controls pitch while increasing the loudness depends upon increasing the force of air vibrating the vocal cords

During normal breathing the vocal cords are relaxed and the

glottis is a triangular slit

bull During swallowing the false vocal cords and epiglottis close off the glottis

THE TRACHEA

bull It is a tubular passage way for airlocated anterior to the esophagus

bull It extends from the larynx to the 5th thoracic vertebra where it divides into the

right and left bronchi

bull The inner wall of the trachea is lined with

ciliated mucous membrane

with many goblet cells

that serve to trap incoming

particles

bull The tracheal wall is

supported by 20 incomplete

cartilaginous rings

BRONCHI The Bronchi are the two main air passages

into the lungs

They are composed of the

ldquoRight Primary Bronchusrdquo- leading to the right lung

ldquoLeft Primary Bronchusrdquo - leading to the left lung

The Bronchial Tree

The bronchial tree consists of branched tubes leading from the trachea to the alveoli

The bronchial tree begins with the two primary bronchi each leading to a lung

The branches of the bronchial tree from the trachea are right and left primary bronchi

these further subdivide until bronchioles give rise to alveolar ducts which terminate in alveoli

LUNGS

bull One on either side

bull Large cone-shaped spongy structures

which occupy most of thoracic cavity

bull Left lung is divided into 2 lobes and right

into 3

bull Lined by pleura (visceral and parietal)

The Vocal Cords Inside the larynx 2 pairs of folds of muscle and

connective tissues covered with mucous membrane make up the vocal cords

a The upper pair is the false vocal cords

b The lower pair is the true vocal cords

c Changing tension on the vocal cords controls pitch while increasing the loudness depends upon increasing the force of air vibrating the vocal cords

During normal breathing the vocal cords are relaxed and the

glottis is a triangular slit

bull During swallowing the false vocal cords and epiglottis close off the glottis

THE TRACHEA

bull It is a tubular passage way for airlocated anterior to the esophagus

bull It extends from the larynx to the 5th thoracic vertebra where it divides into the

right and left bronchi

bull The inner wall of the trachea is lined with

ciliated mucous membrane

with many goblet cells

that serve to trap incoming

particles

bull The tracheal wall is

supported by 20 incomplete

cartilaginous rings

BRONCHI The Bronchi are the two main air passages

into the lungs

They are composed of the

ldquoRight Primary Bronchusrdquo- leading to the right lung

ldquoLeft Primary Bronchusrdquo - leading to the left lung

The Bronchial Tree

The bronchial tree consists of branched tubes leading from the trachea to the alveoli

The bronchial tree begins with the two primary bronchi each leading to a lung

The branches of the bronchial tree from the trachea are right and left primary bronchi

these further subdivide until bronchioles give rise to alveolar ducts which terminate in alveoli

LUNGS

bull One on either side

bull Large cone-shaped spongy structures

which occupy most of thoracic cavity

bull Left lung is divided into 2 lobes and right

into 3

bull Lined by pleura (visceral and parietal)

During normal breathing the vocal cords are relaxed and the

glottis is a triangular slit

bull During swallowing the false vocal cords and epiglottis close off the glottis

THE TRACHEA

bull It is a tubular passage way for airlocated anterior to the esophagus

bull It extends from the larynx to the 5th thoracic vertebra where it divides into the

right and left bronchi

bull The inner wall of the trachea is lined with

ciliated mucous membrane

with many goblet cells

that serve to trap incoming

particles

bull The tracheal wall is

supported by 20 incomplete

cartilaginous rings

BRONCHI The Bronchi are the two main air passages

into the lungs

They are composed of the

ldquoRight Primary Bronchusrdquo- leading to the right lung

ldquoLeft Primary Bronchusrdquo - leading to the left lung

The Bronchial Tree

The bronchial tree consists of branched tubes leading from the trachea to the alveoli

The bronchial tree begins with the two primary bronchi each leading to a lung

The branches of the bronchial tree from the trachea are right and left primary bronchi

these further subdivide until bronchioles give rise to alveolar ducts which terminate in alveoli

LUNGS

bull One on either side

bull Large cone-shaped spongy structures

which occupy most of thoracic cavity

bull Left lung is divided into 2 lobes and right

into 3

bull Lined by pleura (visceral and parietal)

THE TRACHEA

bull It is a tubular passage way for airlocated anterior to the esophagus

bull It extends from the larynx to the 5th thoracic vertebra where it divides into the

right and left bronchi

bull The inner wall of the trachea is lined with

ciliated mucous membrane

with many goblet cells

that serve to trap incoming

particles

bull The tracheal wall is

supported by 20 incomplete

cartilaginous rings

BRONCHI The Bronchi are the two main air passages

into the lungs

They are composed of the

ldquoRight Primary Bronchusrdquo- leading to the right lung

ldquoLeft Primary Bronchusrdquo - leading to the left lung

The Bronchial Tree

The bronchial tree consists of branched tubes leading from the trachea to the alveoli

The bronchial tree begins with the two primary bronchi each leading to a lung

The branches of the bronchial tree from the trachea are right and left primary bronchi

these further subdivide until bronchioles give rise to alveolar ducts which terminate in alveoli

LUNGS

bull One on either side

bull Large cone-shaped spongy structures

which occupy most of thoracic cavity

bull Left lung is divided into 2 lobes and right

into 3

bull Lined by pleura (visceral and parietal)

bull The inner wall of the trachea is lined with

ciliated mucous membrane

with many goblet cells

that serve to trap incoming

particles

bull The tracheal wall is

supported by 20 incomplete

cartilaginous rings

BRONCHI The Bronchi are the two main air passages

into the lungs

They are composed of the

ldquoRight Primary Bronchusrdquo- leading to the right lung

ldquoLeft Primary Bronchusrdquo - leading to the left lung

The Bronchial Tree

The bronchial tree consists of branched tubes leading from the trachea to the alveoli

The bronchial tree begins with the two primary bronchi each leading to a lung

The branches of the bronchial tree from the trachea are right and left primary bronchi

these further subdivide until bronchioles give rise to alveolar ducts which terminate in alveoli

LUNGS

bull One on either side

bull Large cone-shaped spongy structures

which occupy most of thoracic cavity

bull Left lung is divided into 2 lobes and right

into 3

bull Lined by pleura (visceral and parietal)

BRONCHI The Bronchi are the two main air passages

into the lungs

They are composed of the

ldquoRight Primary Bronchusrdquo- leading to the right lung

ldquoLeft Primary Bronchusrdquo - leading to the left lung

The Bronchial Tree

The bronchial tree consists of branched tubes leading from the trachea to the alveoli

The bronchial tree begins with the two primary bronchi each leading to a lung

The branches of the bronchial tree from the trachea are right and left primary bronchi

these further subdivide until bronchioles give rise to alveolar ducts which terminate in alveoli

LUNGS

bull One on either side

bull Large cone-shaped spongy structures

which occupy most of thoracic cavity

bull Left lung is divided into 2 lobes and right

into 3

bull Lined by pleura (visceral and parietal)

The Bronchial Tree

The bronchial tree consists of branched tubes leading from the trachea to the alveoli

The bronchial tree begins with the two primary bronchi each leading to a lung

The branches of the bronchial tree from the trachea are right and left primary bronchi

these further subdivide until bronchioles give rise to alveolar ducts which terminate in alveoli

LUNGS

bull One on either side

bull Large cone-shaped spongy structures

which occupy most of thoracic cavity

bull Left lung is divided into 2 lobes and right

into 3

bull Lined by pleura (visceral and parietal)

LUNGS

bull One on either side

bull Large cone-shaped spongy structures

which occupy most of thoracic cavity

bull Left lung is divided into 2 lobes and right

into 3

bull Lined by pleura (visceral and parietal)

Terminal branches

bull Bronchioles branch further

and the smallest

subdivisions being terminal

bronchiole

bull It is estimated no of

divisions from tracheal

bifurcation to terminal

bronchiole is 16

bull Total no of divisions till

alveoli is 23

The right lung has three lobes

The left lung has two lobes

Each lobe is composed of lobules

that contain air passages alveoli nerves

blood vessels lymphatic vessels

and connective tissues

Pulmonary alveolibull Alveoli are lined by a single layer of flat epithelialcellsbull Alveolar type I cells are principal liningbull Type II are cuboidal cells secrete surfactantbull Average width is 03 mmbull 300 million alveoli in human lung

Surfactantbull Formed from fatty acids by alveolar type II cellsbull Complex mixture of several phospholipidsproteins and ionsbull Most important components are phospholipiddipalmitoyl phosphatidyl choline (DDPC)surfactant appoproteins and calcium ions

The Pleural Cavities

A layer of serous membrane between the visceral pleura and the parietal pleura

bull It contains a lubricating fluid secretedby the membranes that preventsfriction between the membranes and allows their easy movement on one another during breathing

The Alveoli

They are cup-shaped out pouching lined by epithelium and supported by a thin elastic basement membrane

bull With that you can imagine having bunch of grapeswith each grape indicating and alveolus

Alveolar sacs are 2 or more alveoli that share a common opening

This is where the primary exchange of gases occur

STRUCTURE

nose nasal cavity

pharynx (throat)

larynx

trachea (windpipe)

bronchi

bronchioles

alveoli

FUNCTION

warms moistens amp filters air as it is inhaled

passageway for air leads to trachea

the voice box where vocal chords are located

tube from pharynx to bronchi

rings of cartilage provide structure keeps the

windpipe open

trachea is lined with fine hairs called cilia which

filter air before it reaches the lungs

two branches at the end of the trachea each

lead to a lung

a network of smaller branches leading from the

bronchi into the lung tissue amp ultimately to air

sacs

the functional respiratory units in the lung

where gases (oxygen amp carbon dioxide) are

exchanged (enter amp exit the blood stream)

Summary of FUNCTIONS

LIST OF RESPIRATORY AND LUNG DISEASES

bull Upper respiratory tract infections

bull Lower respiratory tract infections

bull Asthma

bull Copd

bull Inflammatory lung diseases

bull Obstructive lung diseases

bull Restrictive lung diseases

bull Respiratory tumors

bull Pleural cavity diseases

bull Pulmonary vascular diseases

Diagnostic Test

bull CHEST XRAY

bull ABG ANALYSIS

bull EXERCISE TESTING

bull MEDIASTINOSCOPY amp MEDIASTINOTOMY

bull BRONCHOSCOPY

bull CHEST IMAGING

bull CHEST TUBE INSERTION

bull NEEDLE BIOPSY OF THE PLEURA OR LUNG

bull PULMONARY FUNCTION TEST (PFT)

bull SUCTIONING

bull THORACOCENTESIS

bull THORACOSCOPY

bull THORACOTOMY

COPD

bull Also known as

COLD (Chronic Obstructive Lung Disease )

COAD (Chronic Obstructive Airway Disease)

Smokerrsquos lung

CAL (Chronic Airflow Limitation)

CORD (Chronic Obstructive Respiratory Disease)

DEFINITION

Chronic obstructive pulmonary disease (COPD) is

a preventable and treatable disease characterized

by airflow limitation that is progressive not fully

reversible and associated with an abnormal

inflammatory response of the lungs

Chronic Bronchitis

bull Chronic bronchitis is a chronic inflammatory

condition in the lungs

bull It causes a cough that often brings up mucus as well as shortness of

breathwheezing and

chest tightness

Emphysema

bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs

EPIDEMIOLOGYbull More common in older people especially those

gt65 years

bull Fifth leading cause of death and disabilityworldwide

bull Death rates for males and females are roughlyequivalent

bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod

Risk Factors

Exposures Host Factors

Environmental tobacco smoke

Genetic predisposition (AAT deficiency)

Occupational dusts and chemicals

Airway hyperresponsiveness

Air pollution Impaired lung growth

Risk Factors

bull Exposures

ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD

ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD

Host Factors

bull Host factor refers to the traits of an individual person that affect susceptibility to disease

ndash AAT deficiency accounts for less than 1 of COPD cases

ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function

ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses

Pathophysiology of COPD

1 Airway inflammation

2 Structural changes

3 Mucociliary dysfunction

- Chronic inflammatory cascade for COPD

The right lung has three lobes

The left lung has two lobes

Each lobe is composed of lobules

that contain air passages alveoli nerves

blood vessels lymphatic vessels

and connective tissues

Pulmonary alveolibull Alveoli are lined by a single layer of flat epithelialcellsbull Alveolar type I cells are principal liningbull Type II are cuboidal cells secrete surfactantbull Average width is 03 mmbull 300 million alveoli in human lung

Surfactantbull Formed from fatty acids by alveolar type II cellsbull Complex mixture of several phospholipidsproteins and ionsbull Most important components are phospholipiddipalmitoyl phosphatidyl choline (DDPC)surfactant appoproteins and calcium ions

The Pleural Cavities

A layer of serous membrane between the visceral pleura and the parietal pleura

bull It contains a lubricating fluid secretedby the membranes that preventsfriction between the membranes and allows their easy movement on one another during breathing

The Alveoli

They are cup-shaped out pouching lined by epithelium and supported by a thin elastic basement membrane

bull With that you can imagine having bunch of grapeswith each grape indicating and alveolus

Alveolar sacs are 2 or more alveoli that share a common opening

This is where the primary exchange of gases occur

STRUCTURE

nose nasal cavity

pharynx (throat)

larynx

trachea (windpipe)

bronchi

bronchioles

alveoli

FUNCTION

warms moistens amp filters air as it is inhaled

passageway for air leads to trachea

the voice box where vocal chords are located

tube from pharynx to bronchi

rings of cartilage provide structure keeps the

windpipe open

trachea is lined with fine hairs called cilia which

filter air before it reaches the lungs

two branches at the end of the trachea each

lead to a lung

a network of smaller branches leading from the

bronchi into the lung tissue amp ultimately to air

sacs

the functional respiratory units in the lung

where gases (oxygen amp carbon dioxide) are

exchanged (enter amp exit the blood stream)

Summary of FUNCTIONS

LIST OF RESPIRATORY AND LUNG DISEASES

bull Upper respiratory tract infections

bull Lower respiratory tract infections

bull Asthma

bull Copd

bull Inflammatory lung diseases

bull Obstructive lung diseases

bull Restrictive lung diseases

bull Respiratory tumors

bull Pleural cavity diseases

bull Pulmonary vascular diseases

Diagnostic Test

bull CHEST XRAY

bull ABG ANALYSIS

bull EXERCISE TESTING

bull MEDIASTINOSCOPY amp MEDIASTINOTOMY

bull BRONCHOSCOPY

bull CHEST IMAGING

bull CHEST TUBE INSERTION

bull NEEDLE BIOPSY OF THE PLEURA OR LUNG

bull PULMONARY FUNCTION TEST (PFT)

bull SUCTIONING

bull THORACOCENTESIS

bull THORACOSCOPY

bull THORACOTOMY

COPD

bull Also known as

COLD (Chronic Obstructive Lung Disease )

COAD (Chronic Obstructive Airway Disease)

Smokerrsquos lung

CAL (Chronic Airflow Limitation)

CORD (Chronic Obstructive Respiratory Disease)

DEFINITION

Chronic obstructive pulmonary disease (COPD) is

a preventable and treatable disease characterized

by airflow limitation that is progressive not fully

reversible and associated with an abnormal

inflammatory response of the lungs

Chronic Bronchitis

bull Chronic bronchitis is a chronic inflammatory

condition in the lungs

bull It causes a cough that often brings up mucus as well as shortness of

breathwheezing and

chest tightness

Emphysema

bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs

EPIDEMIOLOGYbull More common in older people especially those

gt65 years

bull Fifth leading cause of death and disabilityworldwide

bull Death rates for males and females are roughlyequivalent

bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod

Risk Factors

Exposures Host Factors

Environmental tobacco smoke

Genetic predisposition (AAT deficiency)

Occupational dusts and chemicals

Airway hyperresponsiveness

Air pollution Impaired lung growth

Risk Factors

bull Exposures

ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD

ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD

Host Factors

bull Host factor refers to the traits of an individual person that affect susceptibility to disease

ndash AAT deficiency accounts for less than 1 of COPD cases

ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function

ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses

Pathophysiology of COPD

1 Airway inflammation

2 Structural changes

3 Mucociliary dysfunction

- Chronic inflammatory cascade for COPD

Pulmonary alveolibull Alveoli are lined by a single layer of flat epithelialcellsbull Alveolar type I cells are principal liningbull Type II are cuboidal cells secrete surfactantbull Average width is 03 mmbull 300 million alveoli in human lung

Surfactantbull Formed from fatty acids by alveolar type II cellsbull Complex mixture of several phospholipidsproteins and ionsbull Most important components are phospholipiddipalmitoyl phosphatidyl choline (DDPC)surfactant appoproteins and calcium ions

The Pleural Cavities

A layer of serous membrane between the visceral pleura and the parietal pleura

bull It contains a lubricating fluid secretedby the membranes that preventsfriction between the membranes and allows their easy movement on one another during breathing

The Alveoli

They are cup-shaped out pouching lined by epithelium and supported by a thin elastic basement membrane

bull With that you can imagine having bunch of grapeswith each grape indicating and alveolus

Alveolar sacs are 2 or more alveoli that share a common opening

This is where the primary exchange of gases occur

STRUCTURE

nose nasal cavity

pharynx (throat)

larynx

trachea (windpipe)

bronchi

bronchioles

alveoli

FUNCTION

warms moistens amp filters air as it is inhaled

passageway for air leads to trachea

the voice box where vocal chords are located

tube from pharynx to bronchi

rings of cartilage provide structure keeps the

windpipe open

trachea is lined with fine hairs called cilia which

filter air before it reaches the lungs

two branches at the end of the trachea each

lead to a lung

a network of smaller branches leading from the

bronchi into the lung tissue amp ultimately to air

sacs

the functional respiratory units in the lung

where gases (oxygen amp carbon dioxide) are

exchanged (enter amp exit the blood stream)

Summary of FUNCTIONS

LIST OF RESPIRATORY AND LUNG DISEASES

bull Upper respiratory tract infections

bull Lower respiratory tract infections

bull Asthma

bull Copd

bull Inflammatory lung diseases

bull Obstructive lung diseases

bull Restrictive lung diseases

bull Respiratory tumors

bull Pleural cavity diseases

bull Pulmonary vascular diseases

Diagnostic Test

bull CHEST XRAY

bull ABG ANALYSIS

bull EXERCISE TESTING

bull MEDIASTINOSCOPY amp MEDIASTINOTOMY

bull BRONCHOSCOPY

bull CHEST IMAGING

bull CHEST TUBE INSERTION

bull NEEDLE BIOPSY OF THE PLEURA OR LUNG

bull PULMONARY FUNCTION TEST (PFT)

bull SUCTIONING

bull THORACOCENTESIS

bull THORACOSCOPY

bull THORACOTOMY

COPD

bull Also known as

COLD (Chronic Obstructive Lung Disease )

COAD (Chronic Obstructive Airway Disease)

Smokerrsquos lung

CAL (Chronic Airflow Limitation)

CORD (Chronic Obstructive Respiratory Disease)

DEFINITION

Chronic obstructive pulmonary disease (COPD) is

a preventable and treatable disease characterized

by airflow limitation that is progressive not fully

reversible and associated with an abnormal

inflammatory response of the lungs

Chronic Bronchitis

bull Chronic bronchitis is a chronic inflammatory

condition in the lungs

bull It causes a cough that often brings up mucus as well as shortness of

breathwheezing and

chest tightness

Emphysema

bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs

EPIDEMIOLOGYbull More common in older people especially those

gt65 years

bull Fifth leading cause of death and disabilityworldwide

bull Death rates for males and females are roughlyequivalent

bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod

Risk Factors

Exposures Host Factors

Environmental tobacco smoke

Genetic predisposition (AAT deficiency)

Occupational dusts and chemicals

Airway hyperresponsiveness

Air pollution Impaired lung growth

Risk Factors

bull Exposures

ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD

ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD

Host Factors

bull Host factor refers to the traits of an individual person that affect susceptibility to disease

ndash AAT deficiency accounts for less than 1 of COPD cases

ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function

ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses

Pathophysiology of COPD

1 Airway inflammation

2 Structural changes

3 Mucociliary dysfunction

- Chronic inflammatory cascade for COPD

The Pleural Cavities

A layer of serous membrane between the visceral pleura and the parietal pleura

bull It contains a lubricating fluid secretedby the membranes that preventsfriction between the membranes and allows their easy movement on one another during breathing

The Alveoli

They are cup-shaped out pouching lined by epithelium and supported by a thin elastic basement membrane

bull With that you can imagine having bunch of grapeswith each grape indicating and alveolus

Alveolar sacs are 2 or more alveoli that share a common opening

This is where the primary exchange of gases occur

STRUCTURE

nose nasal cavity

pharynx (throat)

larynx

trachea (windpipe)

bronchi

bronchioles

alveoli

FUNCTION

warms moistens amp filters air as it is inhaled

passageway for air leads to trachea

the voice box where vocal chords are located

tube from pharynx to bronchi

rings of cartilage provide structure keeps the

windpipe open

trachea is lined with fine hairs called cilia which

filter air before it reaches the lungs

two branches at the end of the trachea each

lead to a lung

a network of smaller branches leading from the

bronchi into the lung tissue amp ultimately to air

sacs

the functional respiratory units in the lung

where gases (oxygen amp carbon dioxide) are

exchanged (enter amp exit the blood stream)

Summary of FUNCTIONS

LIST OF RESPIRATORY AND LUNG DISEASES

bull Upper respiratory tract infections

bull Lower respiratory tract infections

bull Asthma

bull Copd

bull Inflammatory lung diseases

bull Obstructive lung diseases

bull Restrictive lung diseases

bull Respiratory tumors

bull Pleural cavity diseases

bull Pulmonary vascular diseases

Diagnostic Test

bull CHEST XRAY

bull ABG ANALYSIS

bull EXERCISE TESTING

bull MEDIASTINOSCOPY amp MEDIASTINOTOMY

bull BRONCHOSCOPY

bull CHEST IMAGING

bull CHEST TUBE INSERTION

bull NEEDLE BIOPSY OF THE PLEURA OR LUNG

bull PULMONARY FUNCTION TEST (PFT)

bull SUCTIONING

bull THORACOCENTESIS

bull THORACOSCOPY

bull THORACOTOMY

COPD

bull Also known as

COLD (Chronic Obstructive Lung Disease )

COAD (Chronic Obstructive Airway Disease)

Smokerrsquos lung

CAL (Chronic Airflow Limitation)

CORD (Chronic Obstructive Respiratory Disease)

DEFINITION

Chronic obstructive pulmonary disease (COPD) is

a preventable and treatable disease characterized

by airflow limitation that is progressive not fully

reversible and associated with an abnormal

inflammatory response of the lungs

Chronic Bronchitis

bull Chronic bronchitis is a chronic inflammatory

condition in the lungs

bull It causes a cough that often brings up mucus as well as shortness of

breathwheezing and

chest tightness

Emphysema

bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs

EPIDEMIOLOGYbull More common in older people especially those

gt65 years

bull Fifth leading cause of death and disabilityworldwide

bull Death rates for males and females are roughlyequivalent

bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod

Risk Factors

Exposures Host Factors

Environmental tobacco smoke

Genetic predisposition (AAT deficiency)

Occupational dusts and chemicals

Airway hyperresponsiveness

Air pollution Impaired lung growth

Risk Factors

bull Exposures

ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD

ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD

Host Factors

bull Host factor refers to the traits of an individual person that affect susceptibility to disease

ndash AAT deficiency accounts for less than 1 of COPD cases

ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function

ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses

Pathophysiology of COPD

1 Airway inflammation

2 Structural changes

3 Mucociliary dysfunction

- Chronic inflammatory cascade for COPD

The Alveoli

They are cup-shaped out pouching lined by epithelium and supported by a thin elastic basement membrane

bull With that you can imagine having bunch of grapeswith each grape indicating and alveolus

Alveolar sacs are 2 or more alveoli that share a common opening

This is where the primary exchange of gases occur

STRUCTURE

nose nasal cavity

pharynx (throat)

larynx

trachea (windpipe)

bronchi

bronchioles

alveoli

FUNCTION

warms moistens amp filters air as it is inhaled

passageway for air leads to trachea

the voice box where vocal chords are located

tube from pharynx to bronchi

rings of cartilage provide structure keeps the

windpipe open

trachea is lined with fine hairs called cilia which

filter air before it reaches the lungs

two branches at the end of the trachea each

lead to a lung

a network of smaller branches leading from the

bronchi into the lung tissue amp ultimately to air

sacs

the functional respiratory units in the lung

where gases (oxygen amp carbon dioxide) are

exchanged (enter amp exit the blood stream)

Summary of FUNCTIONS

LIST OF RESPIRATORY AND LUNG DISEASES

bull Upper respiratory tract infections

bull Lower respiratory tract infections

bull Asthma

bull Copd

bull Inflammatory lung diseases

bull Obstructive lung diseases

bull Restrictive lung diseases

bull Respiratory tumors

bull Pleural cavity diseases

bull Pulmonary vascular diseases

Diagnostic Test

bull CHEST XRAY

bull ABG ANALYSIS

bull EXERCISE TESTING

bull MEDIASTINOSCOPY amp MEDIASTINOTOMY

bull BRONCHOSCOPY

bull CHEST IMAGING

bull CHEST TUBE INSERTION

bull NEEDLE BIOPSY OF THE PLEURA OR LUNG

bull PULMONARY FUNCTION TEST (PFT)

bull SUCTIONING

bull THORACOCENTESIS

bull THORACOSCOPY

bull THORACOTOMY

COPD

bull Also known as

COLD (Chronic Obstructive Lung Disease )

COAD (Chronic Obstructive Airway Disease)

Smokerrsquos lung

CAL (Chronic Airflow Limitation)

CORD (Chronic Obstructive Respiratory Disease)

DEFINITION

Chronic obstructive pulmonary disease (COPD) is

a preventable and treatable disease characterized

by airflow limitation that is progressive not fully

reversible and associated with an abnormal

inflammatory response of the lungs

Chronic Bronchitis

bull Chronic bronchitis is a chronic inflammatory

condition in the lungs

bull It causes a cough that often brings up mucus as well as shortness of

breathwheezing and

chest tightness

Emphysema

bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs

EPIDEMIOLOGYbull More common in older people especially those

gt65 years

bull Fifth leading cause of death and disabilityworldwide

bull Death rates for males and females are roughlyequivalent

bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod

Risk Factors

Exposures Host Factors

Environmental tobacco smoke

Genetic predisposition (AAT deficiency)

Occupational dusts and chemicals

Airway hyperresponsiveness

Air pollution Impaired lung growth

Risk Factors

bull Exposures

ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD

ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD

Host Factors

bull Host factor refers to the traits of an individual person that affect susceptibility to disease

ndash AAT deficiency accounts for less than 1 of COPD cases

ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function

ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses

Pathophysiology of COPD

1 Airway inflammation

2 Structural changes

3 Mucociliary dysfunction

- Chronic inflammatory cascade for COPD

STRUCTURE

nose nasal cavity

pharynx (throat)

larynx

trachea (windpipe)

bronchi

bronchioles

alveoli

FUNCTION

warms moistens amp filters air as it is inhaled

passageway for air leads to trachea

the voice box where vocal chords are located

tube from pharynx to bronchi

rings of cartilage provide structure keeps the

windpipe open

trachea is lined with fine hairs called cilia which

filter air before it reaches the lungs

two branches at the end of the trachea each

lead to a lung

a network of smaller branches leading from the

bronchi into the lung tissue amp ultimately to air

sacs

the functional respiratory units in the lung

where gases (oxygen amp carbon dioxide) are

exchanged (enter amp exit the blood stream)

Summary of FUNCTIONS

LIST OF RESPIRATORY AND LUNG DISEASES

bull Upper respiratory tract infections

bull Lower respiratory tract infections

bull Asthma

bull Copd

bull Inflammatory lung diseases

bull Obstructive lung diseases

bull Restrictive lung diseases

bull Respiratory tumors

bull Pleural cavity diseases

bull Pulmonary vascular diseases

Diagnostic Test

bull CHEST XRAY

bull ABG ANALYSIS

bull EXERCISE TESTING

bull MEDIASTINOSCOPY amp MEDIASTINOTOMY

bull BRONCHOSCOPY

bull CHEST IMAGING

bull CHEST TUBE INSERTION

bull NEEDLE BIOPSY OF THE PLEURA OR LUNG

bull PULMONARY FUNCTION TEST (PFT)

bull SUCTIONING

bull THORACOCENTESIS

bull THORACOSCOPY

bull THORACOTOMY

COPD

bull Also known as

COLD (Chronic Obstructive Lung Disease )

COAD (Chronic Obstructive Airway Disease)

Smokerrsquos lung

CAL (Chronic Airflow Limitation)

CORD (Chronic Obstructive Respiratory Disease)

DEFINITION

Chronic obstructive pulmonary disease (COPD) is

a preventable and treatable disease characterized

by airflow limitation that is progressive not fully

reversible and associated with an abnormal

inflammatory response of the lungs

Chronic Bronchitis

bull Chronic bronchitis is a chronic inflammatory

condition in the lungs

bull It causes a cough that often brings up mucus as well as shortness of

breathwheezing and

chest tightness

Emphysema

bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs

EPIDEMIOLOGYbull More common in older people especially those

gt65 years

bull Fifth leading cause of death and disabilityworldwide

bull Death rates for males and females are roughlyequivalent

bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod

Risk Factors

Exposures Host Factors

Environmental tobacco smoke

Genetic predisposition (AAT deficiency)

Occupational dusts and chemicals

Airway hyperresponsiveness

Air pollution Impaired lung growth

Risk Factors

bull Exposures

ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD

ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD

Host Factors

bull Host factor refers to the traits of an individual person that affect susceptibility to disease

ndash AAT deficiency accounts for less than 1 of COPD cases

ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function

ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses

Pathophysiology of COPD

1 Airway inflammation

2 Structural changes

3 Mucociliary dysfunction

- Chronic inflammatory cascade for COPD

LIST OF RESPIRATORY AND LUNG DISEASES

bull Upper respiratory tract infections

bull Lower respiratory tract infections

bull Asthma

bull Copd

bull Inflammatory lung diseases

bull Obstructive lung diseases

bull Restrictive lung diseases

bull Respiratory tumors

bull Pleural cavity diseases

bull Pulmonary vascular diseases

Diagnostic Test

bull CHEST XRAY

bull ABG ANALYSIS

bull EXERCISE TESTING

bull MEDIASTINOSCOPY amp MEDIASTINOTOMY

bull BRONCHOSCOPY

bull CHEST IMAGING

bull CHEST TUBE INSERTION

bull NEEDLE BIOPSY OF THE PLEURA OR LUNG

bull PULMONARY FUNCTION TEST (PFT)

bull SUCTIONING

bull THORACOCENTESIS

bull THORACOSCOPY

bull THORACOTOMY

COPD

bull Also known as

COLD (Chronic Obstructive Lung Disease )

COAD (Chronic Obstructive Airway Disease)

Smokerrsquos lung

CAL (Chronic Airflow Limitation)

CORD (Chronic Obstructive Respiratory Disease)

DEFINITION

Chronic obstructive pulmonary disease (COPD) is

a preventable and treatable disease characterized

by airflow limitation that is progressive not fully

reversible and associated with an abnormal

inflammatory response of the lungs

Chronic Bronchitis

bull Chronic bronchitis is a chronic inflammatory

condition in the lungs

bull It causes a cough that often brings up mucus as well as shortness of

breathwheezing and

chest tightness

Emphysema

bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs

EPIDEMIOLOGYbull More common in older people especially those

gt65 years

bull Fifth leading cause of death and disabilityworldwide

bull Death rates for males and females are roughlyequivalent

bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod

Risk Factors

Exposures Host Factors

Environmental tobacco smoke

Genetic predisposition (AAT deficiency)

Occupational dusts and chemicals

Airway hyperresponsiveness

Air pollution Impaired lung growth

Risk Factors

bull Exposures

ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD

ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD

Host Factors

bull Host factor refers to the traits of an individual person that affect susceptibility to disease

ndash AAT deficiency accounts for less than 1 of COPD cases

ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function

ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses

Pathophysiology of COPD

1 Airway inflammation

2 Structural changes

3 Mucociliary dysfunction

- Chronic inflammatory cascade for COPD

bull Obstructive lung diseases

bull Restrictive lung diseases

bull Respiratory tumors

bull Pleural cavity diseases

bull Pulmonary vascular diseases

Diagnostic Test

bull CHEST XRAY

bull ABG ANALYSIS

bull EXERCISE TESTING

bull MEDIASTINOSCOPY amp MEDIASTINOTOMY

bull BRONCHOSCOPY

bull CHEST IMAGING

bull CHEST TUBE INSERTION

bull NEEDLE BIOPSY OF THE PLEURA OR LUNG

bull PULMONARY FUNCTION TEST (PFT)

bull SUCTIONING

bull THORACOCENTESIS

bull THORACOSCOPY

bull THORACOTOMY

COPD

bull Also known as

COLD (Chronic Obstructive Lung Disease )

COAD (Chronic Obstructive Airway Disease)

Smokerrsquos lung

CAL (Chronic Airflow Limitation)

CORD (Chronic Obstructive Respiratory Disease)

DEFINITION

Chronic obstructive pulmonary disease (COPD) is

a preventable and treatable disease characterized

by airflow limitation that is progressive not fully

reversible and associated with an abnormal

inflammatory response of the lungs

Chronic Bronchitis

bull Chronic bronchitis is a chronic inflammatory

condition in the lungs

bull It causes a cough that often brings up mucus as well as shortness of

breathwheezing and

chest tightness

Emphysema

bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs

EPIDEMIOLOGYbull More common in older people especially those

gt65 years

bull Fifth leading cause of death and disabilityworldwide

bull Death rates for males and females are roughlyequivalent

bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod

Risk Factors

Exposures Host Factors

Environmental tobacco smoke

Genetic predisposition (AAT deficiency)

Occupational dusts and chemicals

Airway hyperresponsiveness

Air pollution Impaired lung growth

Risk Factors

bull Exposures

ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD

ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD

Host Factors

bull Host factor refers to the traits of an individual person that affect susceptibility to disease

ndash AAT deficiency accounts for less than 1 of COPD cases

ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function

ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses

Pathophysiology of COPD

1 Airway inflammation

2 Structural changes

3 Mucociliary dysfunction

- Chronic inflammatory cascade for COPD

Diagnostic Test

bull CHEST XRAY

bull ABG ANALYSIS

bull EXERCISE TESTING

bull MEDIASTINOSCOPY amp MEDIASTINOTOMY

bull BRONCHOSCOPY

bull CHEST IMAGING

bull CHEST TUBE INSERTION

bull NEEDLE BIOPSY OF THE PLEURA OR LUNG

bull PULMONARY FUNCTION TEST (PFT)

bull SUCTIONING

bull THORACOCENTESIS

bull THORACOSCOPY

bull THORACOTOMY

COPD

bull Also known as

COLD (Chronic Obstructive Lung Disease )

COAD (Chronic Obstructive Airway Disease)

Smokerrsquos lung

CAL (Chronic Airflow Limitation)

CORD (Chronic Obstructive Respiratory Disease)

DEFINITION

Chronic obstructive pulmonary disease (COPD) is

a preventable and treatable disease characterized

by airflow limitation that is progressive not fully

reversible and associated with an abnormal

inflammatory response of the lungs

Chronic Bronchitis

bull Chronic bronchitis is a chronic inflammatory

condition in the lungs

bull It causes a cough that often brings up mucus as well as shortness of

breathwheezing and

chest tightness

Emphysema

bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs

EPIDEMIOLOGYbull More common in older people especially those

gt65 years

bull Fifth leading cause of death and disabilityworldwide

bull Death rates for males and females are roughlyequivalent

bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod

Risk Factors

Exposures Host Factors

Environmental tobacco smoke

Genetic predisposition (AAT deficiency)

Occupational dusts and chemicals

Airway hyperresponsiveness

Air pollution Impaired lung growth

Risk Factors

bull Exposures

ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD

ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD

Host Factors

bull Host factor refers to the traits of an individual person that affect susceptibility to disease

ndash AAT deficiency accounts for less than 1 of COPD cases

ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function

ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses

Pathophysiology of COPD

1 Airway inflammation

2 Structural changes

3 Mucociliary dysfunction

- Chronic inflammatory cascade for COPD

bull BRONCHOSCOPY

bull CHEST IMAGING

bull CHEST TUBE INSERTION

bull NEEDLE BIOPSY OF THE PLEURA OR LUNG

bull PULMONARY FUNCTION TEST (PFT)

bull SUCTIONING

bull THORACOCENTESIS

bull THORACOSCOPY

bull THORACOTOMY

COPD

bull Also known as

COLD (Chronic Obstructive Lung Disease )

COAD (Chronic Obstructive Airway Disease)

Smokerrsquos lung

CAL (Chronic Airflow Limitation)

CORD (Chronic Obstructive Respiratory Disease)

DEFINITION

Chronic obstructive pulmonary disease (COPD) is

a preventable and treatable disease characterized

by airflow limitation that is progressive not fully

reversible and associated with an abnormal

inflammatory response of the lungs

Chronic Bronchitis

bull Chronic bronchitis is a chronic inflammatory

condition in the lungs

bull It causes a cough that often brings up mucus as well as shortness of

breathwheezing and

chest tightness

Emphysema

bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs

EPIDEMIOLOGYbull More common in older people especially those

gt65 years

bull Fifth leading cause of death and disabilityworldwide

bull Death rates for males and females are roughlyequivalent

bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod

Risk Factors

Exposures Host Factors

Environmental tobacco smoke

Genetic predisposition (AAT deficiency)

Occupational dusts and chemicals

Airway hyperresponsiveness

Air pollution Impaired lung growth

Risk Factors

bull Exposures

ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD

ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD

Host Factors

bull Host factor refers to the traits of an individual person that affect susceptibility to disease

ndash AAT deficiency accounts for less than 1 of COPD cases

ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function

ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses

Pathophysiology of COPD

1 Airway inflammation

2 Structural changes

3 Mucociliary dysfunction

- Chronic inflammatory cascade for COPD

bull NEEDLE BIOPSY OF THE PLEURA OR LUNG

bull PULMONARY FUNCTION TEST (PFT)

bull SUCTIONING

bull THORACOCENTESIS

bull THORACOSCOPY

bull THORACOTOMY

COPD

bull Also known as

COLD (Chronic Obstructive Lung Disease )

COAD (Chronic Obstructive Airway Disease)

Smokerrsquos lung

CAL (Chronic Airflow Limitation)

CORD (Chronic Obstructive Respiratory Disease)

DEFINITION

Chronic obstructive pulmonary disease (COPD) is

a preventable and treatable disease characterized

by airflow limitation that is progressive not fully

reversible and associated with an abnormal

inflammatory response of the lungs

Chronic Bronchitis

bull Chronic bronchitis is a chronic inflammatory

condition in the lungs

bull It causes a cough that often brings up mucus as well as shortness of

breathwheezing and

chest tightness

Emphysema

bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs

EPIDEMIOLOGYbull More common in older people especially those

gt65 years

bull Fifth leading cause of death and disabilityworldwide

bull Death rates for males and females are roughlyequivalent

bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod

Risk Factors

Exposures Host Factors

Environmental tobacco smoke

Genetic predisposition (AAT deficiency)

Occupational dusts and chemicals

Airway hyperresponsiveness

Air pollution Impaired lung growth

Risk Factors

bull Exposures

ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD

ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD

Host Factors

bull Host factor refers to the traits of an individual person that affect susceptibility to disease

ndash AAT deficiency accounts for less than 1 of COPD cases

ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function

ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses

Pathophysiology of COPD

1 Airway inflammation

2 Structural changes

3 Mucociliary dysfunction

- Chronic inflammatory cascade for COPD

COPD

bull Also known as

COLD (Chronic Obstructive Lung Disease )

COAD (Chronic Obstructive Airway Disease)

Smokerrsquos lung

CAL (Chronic Airflow Limitation)

CORD (Chronic Obstructive Respiratory Disease)

DEFINITION

Chronic obstructive pulmonary disease (COPD) is

a preventable and treatable disease characterized

by airflow limitation that is progressive not fully

reversible and associated with an abnormal

inflammatory response of the lungs

Chronic Bronchitis

bull Chronic bronchitis is a chronic inflammatory

condition in the lungs

bull It causes a cough that often brings up mucus as well as shortness of

breathwheezing and

chest tightness

Emphysema

bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs

EPIDEMIOLOGYbull More common in older people especially those

gt65 years

bull Fifth leading cause of death and disabilityworldwide

bull Death rates for males and females are roughlyequivalent

bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod

Risk Factors

Exposures Host Factors

Environmental tobacco smoke

Genetic predisposition (AAT deficiency)

Occupational dusts and chemicals

Airway hyperresponsiveness

Air pollution Impaired lung growth

Risk Factors

bull Exposures

ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD

ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD

Host Factors

bull Host factor refers to the traits of an individual person that affect susceptibility to disease

ndash AAT deficiency accounts for less than 1 of COPD cases

ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function

ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses

Pathophysiology of COPD

1 Airway inflammation

2 Structural changes

3 Mucociliary dysfunction

- Chronic inflammatory cascade for COPD

DEFINITION

Chronic obstructive pulmonary disease (COPD) is

a preventable and treatable disease characterized

by airflow limitation that is progressive not fully

reversible and associated with an abnormal

inflammatory response of the lungs

Chronic Bronchitis

bull Chronic bronchitis is a chronic inflammatory

condition in the lungs

bull It causes a cough that often brings up mucus as well as shortness of

breathwheezing and

chest tightness

Emphysema

bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs

EPIDEMIOLOGYbull More common in older people especially those

gt65 years

bull Fifth leading cause of death and disabilityworldwide

bull Death rates for males and females are roughlyequivalent

bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod

Risk Factors

Exposures Host Factors

Environmental tobacco smoke

Genetic predisposition (AAT deficiency)

Occupational dusts and chemicals

Airway hyperresponsiveness

Air pollution Impaired lung growth

Risk Factors

bull Exposures

ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD

ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD

Host Factors

bull Host factor refers to the traits of an individual person that affect susceptibility to disease

ndash AAT deficiency accounts for less than 1 of COPD cases

ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function

ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses

Pathophysiology of COPD

1 Airway inflammation

2 Structural changes

3 Mucociliary dysfunction

- Chronic inflammatory cascade for COPD

Chronic Bronchitis

bull Chronic bronchitis is a chronic inflammatory

condition in the lungs

bull It causes a cough that often brings up mucus as well as shortness of

breathwheezing and

chest tightness

Emphysema

bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs

EPIDEMIOLOGYbull More common in older people especially those

gt65 years

bull Fifth leading cause of death and disabilityworldwide

bull Death rates for males and females are roughlyequivalent

bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod

Risk Factors

Exposures Host Factors

Environmental tobacco smoke

Genetic predisposition (AAT deficiency)

Occupational dusts and chemicals

Airway hyperresponsiveness

Air pollution Impaired lung growth

Risk Factors

bull Exposures

ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD

ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD

Host Factors

bull Host factor refers to the traits of an individual person that affect susceptibility to disease

ndash AAT deficiency accounts for less than 1 of COPD cases

ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function

ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses

Pathophysiology of COPD

1 Airway inflammation

2 Structural changes

3 Mucociliary dysfunction

- Chronic inflammatory cascade for COPD

Emphysema

bull In emphysema there isover-inflation of the airsacs (alveoli) in thelungs causing adecrease in lungfunction and oftenbreathlessness Itinvolves destruction ofthe lungs

EPIDEMIOLOGYbull More common in older people especially those

gt65 years

bull Fifth leading cause of death and disabilityworldwide

bull Death rates for males and females are roughlyequivalent

bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod

Risk Factors

Exposures Host Factors

Environmental tobacco smoke

Genetic predisposition (AAT deficiency)

Occupational dusts and chemicals

Airway hyperresponsiveness

Air pollution Impaired lung growth

Risk Factors

bull Exposures

ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD

ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD

Host Factors

bull Host factor refers to the traits of an individual person that affect susceptibility to disease

ndash AAT deficiency accounts for less than 1 of COPD cases

ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function

ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses

Pathophysiology of COPD

1 Airway inflammation

2 Structural changes

3 Mucociliary dysfunction

- Chronic inflammatory cascade for COPD

EPIDEMIOLOGYbull More common in older people especially those

gt65 years

bull Fifth leading cause of death and disabilityworldwide

bull Death rates for males and females are roughlyequivalent

bull COPD mortality has also increased compared withheart and cerebrovascular disease over the sameperiod

Risk Factors

Exposures Host Factors

Environmental tobacco smoke

Genetic predisposition (AAT deficiency)

Occupational dusts and chemicals

Airway hyperresponsiveness

Air pollution Impaired lung growth

Risk Factors

bull Exposures

ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD

ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD

Host Factors

bull Host factor refers to the traits of an individual person that affect susceptibility to disease

ndash AAT deficiency accounts for less than 1 of COPD cases

ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function

ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses

Pathophysiology of COPD

1 Airway inflammation

2 Structural changes

3 Mucociliary dysfunction

- Chronic inflammatory cascade for COPD

Risk Factors

Exposures Host Factors

Environmental tobacco smoke

Genetic predisposition (AAT deficiency)

Occupational dusts and chemicals

Airway hyperresponsiveness

Air pollution Impaired lung growth

Risk Factors

bull Exposures

ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD

ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD

Host Factors

bull Host factor refers to the traits of an individual person that affect susceptibility to disease

ndash AAT deficiency accounts for less than 1 of COPD cases

ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function

ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses

Pathophysiology of COPD

1 Airway inflammation

2 Structural changes

3 Mucociliary dysfunction

- Chronic inflammatory cascade for COPD

Risk Factors

bull Exposures

ndash Cigarette smoking (tobacco exposure) accounts for 85 to 90 of cases of COPD

ndash Air pollution and occupational exposures result in inflammation and cell injury which leads to COPD

Host Factors

bull Host factor refers to the traits of an individual person that affect susceptibility to disease

ndash AAT deficiency accounts for less than 1 of COPD cases

ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function

ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses

Pathophysiology of COPD

1 Airway inflammation

2 Structural changes

3 Mucociliary dysfunction

- Chronic inflammatory cascade for COPD

Host Factors

bull Host factor refers to the traits of an individual person that affect susceptibility to disease

ndash AAT deficiency accounts for less than 1 of COPD cases

ndash Airway hyperresponsiveness due to various inhaled particles may cause an accelerated decline in lung function

ndash Impaired lung growth due to low birth weight prematurity at birth or childhood illnesses

Pathophysiology of COPD

1 Airway inflammation

2 Structural changes

3 Mucociliary dysfunction

- Chronic inflammatory cascade for COPD

Pathophysiology of COPD

1 Airway inflammation

2 Structural changes

3 Mucociliary dysfunction

- Chronic inflammatory cascade for COPD

ASSESSMENT

1 Clinical presentation

ndash History

ndash Physical examination

2 Diagnostic testing

ndash Pulmonary function testing

ndash Laboratories

ndash Imaging

Clinical Presentation

HistoryPhysical

Examination

- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors

- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles

ASSESSMENT

bull General appearance

bull Vital signs Heart rhythm

bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)

bull ABGs SaO2 CBC WBC and chest x-ray results

bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea

bull Nutrition and weight loss

bull Monitor for signs and symptoms

Chronic dyspnea Chronic cough

Hypoxemia Hypercarbia (increased PaCO2)

Respiratory acidosis and

compensatory metabolic alkalosis

bull Crackles Rapid and shallow respirations

bull Use of accessory muscles

bull Barrel chest or increased

chest diameter

bull Hyper resonance on percussion

due to ldquotrapped airrdquo (emphysema)

bull Asynchronous breathing

bull Thin extremities and enlarged neck muscles

bull Dependent edema secondary to right-sided heart failure

bull

Diagnostic Testingbull Pulmonary function testing or

Spirometry

ndash Comprehensive assessment of lung volumes and capacities

ndash Performed in all patients suspected of COPD

ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality

bull Bronchodilator reversibility

ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma

Diagnostic Testingbull Laboratories

ndashABG Monitoring

bull Done for patients with severe COPD respiratory failure or a severe exacerbation

ndashATT levels (15 - 35 gram liter)

bull Measured in young patients who develop COPD and have a strong family history

bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency

Diagnostic Testingbull Imaging

ndash Chest radiographs

bull Not sensitive for the diagnosis of COPD

bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)

ndash Chest CT

bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation

COPD Management

bull Goals of COPD Management

ndash To relieve symptoms

ndash To improve quality of life

ndash To decrease the frequency amp severity of acute attacks

ndash To slow the progression of disease

ndash To prolong survival

COPD Management

Nonpharmacologic Treatment

Smoking cessation

Immunization

Long term oxygen therapy

Pulmonaryrehabilitation

Pharmacologic Treatment

Corticosteroids

Bronchodilators

AAT Replacement therapy

Smoking Cessationbull Only proven intervention to affect long term

decline in FEV1 amp slow the progression of COPD

ndash Nicotine replacement therapy

bull Transdermal patch

bull Chewing gum

bull Inhaler

bull Nasal spray

bull Lozenges

ndash Non-nicotine pharmacotherapy

bull Bupropion

bull Varenicline

Smoking Cessation

Product Side effectsPrecautions

Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision

Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors

Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness

Immunizationbull Influenza vaccination

ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients

ndash Patients with serious allergy to eggs should not be given this vaccine

ndash Brand available Fluarixreg

ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects

ndash Available brand Tamiflureg

Immunizationbull Polyvalent pnuemococcal vaccine

ndash Recommended for all COPD patients

bull 65 years and older

bull Less than 65 years only if the FEV1 is less than 40 predicted

ndash Dosage 05ml IM

ndash Available brand Pneumovaxreg (05ml pre-filled syringes)

Long-term Oxygen Therapy

bull Should be started if

ndash Resting PaO2 is less than 55 mm Hg

ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg

Pulmonary Rehabilitation

bull Improves symptoms and quality of life

bull Reduces frequency of exacerbations

bull Components include

ndash Exercise training

ndash Nutritional counselling

ndash Psychosocial support

Pharmacologic Treatment

Bronchodilators

Long-acting

2-agonists

Anticholinergics

Methylxanthines

Short-acting

2-agonists

Anticholinergics

Short-acting 2-agonists

bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation

bull Improve mucociliary clearance

MOA

bull 4 to 6 hoursDuration of action

bull Albuterol (Ventolinreg) levalbuterol pirbuterol

Selective 2-agonists

bull Metaproterenol isoetharine isoproterenol epinephrine

Less selective 2-agonists

Short-acting Anticholinergics

bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle

MOA

bull 4 to 6 hours slower onset of action in comparison to -agonists

Duration of action

bull Ipratropium (Atroventreg Atemreg)

bull AtropineExamples

Long-acting 2-agonists

bull Same as that of short-acting 2-agonistsMOA

bull 12 hoursDuration of action

bull Salmeterol (Sereventreg)

bull Formoterol

bull ArformoterolExamples

Long-acting Anticholinergics

bull Same as that of short-acting anticholinergicsMOA

bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing

Duration of action

bull TiotropiumExample

Combination Anticholinergics amp 2-agonists

bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects

bull Albuterol and Ipratropium available as an MDI Combiventreg

Methylxanthines

bull Produce bronchodilation by

bull Inhibition of PDE increasing cAMP levels

bull Inhibition of calcium ion influx intosmooth muscle

bull Prostaglandin antagonism

bull Stimulation of endogenouscatecholamines

bull Inhibition of release of mediators frommast cells and leukocytes

MOA

bull 8-12 mcgmlTherapeutic

Serum Levels

Methylxanthines

bull Minor side effects

ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia

bull Serious toxic effects

ndash arrhythmias and seizures

bull Considered in patients who donot respond well to bronchodilators

Corticosteroids

bull Mechanism of Action

ndash Reduction in capillary permeability to decrease mucus

ndash Inhibition of release of proteolytic enzymes from leukocytes

ndash Inhibition of prostaglandins

bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone

bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone

Corticosteroids

bull Inhaled CS

ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy

bull Systemic CS

ndashShort term use for acute exacerbations

ndashNot used in chronic management because of high risk of toxicity

Combination ICS amp Bronchodilators

bull Effective in reducing the rate of COPD exacerbations

bull Reduces the number of total inhalations needed more patient compliance

bull Available combination

ndash Beclomethasone with salbutamol (Clenil Compositumreg)

ndash Budesonide with formeterol

ndash Fluticasone with salmeterol

AAT Replacement Therapy

bull Considered for patients with AAT deficiency

bull Life time treatment

bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma

bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week

Indacaterol

bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist

bull Approved by FDA on July 1 2011

bull Requires once daily dosing unlike other long-acting

bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea

bull Recommended dose is one capsule (75mcg) per day

Devices used in COPDbull Inhalers

bull Small handheld devices that

deliver a puff of medicine into the airways

bull Metered-dose inhalers (MDIs)

bull Dry powder inhalers (DPIs) or

breath activated inhalers

bull Inhalers with spacer devices

Metered-dose Inhalersbull Contains a liquid

medication delivered as an aerosol spray

bull Quick to use small and convenient to carry

bull Needs good co-ordination to press the canister and breathe in fully at the same time

Breath-activated inhalersor DPI

bull It releases a puff of drypowder instead of aliquid mist

bull Require less co-ordination than thestandard MDI

bull Slightly bigger than thestandard MDI

bull Example Rotahaler

Inhalers with spacer devices

bull Spacer devices are used with pressurised MDIs

bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed

Nebulizers

bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol

bull Useful in people whoare very breathless egIn severe attack ofCOPD

bull They are not portable

Nanda Nursing Diagnosis for COPD

1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection

2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants

3 Impaired gas exchange related to ventilation perfusion inequality

4 Activity intolerance related to imbalance between oxygen supply with demand

5 Imbalanced Nutrition less than body requirements related to anorexia

Clinical Presentation

HistoryPhysical

Examination

- Symptoms Cough dyspnea sputum wheezing- Smoking history environmental and occupational risk factors

- Cyanosis of mucosal membranes - Barrel chest - Increased resting respiratory rate - Shallow breathing - Pursed lips during expiration - Use of accessory respiratory muscles

ASSESSMENT

bull General appearance

bull Vital signs Heart rhythm

bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)

bull ABGs SaO2 CBC WBC and chest x-ray results

bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea

bull Nutrition and weight loss

bull Monitor for signs and symptoms

Chronic dyspnea Chronic cough

Hypoxemia Hypercarbia (increased PaCO2)

Respiratory acidosis and

compensatory metabolic alkalosis

bull Crackles Rapid and shallow respirations

bull Use of accessory muscles

bull Barrel chest or increased

chest diameter

bull Hyper resonance on percussion

due to ldquotrapped airrdquo (emphysema)

bull Asynchronous breathing

bull Thin extremities and enlarged neck muscles

bull Dependent edema secondary to right-sided heart failure

bull

Diagnostic Testingbull Pulmonary function testing or

Spirometry

ndash Comprehensive assessment of lung volumes and capacities

ndash Performed in all patients suspected of COPD

ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality

bull Bronchodilator reversibility

ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma

Diagnostic Testingbull Laboratories

ndashABG Monitoring

bull Done for patients with severe COPD respiratory failure or a severe exacerbation

ndashATT levels (15 - 35 gram liter)

bull Measured in young patients who develop COPD and have a strong family history

bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency

Diagnostic Testingbull Imaging

ndash Chest radiographs

bull Not sensitive for the diagnosis of COPD

bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)

ndash Chest CT

bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation

COPD Management

bull Goals of COPD Management

ndash To relieve symptoms

ndash To improve quality of life

ndash To decrease the frequency amp severity of acute attacks

ndash To slow the progression of disease

ndash To prolong survival

COPD Management

Nonpharmacologic Treatment

Smoking cessation

Immunization

Long term oxygen therapy

Pulmonaryrehabilitation

Pharmacologic Treatment

Corticosteroids

Bronchodilators

AAT Replacement therapy

Smoking Cessationbull Only proven intervention to affect long term

decline in FEV1 amp slow the progression of COPD

ndash Nicotine replacement therapy

bull Transdermal patch

bull Chewing gum

bull Inhaler

bull Nasal spray

bull Lozenges

ndash Non-nicotine pharmacotherapy

bull Bupropion

bull Varenicline

Smoking Cessation

Product Side effectsPrecautions

Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision

Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors

Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness

Immunizationbull Influenza vaccination

ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients

ndash Patients with serious allergy to eggs should not be given this vaccine

ndash Brand available Fluarixreg

ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects

ndash Available brand Tamiflureg

Immunizationbull Polyvalent pnuemococcal vaccine

ndash Recommended for all COPD patients

bull 65 years and older

bull Less than 65 years only if the FEV1 is less than 40 predicted

ndash Dosage 05ml IM

ndash Available brand Pneumovaxreg (05ml pre-filled syringes)

Long-term Oxygen Therapy

bull Should be started if

ndash Resting PaO2 is less than 55 mm Hg

ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg

Pulmonary Rehabilitation

bull Improves symptoms and quality of life

bull Reduces frequency of exacerbations

bull Components include

ndash Exercise training

ndash Nutritional counselling

ndash Psychosocial support

Pharmacologic Treatment

Bronchodilators

Long-acting

2-agonists

Anticholinergics

Methylxanthines

Short-acting

2-agonists

Anticholinergics

Short-acting 2-agonists

bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation

bull Improve mucociliary clearance

MOA

bull 4 to 6 hoursDuration of action

bull Albuterol (Ventolinreg) levalbuterol pirbuterol

Selective 2-agonists

bull Metaproterenol isoetharine isoproterenol epinephrine

Less selective 2-agonists

Short-acting Anticholinergics

bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle

MOA

bull 4 to 6 hours slower onset of action in comparison to -agonists

Duration of action

bull Ipratropium (Atroventreg Atemreg)

bull AtropineExamples

Long-acting 2-agonists

bull Same as that of short-acting 2-agonistsMOA

bull 12 hoursDuration of action

bull Salmeterol (Sereventreg)

bull Formoterol

bull ArformoterolExamples

Long-acting Anticholinergics

bull Same as that of short-acting anticholinergicsMOA

bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing

Duration of action

bull TiotropiumExample

Combination Anticholinergics amp 2-agonists

bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects

bull Albuterol and Ipratropium available as an MDI Combiventreg

Methylxanthines

bull Produce bronchodilation by

bull Inhibition of PDE increasing cAMP levels

bull Inhibition of calcium ion influx intosmooth muscle

bull Prostaglandin antagonism

bull Stimulation of endogenouscatecholamines

bull Inhibition of release of mediators frommast cells and leukocytes

MOA

bull 8-12 mcgmlTherapeutic

Serum Levels

Methylxanthines

bull Minor side effects

ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia

bull Serious toxic effects

ndash arrhythmias and seizures

bull Considered in patients who donot respond well to bronchodilators

Corticosteroids

bull Mechanism of Action

ndash Reduction in capillary permeability to decrease mucus

ndash Inhibition of release of proteolytic enzymes from leukocytes

ndash Inhibition of prostaglandins

bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone

bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone

Corticosteroids

bull Inhaled CS

ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy

bull Systemic CS

ndashShort term use for acute exacerbations

ndashNot used in chronic management because of high risk of toxicity

Combination ICS amp Bronchodilators

bull Effective in reducing the rate of COPD exacerbations

bull Reduces the number of total inhalations needed more patient compliance

bull Available combination

ndash Beclomethasone with salbutamol (Clenil Compositumreg)

ndash Budesonide with formeterol

ndash Fluticasone with salmeterol

AAT Replacement Therapy

bull Considered for patients with AAT deficiency

bull Life time treatment

bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma

bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week

Indacaterol

bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist

bull Approved by FDA on July 1 2011

bull Requires once daily dosing unlike other long-acting

bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea

bull Recommended dose is one capsule (75mcg) per day

Devices used in COPDbull Inhalers

bull Small handheld devices that

deliver a puff of medicine into the airways

bull Metered-dose inhalers (MDIs)

bull Dry powder inhalers (DPIs) or

breath activated inhalers

bull Inhalers with spacer devices

Metered-dose Inhalersbull Contains a liquid

medication delivered as an aerosol spray

bull Quick to use small and convenient to carry

bull Needs good co-ordination to press the canister and breathe in fully at the same time

Breath-activated inhalersor DPI

bull It releases a puff of drypowder instead of aliquid mist

bull Require less co-ordination than thestandard MDI

bull Slightly bigger than thestandard MDI

bull Example Rotahaler

Inhalers with spacer devices

bull Spacer devices are used with pressurised MDIs

bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed

Nebulizers

bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol

bull Useful in people whoare very breathless egIn severe attack ofCOPD

bull They are not portable

Nanda Nursing Diagnosis for COPD

1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection

2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants

3 Impaired gas exchange related to ventilation perfusion inequality

4 Activity intolerance related to imbalance between oxygen supply with demand

5 Imbalanced Nutrition less than body requirements related to anorexia

ASSESSMENT

bull General appearance

bull Vital signs Heart rhythm

bull Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)

bull ABGs SaO2 CBC WBC and chest x-ray results

bull AssessMonitor Clientrsquos history (occupational history smoking history) Respiratory rate symmetry and effort Breath sounds Activity tolerance level and dyspnea

bull Nutrition and weight loss

bull Monitor for signs and symptoms

Chronic dyspnea Chronic cough

Hypoxemia Hypercarbia (increased PaCO2)

Respiratory acidosis and

compensatory metabolic alkalosis

bull Crackles Rapid and shallow respirations

bull Use of accessory muscles

bull Barrel chest or increased

chest diameter

bull Hyper resonance on percussion

due to ldquotrapped airrdquo (emphysema)

bull Asynchronous breathing

bull Thin extremities and enlarged neck muscles

bull Dependent edema secondary to right-sided heart failure

bull

Diagnostic Testingbull Pulmonary function testing or

Spirometry

ndash Comprehensive assessment of lung volumes and capacities

ndash Performed in all patients suspected of COPD

ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality

bull Bronchodilator reversibility

ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma

Diagnostic Testingbull Laboratories

ndashABG Monitoring

bull Done for patients with severe COPD respiratory failure or a severe exacerbation

ndashATT levels (15 - 35 gram liter)

bull Measured in young patients who develop COPD and have a strong family history

bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency

Diagnostic Testingbull Imaging

ndash Chest radiographs

bull Not sensitive for the diagnosis of COPD

bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)

ndash Chest CT

bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation

COPD Management

bull Goals of COPD Management

ndash To relieve symptoms

ndash To improve quality of life

ndash To decrease the frequency amp severity of acute attacks

ndash To slow the progression of disease

ndash To prolong survival

COPD Management

Nonpharmacologic Treatment

Smoking cessation

Immunization

Long term oxygen therapy

Pulmonaryrehabilitation

Pharmacologic Treatment

Corticosteroids

Bronchodilators

AAT Replacement therapy

Smoking Cessationbull Only proven intervention to affect long term

decline in FEV1 amp slow the progression of COPD

ndash Nicotine replacement therapy

bull Transdermal patch

bull Chewing gum

bull Inhaler

bull Nasal spray

bull Lozenges

ndash Non-nicotine pharmacotherapy

bull Bupropion

bull Varenicline

Smoking Cessation

Product Side effectsPrecautions

Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision

Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors

Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness

Immunizationbull Influenza vaccination

ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients

ndash Patients with serious allergy to eggs should not be given this vaccine

ndash Brand available Fluarixreg

ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects

ndash Available brand Tamiflureg

Immunizationbull Polyvalent pnuemococcal vaccine

ndash Recommended for all COPD patients

bull 65 years and older

bull Less than 65 years only if the FEV1 is less than 40 predicted

ndash Dosage 05ml IM

ndash Available brand Pneumovaxreg (05ml pre-filled syringes)

Long-term Oxygen Therapy

bull Should be started if

ndash Resting PaO2 is less than 55 mm Hg

ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg

Pulmonary Rehabilitation

bull Improves symptoms and quality of life

bull Reduces frequency of exacerbations

bull Components include

ndash Exercise training

ndash Nutritional counselling

ndash Psychosocial support

Pharmacologic Treatment

Bronchodilators

Long-acting

2-agonists

Anticholinergics

Methylxanthines

Short-acting

2-agonists

Anticholinergics

Short-acting 2-agonists

bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation

bull Improve mucociliary clearance

MOA

bull 4 to 6 hoursDuration of action

bull Albuterol (Ventolinreg) levalbuterol pirbuterol

Selective 2-agonists

bull Metaproterenol isoetharine isoproterenol epinephrine

Less selective 2-agonists

Short-acting Anticholinergics

bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle

MOA

bull 4 to 6 hours slower onset of action in comparison to -agonists

Duration of action

bull Ipratropium (Atroventreg Atemreg)

bull AtropineExamples

Long-acting 2-agonists

bull Same as that of short-acting 2-agonistsMOA

bull 12 hoursDuration of action

bull Salmeterol (Sereventreg)

bull Formoterol

bull ArformoterolExamples

Long-acting Anticholinergics

bull Same as that of short-acting anticholinergicsMOA

bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing

Duration of action

bull TiotropiumExample

Combination Anticholinergics amp 2-agonists

bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects

bull Albuterol and Ipratropium available as an MDI Combiventreg

Methylxanthines

bull Produce bronchodilation by

bull Inhibition of PDE increasing cAMP levels

bull Inhibition of calcium ion influx intosmooth muscle

bull Prostaglandin antagonism

bull Stimulation of endogenouscatecholamines

bull Inhibition of release of mediators frommast cells and leukocytes

MOA

bull 8-12 mcgmlTherapeutic

Serum Levels

Methylxanthines

bull Minor side effects

ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia

bull Serious toxic effects

ndash arrhythmias and seizures

bull Considered in patients who donot respond well to bronchodilators

Corticosteroids

bull Mechanism of Action

ndash Reduction in capillary permeability to decrease mucus

ndash Inhibition of release of proteolytic enzymes from leukocytes

ndash Inhibition of prostaglandins

bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone

bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone

Corticosteroids

bull Inhaled CS

ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy

bull Systemic CS

ndashShort term use for acute exacerbations

ndashNot used in chronic management because of high risk of toxicity

Combination ICS amp Bronchodilators

bull Effective in reducing the rate of COPD exacerbations

bull Reduces the number of total inhalations needed more patient compliance

bull Available combination

ndash Beclomethasone with salbutamol (Clenil Compositumreg)

ndash Budesonide with formeterol

ndash Fluticasone with salmeterol

AAT Replacement Therapy

bull Considered for patients with AAT deficiency

bull Life time treatment

bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma

bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week

Indacaterol

bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist

bull Approved by FDA on July 1 2011

bull Requires once daily dosing unlike other long-acting

bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea

bull Recommended dose is one capsule (75mcg) per day

Devices used in COPDbull Inhalers

bull Small handheld devices that

deliver a puff of medicine into the airways

bull Metered-dose inhalers (MDIs)

bull Dry powder inhalers (DPIs) or

breath activated inhalers

bull Inhalers with spacer devices

Metered-dose Inhalersbull Contains a liquid

medication delivered as an aerosol spray

bull Quick to use small and convenient to carry

bull Needs good co-ordination to press the canister and breathe in fully at the same time

Breath-activated inhalersor DPI

bull It releases a puff of drypowder instead of aliquid mist

bull Require less co-ordination than thestandard MDI

bull Slightly bigger than thestandard MDI

bull Example Rotahaler

Inhalers with spacer devices

bull Spacer devices are used with pressurised MDIs

bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed

Nebulizers

bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol

bull Useful in people whoare very breathless egIn severe attack ofCOPD

bull They are not portable

Nanda Nursing Diagnosis for COPD

1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection

2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants

3 Impaired gas exchange related to ventilation perfusion inequality

4 Activity intolerance related to imbalance between oxygen supply with demand

5 Imbalanced Nutrition less than body requirements related to anorexia

bull Monitor for signs and symptoms

Chronic dyspnea Chronic cough

Hypoxemia Hypercarbia (increased PaCO2)

Respiratory acidosis and

compensatory metabolic alkalosis

bull Crackles Rapid and shallow respirations

bull Use of accessory muscles

bull Barrel chest or increased

chest diameter

bull Hyper resonance on percussion

due to ldquotrapped airrdquo (emphysema)

bull Asynchronous breathing

bull Thin extremities and enlarged neck muscles

bull Dependent edema secondary to right-sided heart failure

bull

Diagnostic Testingbull Pulmonary function testing or

Spirometry

ndash Comprehensive assessment of lung volumes and capacities

ndash Performed in all patients suspected of COPD

ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality

bull Bronchodilator reversibility

ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma

Diagnostic Testingbull Laboratories

ndashABG Monitoring

bull Done for patients with severe COPD respiratory failure or a severe exacerbation

ndashATT levels (15 - 35 gram liter)

bull Measured in young patients who develop COPD and have a strong family history

bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency

Diagnostic Testingbull Imaging

ndash Chest radiographs

bull Not sensitive for the diagnosis of COPD

bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)

ndash Chest CT

bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation

COPD Management

bull Goals of COPD Management

ndash To relieve symptoms

ndash To improve quality of life

ndash To decrease the frequency amp severity of acute attacks

ndash To slow the progression of disease

ndash To prolong survival

COPD Management

Nonpharmacologic Treatment

Smoking cessation

Immunization

Long term oxygen therapy

Pulmonaryrehabilitation

Pharmacologic Treatment

Corticosteroids

Bronchodilators

AAT Replacement therapy

Smoking Cessationbull Only proven intervention to affect long term

decline in FEV1 amp slow the progression of COPD

ndash Nicotine replacement therapy

bull Transdermal patch

bull Chewing gum

bull Inhaler

bull Nasal spray

bull Lozenges

ndash Non-nicotine pharmacotherapy

bull Bupropion

bull Varenicline

Smoking Cessation

Product Side effectsPrecautions

Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision

Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors

Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness

Immunizationbull Influenza vaccination

ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients

ndash Patients with serious allergy to eggs should not be given this vaccine

ndash Brand available Fluarixreg

ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects

ndash Available brand Tamiflureg

Immunizationbull Polyvalent pnuemococcal vaccine

ndash Recommended for all COPD patients

bull 65 years and older

bull Less than 65 years only if the FEV1 is less than 40 predicted

ndash Dosage 05ml IM

ndash Available brand Pneumovaxreg (05ml pre-filled syringes)

Long-term Oxygen Therapy

bull Should be started if

ndash Resting PaO2 is less than 55 mm Hg

ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg

Pulmonary Rehabilitation

bull Improves symptoms and quality of life

bull Reduces frequency of exacerbations

bull Components include

ndash Exercise training

ndash Nutritional counselling

ndash Psychosocial support

Pharmacologic Treatment

Bronchodilators

Long-acting

2-agonists

Anticholinergics

Methylxanthines

Short-acting

2-agonists

Anticholinergics

Short-acting 2-agonists

bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation

bull Improve mucociliary clearance

MOA

bull 4 to 6 hoursDuration of action

bull Albuterol (Ventolinreg) levalbuterol pirbuterol

Selective 2-agonists

bull Metaproterenol isoetharine isoproterenol epinephrine

Less selective 2-agonists

Short-acting Anticholinergics

bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle

MOA

bull 4 to 6 hours slower onset of action in comparison to -agonists

Duration of action

bull Ipratropium (Atroventreg Atemreg)

bull AtropineExamples

Long-acting 2-agonists

bull Same as that of short-acting 2-agonistsMOA

bull 12 hoursDuration of action

bull Salmeterol (Sereventreg)

bull Formoterol

bull ArformoterolExamples

Long-acting Anticholinergics

bull Same as that of short-acting anticholinergicsMOA

bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing

Duration of action

bull TiotropiumExample

Combination Anticholinergics amp 2-agonists

bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects

bull Albuterol and Ipratropium available as an MDI Combiventreg

Methylxanthines

bull Produce bronchodilation by

bull Inhibition of PDE increasing cAMP levels

bull Inhibition of calcium ion influx intosmooth muscle

bull Prostaglandin antagonism

bull Stimulation of endogenouscatecholamines

bull Inhibition of release of mediators frommast cells and leukocytes

MOA

bull 8-12 mcgmlTherapeutic

Serum Levels

Methylxanthines

bull Minor side effects

ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia

bull Serious toxic effects

ndash arrhythmias and seizures

bull Considered in patients who donot respond well to bronchodilators

Corticosteroids

bull Mechanism of Action

ndash Reduction in capillary permeability to decrease mucus

ndash Inhibition of release of proteolytic enzymes from leukocytes

ndash Inhibition of prostaglandins

bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone

bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone

Corticosteroids

bull Inhaled CS

ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy

bull Systemic CS

ndashShort term use for acute exacerbations

ndashNot used in chronic management because of high risk of toxicity

Combination ICS amp Bronchodilators

bull Effective in reducing the rate of COPD exacerbations

bull Reduces the number of total inhalations needed more patient compliance

bull Available combination

ndash Beclomethasone with salbutamol (Clenil Compositumreg)

ndash Budesonide with formeterol

ndash Fluticasone with salmeterol

AAT Replacement Therapy

bull Considered for patients with AAT deficiency

bull Life time treatment

bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma

bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week

Indacaterol

bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist

bull Approved by FDA on July 1 2011

bull Requires once daily dosing unlike other long-acting

bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea

bull Recommended dose is one capsule (75mcg) per day

Devices used in COPDbull Inhalers

bull Small handheld devices that

deliver a puff of medicine into the airways

bull Metered-dose inhalers (MDIs)

bull Dry powder inhalers (DPIs) or

breath activated inhalers

bull Inhalers with spacer devices

Metered-dose Inhalersbull Contains a liquid

medication delivered as an aerosol spray

bull Quick to use small and convenient to carry

bull Needs good co-ordination to press the canister and breathe in fully at the same time

Breath-activated inhalersor DPI

bull It releases a puff of drypowder instead of aliquid mist

bull Require less co-ordination than thestandard MDI

bull Slightly bigger than thestandard MDI

bull Example Rotahaler

Inhalers with spacer devices

bull Spacer devices are used with pressurised MDIs

bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed

Nebulizers

bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol

bull Useful in people whoare very breathless egIn severe attack ofCOPD

bull They are not portable

Nanda Nursing Diagnosis for COPD

1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection

2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants

3 Impaired gas exchange related to ventilation perfusion inequality

4 Activity intolerance related to imbalance between oxygen supply with demand

5 Imbalanced Nutrition less than body requirements related to anorexia

bull Barrel chest or increased

chest diameter

bull Hyper resonance on percussion

due to ldquotrapped airrdquo (emphysema)

bull Asynchronous breathing

bull Thin extremities and enlarged neck muscles

bull Dependent edema secondary to right-sided heart failure

bull

Diagnostic Testingbull Pulmonary function testing or

Spirometry

ndash Comprehensive assessment of lung volumes and capacities

ndash Performed in all patients suspected of COPD

ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality

bull Bronchodilator reversibility

ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma

Diagnostic Testingbull Laboratories

ndashABG Monitoring

bull Done for patients with severe COPD respiratory failure or a severe exacerbation

ndashATT levels (15 - 35 gram liter)

bull Measured in young patients who develop COPD and have a strong family history

bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency

Diagnostic Testingbull Imaging

ndash Chest radiographs

bull Not sensitive for the diagnosis of COPD

bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)

ndash Chest CT

bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation

COPD Management

bull Goals of COPD Management

ndash To relieve symptoms

ndash To improve quality of life

ndash To decrease the frequency amp severity of acute attacks

ndash To slow the progression of disease

ndash To prolong survival

COPD Management

Nonpharmacologic Treatment

Smoking cessation

Immunization

Long term oxygen therapy

Pulmonaryrehabilitation

Pharmacologic Treatment

Corticosteroids

Bronchodilators

AAT Replacement therapy

Smoking Cessationbull Only proven intervention to affect long term

decline in FEV1 amp slow the progression of COPD

ndash Nicotine replacement therapy

bull Transdermal patch

bull Chewing gum

bull Inhaler

bull Nasal spray

bull Lozenges

ndash Non-nicotine pharmacotherapy

bull Bupropion

bull Varenicline

Smoking Cessation

Product Side effectsPrecautions

Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision

Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors

Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness

Immunizationbull Influenza vaccination

ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients

ndash Patients with serious allergy to eggs should not be given this vaccine

ndash Brand available Fluarixreg

ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects

ndash Available brand Tamiflureg

Immunizationbull Polyvalent pnuemococcal vaccine

ndash Recommended for all COPD patients

bull 65 years and older

bull Less than 65 years only if the FEV1 is less than 40 predicted

ndash Dosage 05ml IM

ndash Available brand Pneumovaxreg (05ml pre-filled syringes)

Long-term Oxygen Therapy

bull Should be started if

ndash Resting PaO2 is less than 55 mm Hg

ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg

Pulmonary Rehabilitation

bull Improves symptoms and quality of life

bull Reduces frequency of exacerbations

bull Components include

ndash Exercise training

ndash Nutritional counselling

ndash Psychosocial support

Pharmacologic Treatment

Bronchodilators

Long-acting

2-agonists

Anticholinergics

Methylxanthines

Short-acting

2-agonists

Anticholinergics

Short-acting 2-agonists

bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation

bull Improve mucociliary clearance

MOA

bull 4 to 6 hoursDuration of action

bull Albuterol (Ventolinreg) levalbuterol pirbuterol

Selective 2-agonists

bull Metaproterenol isoetharine isoproterenol epinephrine

Less selective 2-agonists

Short-acting Anticholinergics

bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle

MOA

bull 4 to 6 hours slower onset of action in comparison to -agonists

Duration of action

bull Ipratropium (Atroventreg Atemreg)

bull AtropineExamples

Long-acting 2-agonists

bull Same as that of short-acting 2-agonistsMOA

bull 12 hoursDuration of action

bull Salmeterol (Sereventreg)

bull Formoterol

bull ArformoterolExamples

Long-acting Anticholinergics

bull Same as that of short-acting anticholinergicsMOA

bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing

Duration of action

bull TiotropiumExample

Combination Anticholinergics amp 2-agonists

bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects

bull Albuterol and Ipratropium available as an MDI Combiventreg

Methylxanthines

bull Produce bronchodilation by

bull Inhibition of PDE increasing cAMP levels

bull Inhibition of calcium ion influx intosmooth muscle

bull Prostaglandin antagonism

bull Stimulation of endogenouscatecholamines

bull Inhibition of release of mediators frommast cells and leukocytes

MOA

bull 8-12 mcgmlTherapeutic

Serum Levels

Methylxanthines

bull Minor side effects

ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia

bull Serious toxic effects

ndash arrhythmias and seizures

bull Considered in patients who donot respond well to bronchodilators

Corticosteroids

bull Mechanism of Action

ndash Reduction in capillary permeability to decrease mucus

ndash Inhibition of release of proteolytic enzymes from leukocytes

ndash Inhibition of prostaglandins

bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone

bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone

Corticosteroids

bull Inhaled CS

ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy

bull Systemic CS

ndashShort term use for acute exacerbations

ndashNot used in chronic management because of high risk of toxicity

Combination ICS amp Bronchodilators

bull Effective in reducing the rate of COPD exacerbations

bull Reduces the number of total inhalations needed more patient compliance

bull Available combination

ndash Beclomethasone with salbutamol (Clenil Compositumreg)

ndash Budesonide with formeterol

ndash Fluticasone with salmeterol

AAT Replacement Therapy

bull Considered for patients with AAT deficiency

bull Life time treatment

bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma

bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week

Indacaterol

bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist

bull Approved by FDA on July 1 2011

bull Requires once daily dosing unlike other long-acting

bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea

bull Recommended dose is one capsule (75mcg) per day

Devices used in COPDbull Inhalers

bull Small handheld devices that

deliver a puff of medicine into the airways

bull Metered-dose inhalers (MDIs)

bull Dry powder inhalers (DPIs) or

breath activated inhalers

bull Inhalers with spacer devices

Metered-dose Inhalersbull Contains a liquid

medication delivered as an aerosol spray

bull Quick to use small and convenient to carry

bull Needs good co-ordination to press the canister and breathe in fully at the same time

Breath-activated inhalersor DPI

bull It releases a puff of drypowder instead of aliquid mist

bull Require less co-ordination than thestandard MDI

bull Slightly bigger than thestandard MDI

bull Example Rotahaler

Inhalers with spacer devices

bull Spacer devices are used with pressurised MDIs

bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed

Nebulizers

bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol

bull Useful in people whoare very breathless egIn severe attack ofCOPD

bull They are not portable

Nanda Nursing Diagnosis for COPD

1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection

2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants

3 Impaired gas exchange related to ventilation perfusion inequality

4 Activity intolerance related to imbalance between oxygen supply with demand

5 Imbalanced Nutrition less than body requirements related to anorexia

Diagnostic Testingbull Pulmonary function testing or

Spirometry

ndash Comprehensive assessment of lung volumes and capacities

ndash Performed in all patients suspected of COPD

ndash FEV1 defines the severity of expiratory airflow obstruction and is a predictor of mortality

bull Bronchodilator reversibility

ndash A large increase in post-bronchodilator FEV1 supports the diagnosis of asthma

Diagnostic Testingbull Laboratories

ndashABG Monitoring

bull Done for patients with severe COPD respiratory failure or a severe exacerbation

ndashATT levels (15 - 35 gram liter)

bull Measured in young patients who develop COPD and have a strong family history

bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency

Diagnostic Testingbull Imaging

ndash Chest radiographs

bull Not sensitive for the diagnosis of COPD

bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)

ndash Chest CT

bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation

COPD Management

bull Goals of COPD Management

ndash To relieve symptoms

ndash To improve quality of life

ndash To decrease the frequency amp severity of acute attacks

ndash To slow the progression of disease

ndash To prolong survival

COPD Management

Nonpharmacologic Treatment

Smoking cessation

Immunization

Long term oxygen therapy

Pulmonaryrehabilitation

Pharmacologic Treatment

Corticosteroids

Bronchodilators

AAT Replacement therapy

Smoking Cessationbull Only proven intervention to affect long term

decline in FEV1 amp slow the progression of COPD

ndash Nicotine replacement therapy

bull Transdermal patch

bull Chewing gum

bull Inhaler

bull Nasal spray

bull Lozenges

ndash Non-nicotine pharmacotherapy

bull Bupropion

bull Varenicline

Smoking Cessation

Product Side effectsPrecautions

Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision

Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors

Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness

Immunizationbull Influenza vaccination

ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients

ndash Patients with serious allergy to eggs should not be given this vaccine

ndash Brand available Fluarixreg

ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects

ndash Available brand Tamiflureg

Immunizationbull Polyvalent pnuemococcal vaccine

ndash Recommended for all COPD patients

bull 65 years and older

bull Less than 65 years only if the FEV1 is less than 40 predicted

ndash Dosage 05ml IM

ndash Available brand Pneumovaxreg (05ml pre-filled syringes)

Long-term Oxygen Therapy

bull Should be started if

ndash Resting PaO2 is less than 55 mm Hg

ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg

Pulmonary Rehabilitation

bull Improves symptoms and quality of life

bull Reduces frequency of exacerbations

bull Components include

ndash Exercise training

ndash Nutritional counselling

ndash Psychosocial support

Pharmacologic Treatment

Bronchodilators

Long-acting

2-agonists

Anticholinergics

Methylxanthines

Short-acting

2-agonists

Anticholinergics

Short-acting 2-agonists

bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation

bull Improve mucociliary clearance

MOA

bull 4 to 6 hoursDuration of action

bull Albuterol (Ventolinreg) levalbuterol pirbuterol

Selective 2-agonists

bull Metaproterenol isoetharine isoproterenol epinephrine

Less selective 2-agonists

Short-acting Anticholinergics

bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle

MOA

bull 4 to 6 hours slower onset of action in comparison to -agonists

Duration of action

bull Ipratropium (Atroventreg Atemreg)

bull AtropineExamples

Long-acting 2-agonists

bull Same as that of short-acting 2-agonistsMOA

bull 12 hoursDuration of action

bull Salmeterol (Sereventreg)

bull Formoterol

bull ArformoterolExamples

Long-acting Anticholinergics

bull Same as that of short-acting anticholinergicsMOA

bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing

Duration of action

bull TiotropiumExample

Combination Anticholinergics amp 2-agonists

bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects

bull Albuterol and Ipratropium available as an MDI Combiventreg

Methylxanthines

bull Produce bronchodilation by

bull Inhibition of PDE increasing cAMP levels

bull Inhibition of calcium ion influx intosmooth muscle

bull Prostaglandin antagonism

bull Stimulation of endogenouscatecholamines

bull Inhibition of release of mediators frommast cells and leukocytes

MOA

bull 8-12 mcgmlTherapeutic

Serum Levels

Methylxanthines

bull Minor side effects

ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia

bull Serious toxic effects

ndash arrhythmias and seizures

bull Considered in patients who donot respond well to bronchodilators

Corticosteroids

bull Mechanism of Action

ndash Reduction in capillary permeability to decrease mucus

ndash Inhibition of release of proteolytic enzymes from leukocytes

ndash Inhibition of prostaglandins

bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone

bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone

Corticosteroids

bull Inhaled CS

ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy

bull Systemic CS

ndashShort term use for acute exacerbations

ndashNot used in chronic management because of high risk of toxicity

Combination ICS amp Bronchodilators

bull Effective in reducing the rate of COPD exacerbations

bull Reduces the number of total inhalations needed more patient compliance

bull Available combination

ndash Beclomethasone with salbutamol (Clenil Compositumreg)

ndash Budesonide with formeterol

ndash Fluticasone with salmeterol

AAT Replacement Therapy

bull Considered for patients with AAT deficiency

bull Life time treatment

bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma

bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week

Indacaterol

bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist

bull Approved by FDA on July 1 2011

bull Requires once daily dosing unlike other long-acting

bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea

bull Recommended dose is one capsule (75mcg) per day

Devices used in COPDbull Inhalers

bull Small handheld devices that

deliver a puff of medicine into the airways

bull Metered-dose inhalers (MDIs)

bull Dry powder inhalers (DPIs) or

breath activated inhalers

bull Inhalers with spacer devices

Metered-dose Inhalersbull Contains a liquid

medication delivered as an aerosol spray

bull Quick to use small and convenient to carry

bull Needs good co-ordination to press the canister and breathe in fully at the same time

Breath-activated inhalersor DPI

bull It releases a puff of drypowder instead of aliquid mist

bull Require less co-ordination than thestandard MDI

bull Slightly bigger than thestandard MDI

bull Example Rotahaler

Inhalers with spacer devices

bull Spacer devices are used with pressurised MDIs

bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed

Nebulizers

bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol

bull Useful in people whoare very breathless egIn severe attack ofCOPD

bull They are not portable

Nanda Nursing Diagnosis for COPD

1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection

2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants

3 Impaired gas exchange related to ventilation perfusion inequality

4 Activity intolerance related to imbalance between oxygen supply with demand

5 Imbalanced Nutrition less than body requirements related to anorexia

Diagnostic Testingbull Laboratories

ndashABG Monitoring

bull Done for patients with severe COPD respiratory failure or a severe exacerbation

ndashATT levels (15 - 35 gram liter)

bull Measured in young patients who develop COPD and have a strong family history

bull A serum value lt15ndash20 of the normal limits is highly suggestive of α1-antitrypsin deficiency

Diagnostic Testingbull Imaging

ndash Chest radiographs

bull Not sensitive for the diagnosis of COPD

bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)

ndash Chest CT

bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation

COPD Management

bull Goals of COPD Management

ndash To relieve symptoms

ndash To improve quality of life

ndash To decrease the frequency amp severity of acute attacks

ndash To slow the progression of disease

ndash To prolong survival

COPD Management

Nonpharmacologic Treatment

Smoking cessation

Immunization

Long term oxygen therapy

Pulmonaryrehabilitation

Pharmacologic Treatment

Corticosteroids

Bronchodilators

AAT Replacement therapy

Smoking Cessationbull Only proven intervention to affect long term

decline in FEV1 amp slow the progression of COPD

ndash Nicotine replacement therapy

bull Transdermal patch

bull Chewing gum

bull Inhaler

bull Nasal spray

bull Lozenges

ndash Non-nicotine pharmacotherapy

bull Bupropion

bull Varenicline

Smoking Cessation

Product Side effectsPrecautions

Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision

Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors

Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness

Immunizationbull Influenza vaccination

ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients

ndash Patients with serious allergy to eggs should not be given this vaccine

ndash Brand available Fluarixreg

ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects

ndash Available brand Tamiflureg

Immunizationbull Polyvalent pnuemococcal vaccine

ndash Recommended for all COPD patients

bull 65 years and older

bull Less than 65 years only if the FEV1 is less than 40 predicted

ndash Dosage 05ml IM

ndash Available brand Pneumovaxreg (05ml pre-filled syringes)

Long-term Oxygen Therapy

bull Should be started if

ndash Resting PaO2 is less than 55 mm Hg

ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg

Pulmonary Rehabilitation

bull Improves symptoms and quality of life

bull Reduces frequency of exacerbations

bull Components include

ndash Exercise training

ndash Nutritional counselling

ndash Psychosocial support

Pharmacologic Treatment

Bronchodilators

Long-acting

2-agonists

Anticholinergics

Methylxanthines

Short-acting

2-agonists

Anticholinergics

Short-acting 2-agonists

bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation

bull Improve mucociliary clearance

MOA

bull 4 to 6 hoursDuration of action

bull Albuterol (Ventolinreg) levalbuterol pirbuterol

Selective 2-agonists

bull Metaproterenol isoetharine isoproterenol epinephrine

Less selective 2-agonists

Short-acting Anticholinergics

bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle

MOA

bull 4 to 6 hours slower onset of action in comparison to -agonists

Duration of action

bull Ipratropium (Atroventreg Atemreg)

bull AtropineExamples

Long-acting 2-agonists

bull Same as that of short-acting 2-agonistsMOA

bull 12 hoursDuration of action

bull Salmeterol (Sereventreg)

bull Formoterol

bull ArformoterolExamples

Long-acting Anticholinergics

bull Same as that of short-acting anticholinergicsMOA

bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing

Duration of action

bull TiotropiumExample

Combination Anticholinergics amp 2-agonists

bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects

bull Albuterol and Ipratropium available as an MDI Combiventreg

Methylxanthines

bull Produce bronchodilation by

bull Inhibition of PDE increasing cAMP levels

bull Inhibition of calcium ion influx intosmooth muscle

bull Prostaglandin antagonism

bull Stimulation of endogenouscatecholamines

bull Inhibition of release of mediators frommast cells and leukocytes

MOA

bull 8-12 mcgmlTherapeutic

Serum Levels

Methylxanthines

bull Minor side effects

ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia

bull Serious toxic effects

ndash arrhythmias and seizures

bull Considered in patients who donot respond well to bronchodilators

Corticosteroids

bull Mechanism of Action

ndash Reduction in capillary permeability to decrease mucus

ndash Inhibition of release of proteolytic enzymes from leukocytes

ndash Inhibition of prostaglandins

bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone

bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone

Corticosteroids

bull Inhaled CS

ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy

bull Systemic CS

ndashShort term use for acute exacerbations

ndashNot used in chronic management because of high risk of toxicity

Combination ICS amp Bronchodilators

bull Effective in reducing the rate of COPD exacerbations

bull Reduces the number of total inhalations needed more patient compliance

bull Available combination

ndash Beclomethasone with salbutamol (Clenil Compositumreg)

ndash Budesonide with formeterol

ndash Fluticasone with salmeterol

AAT Replacement Therapy

bull Considered for patients with AAT deficiency

bull Life time treatment

bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma

bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week

Indacaterol

bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist

bull Approved by FDA on July 1 2011

bull Requires once daily dosing unlike other long-acting

bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea

bull Recommended dose is one capsule (75mcg) per day

Devices used in COPDbull Inhalers

bull Small handheld devices that

deliver a puff of medicine into the airways

bull Metered-dose inhalers (MDIs)

bull Dry powder inhalers (DPIs) or

breath activated inhalers

bull Inhalers with spacer devices

Metered-dose Inhalersbull Contains a liquid

medication delivered as an aerosol spray

bull Quick to use small and convenient to carry

bull Needs good co-ordination to press the canister and breathe in fully at the same time

Breath-activated inhalersor DPI

bull It releases a puff of drypowder instead of aliquid mist

bull Require less co-ordination than thestandard MDI

bull Slightly bigger than thestandard MDI

bull Example Rotahaler

Inhalers with spacer devices

bull Spacer devices are used with pressurised MDIs

bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed

Nebulizers

bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol

bull Useful in people whoare very breathless egIn severe attack ofCOPD

bull They are not portable

Nanda Nursing Diagnosis for COPD

1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection

2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants

3 Impaired gas exchange related to ventilation perfusion inequality

4 Activity intolerance related to imbalance between oxygen supply with demand

5 Imbalanced Nutrition less than body requirements related to anorexia

Diagnostic Testingbull Imaging

ndash Chest radiographs

bull Not sensitive for the diagnosis of COPD

bull Helpful in excluding otherdiseases (pneumonia cancercongestive heart failure pleuraleffusion amp pneumothorax)

ndash Chest CT

bull For patients with severe COPD for lung volume reduction surgery (LVRS) amp lung transplantation

COPD Management

bull Goals of COPD Management

ndash To relieve symptoms

ndash To improve quality of life

ndash To decrease the frequency amp severity of acute attacks

ndash To slow the progression of disease

ndash To prolong survival

COPD Management

Nonpharmacologic Treatment

Smoking cessation

Immunization

Long term oxygen therapy

Pulmonaryrehabilitation

Pharmacologic Treatment

Corticosteroids

Bronchodilators

AAT Replacement therapy

Smoking Cessationbull Only proven intervention to affect long term

decline in FEV1 amp slow the progression of COPD

ndash Nicotine replacement therapy

bull Transdermal patch

bull Chewing gum

bull Inhaler

bull Nasal spray

bull Lozenges

ndash Non-nicotine pharmacotherapy

bull Bupropion

bull Varenicline

Smoking Cessation

Product Side effectsPrecautions

Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision

Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors

Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness

Immunizationbull Influenza vaccination

ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients

ndash Patients with serious allergy to eggs should not be given this vaccine

ndash Brand available Fluarixreg

ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects

ndash Available brand Tamiflureg

Immunizationbull Polyvalent pnuemococcal vaccine

ndash Recommended for all COPD patients

bull 65 years and older

bull Less than 65 years only if the FEV1 is less than 40 predicted

ndash Dosage 05ml IM

ndash Available brand Pneumovaxreg (05ml pre-filled syringes)

Long-term Oxygen Therapy

bull Should be started if

ndash Resting PaO2 is less than 55 mm Hg

ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg

Pulmonary Rehabilitation

bull Improves symptoms and quality of life

bull Reduces frequency of exacerbations

bull Components include

ndash Exercise training

ndash Nutritional counselling

ndash Psychosocial support

Pharmacologic Treatment

Bronchodilators

Long-acting

2-agonists

Anticholinergics

Methylxanthines

Short-acting

2-agonists

Anticholinergics

Short-acting 2-agonists

bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation

bull Improve mucociliary clearance

MOA

bull 4 to 6 hoursDuration of action

bull Albuterol (Ventolinreg) levalbuterol pirbuterol

Selective 2-agonists

bull Metaproterenol isoetharine isoproterenol epinephrine

Less selective 2-agonists

Short-acting Anticholinergics

bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle

MOA

bull 4 to 6 hours slower onset of action in comparison to -agonists

Duration of action

bull Ipratropium (Atroventreg Atemreg)

bull AtropineExamples

Long-acting 2-agonists

bull Same as that of short-acting 2-agonistsMOA

bull 12 hoursDuration of action

bull Salmeterol (Sereventreg)

bull Formoterol

bull ArformoterolExamples

Long-acting Anticholinergics

bull Same as that of short-acting anticholinergicsMOA

bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing

Duration of action

bull TiotropiumExample

Combination Anticholinergics amp 2-agonists

bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects

bull Albuterol and Ipratropium available as an MDI Combiventreg

Methylxanthines

bull Produce bronchodilation by

bull Inhibition of PDE increasing cAMP levels

bull Inhibition of calcium ion influx intosmooth muscle

bull Prostaglandin antagonism

bull Stimulation of endogenouscatecholamines

bull Inhibition of release of mediators frommast cells and leukocytes

MOA

bull 8-12 mcgmlTherapeutic

Serum Levels

Methylxanthines

bull Minor side effects

ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia

bull Serious toxic effects

ndash arrhythmias and seizures

bull Considered in patients who donot respond well to bronchodilators

Corticosteroids

bull Mechanism of Action

ndash Reduction in capillary permeability to decrease mucus

ndash Inhibition of release of proteolytic enzymes from leukocytes

ndash Inhibition of prostaglandins

bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone

bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone

Corticosteroids

bull Inhaled CS

ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy

bull Systemic CS

ndashShort term use for acute exacerbations

ndashNot used in chronic management because of high risk of toxicity

Combination ICS amp Bronchodilators

bull Effective in reducing the rate of COPD exacerbations

bull Reduces the number of total inhalations needed more patient compliance

bull Available combination

ndash Beclomethasone with salbutamol (Clenil Compositumreg)

ndash Budesonide with formeterol

ndash Fluticasone with salmeterol

AAT Replacement Therapy

bull Considered for patients with AAT deficiency

bull Life time treatment

bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma

bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week

Indacaterol

bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist

bull Approved by FDA on July 1 2011

bull Requires once daily dosing unlike other long-acting

bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea

bull Recommended dose is one capsule (75mcg) per day

Devices used in COPDbull Inhalers

bull Small handheld devices that

deliver a puff of medicine into the airways

bull Metered-dose inhalers (MDIs)

bull Dry powder inhalers (DPIs) or

breath activated inhalers

bull Inhalers with spacer devices

Metered-dose Inhalersbull Contains a liquid

medication delivered as an aerosol spray

bull Quick to use small and convenient to carry

bull Needs good co-ordination to press the canister and breathe in fully at the same time

Breath-activated inhalersor DPI

bull It releases a puff of drypowder instead of aliquid mist

bull Require less co-ordination than thestandard MDI

bull Slightly bigger than thestandard MDI

bull Example Rotahaler

Inhalers with spacer devices

bull Spacer devices are used with pressurised MDIs

bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed

Nebulizers

bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol

bull Useful in people whoare very breathless egIn severe attack ofCOPD

bull They are not portable

Nanda Nursing Diagnosis for COPD

1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection

2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants

3 Impaired gas exchange related to ventilation perfusion inequality

4 Activity intolerance related to imbalance between oxygen supply with demand

5 Imbalanced Nutrition less than body requirements related to anorexia

COPD Management

bull Goals of COPD Management

ndash To relieve symptoms

ndash To improve quality of life

ndash To decrease the frequency amp severity of acute attacks

ndash To slow the progression of disease

ndash To prolong survival

COPD Management

Nonpharmacologic Treatment

Smoking cessation

Immunization

Long term oxygen therapy

Pulmonaryrehabilitation

Pharmacologic Treatment

Corticosteroids

Bronchodilators

AAT Replacement therapy

Smoking Cessationbull Only proven intervention to affect long term

decline in FEV1 amp slow the progression of COPD

ndash Nicotine replacement therapy

bull Transdermal patch

bull Chewing gum

bull Inhaler

bull Nasal spray

bull Lozenges

ndash Non-nicotine pharmacotherapy

bull Bupropion

bull Varenicline

Smoking Cessation

Product Side effectsPrecautions

Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision

Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors

Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness

Immunizationbull Influenza vaccination

ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients

ndash Patients with serious allergy to eggs should not be given this vaccine

ndash Brand available Fluarixreg

ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects

ndash Available brand Tamiflureg

Immunizationbull Polyvalent pnuemococcal vaccine

ndash Recommended for all COPD patients

bull 65 years and older

bull Less than 65 years only if the FEV1 is less than 40 predicted

ndash Dosage 05ml IM

ndash Available brand Pneumovaxreg (05ml pre-filled syringes)

Long-term Oxygen Therapy

bull Should be started if

ndash Resting PaO2 is less than 55 mm Hg

ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg

Pulmonary Rehabilitation

bull Improves symptoms and quality of life

bull Reduces frequency of exacerbations

bull Components include

ndash Exercise training

ndash Nutritional counselling

ndash Psychosocial support

Pharmacologic Treatment

Bronchodilators

Long-acting

2-agonists

Anticholinergics

Methylxanthines

Short-acting

2-agonists

Anticholinergics

Short-acting 2-agonists

bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation

bull Improve mucociliary clearance

MOA

bull 4 to 6 hoursDuration of action

bull Albuterol (Ventolinreg) levalbuterol pirbuterol

Selective 2-agonists

bull Metaproterenol isoetharine isoproterenol epinephrine

Less selective 2-agonists

Short-acting Anticholinergics

bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle

MOA

bull 4 to 6 hours slower onset of action in comparison to -agonists

Duration of action

bull Ipratropium (Atroventreg Atemreg)

bull AtropineExamples

Long-acting 2-agonists

bull Same as that of short-acting 2-agonistsMOA

bull 12 hoursDuration of action

bull Salmeterol (Sereventreg)

bull Formoterol

bull ArformoterolExamples

Long-acting Anticholinergics

bull Same as that of short-acting anticholinergicsMOA

bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing

Duration of action

bull TiotropiumExample

Combination Anticholinergics amp 2-agonists

bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects

bull Albuterol and Ipratropium available as an MDI Combiventreg

Methylxanthines

bull Produce bronchodilation by

bull Inhibition of PDE increasing cAMP levels

bull Inhibition of calcium ion influx intosmooth muscle

bull Prostaglandin antagonism

bull Stimulation of endogenouscatecholamines

bull Inhibition of release of mediators frommast cells and leukocytes

MOA

bull 8-12 mcgmlTherapeutic

Serum Levels

Methylxanthines

bull Minor side effects

ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia

bull Serious toxic effects

ndash arrhythmias and seizures

bull Considered in patients who donot respond well to bronchodilators

Corticosteroids

bull Mechanism of Action

ndash Reduction in capillary permeability to decrease mucus

ndash Inhibition of release of proteolytic enzymes from leukocytes

ndash Inhibition of prostaglandins

bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone

bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone

Corticosteroids

bull Inhaled CS

ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy

bull Systemic CS

ndashShort term use for acute exacerbations

ndashNot used in chronic management because of high risk of toxicity

Combination ICS amp Bronchodilators

bull Effective in reducing the rate of COPD exacerbations

bull Reduces the number of total inhalations needed more patient compliance

bull Available combination

ndash Beclomethasone with salbutamol (Clenil Compositumreg)

ndash Budesonide with formeterol

ndash Fluticasone with salmeterol

AAT Replacement Therapy

bull Considered for patients with AAT deficiency

bull Life time treatment

bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma

bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week

Indacaterol

bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist

bull Approved by FDA on July 1 2011

bull Requires once daily dosing unlike other long-acting

bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea

bull Recommended dose is one capsule (75mcg) per day

Devices used in COPDbull Inhalers

bull Small handheld devices that

deliver a puff of medicine into the airways

bull Metered-dose inhalers (MDIs)

bull Dry powder inhalers (DPIs) or

breath activated inhalers

bull Inhalers with spacer devices

Metered-dose Inhalersbull Contains a liquid

medication delivered as an aerosol spray

bull Quick to use small and convenient to carry

bull Needs good co-ordination to press the canister and breathe in fully at the same time

Breath-activated inhalersor DPI

bull It releases a puff of drypowder instead of aliquid mist

bull Require less co-ordination than thestandard MDI

bull Slightly bigger than thestandard MDI

bull Example Rotahaler

Inhalers with spacer devices

bull Spacer devices are used with pressurised MDIs

bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed

Nebulizers

bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol

bull Useful in people whoare very breathless egIn severe attack ofCOPD

bull They are not portable

Nanda Nursing Diagnosis for COPD

1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection

2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants

3 Impaired gas exchange related to ventilation perfusion inequality

4 Activity intolerance related to imbalance between oxygen supply with demand

5 Imbalanced Nutrition less than body requirements related to anorexia

COPD Management

Nonpharmacologic Treatment

Smoking cessation

Immunization

Long term oxygen therapy

Pulmonaryrehabilitation

Pharmacologic Treatment

Corticosteroids

Bronchodilators

AAT Replacement therapy

Smoking Cessationbull Only proven intervention to affect long term

decline in FEV1 amp slow the progression of COPD

ndash Nicotine replacement therapy

bull Transdermal patch

bull Chewing gum

bull Inhaler

bull Nasal spray

bull Lozenges

ndash Non-nicotine pharmacotherapy

bull Bupropion

bull Varenicline

Smoking Cessation

Product Side effectsPrecautions

Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision

Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors

Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness

Immunizationbull Influenza vaccination

ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients

ndash Patients with serious allergy to eggs should not be given this vaccine

ndash Brand available Fluarixreg

ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects

ndash Available brand Tamiflureg

Immunizationbull Polyvalent pnuemococcal vaccine

ndash Recommended for all COPD patients

bull 65 years and older

bull Less than 65 years only if the FEV1 is less than 40 predicted

ndash Dosage 05ml IM

ndash Available brand Pneumovaxreg (05ml pre-filled syringes)

Long-term Oxygen Therapy

bull Should be started if

ndash Resting PaO2 is less than 55 mm Hg

ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg

Pulmonary Rehabilitation

bull Improves symptoms and quality of life

bull Reduces frequency of exacerbations

bull Components include

ndash Exercise training

ndash Nutritional counselling

ndash Psychosocial support

Pharmacologic Treatment

Bronchodilators

Long-acting

2-agonists

Anticholinergics

Methylxanthines

Short-acting

2-agonists

Anticholinergics

Short-acting 2-agonists

bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation

bull Improve mucociliary clearance

MOA

bull 4 to 6 hoursDuration of action

bull Albuterol (Ventolinreg) levalbuterol pirbuterol

Selective 2-agonists

bull Metaproterenol isoetharine isoproterenol epinephrine

Less selective 2-agonists

Short-acting Anticholinergics

bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle

MOA

bull 4 to 6 hours slower onset of action in comparison to -agonists

Duration of action

bull Ipratropium (Atroventreg Atemreg)

bull AtropineExamples

Long-acting 2-agonists

bull Same as that of short-acting 2-agonistsMOA

bull 12 hoursDuration of action

bull Salmeterol (Sereventreg)

bull Formoterol

bull ArformoterolExamples

Long-acting Anticholinergics

bull Same as that of short-acting anticholinergicsMOA

bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing

Duration of action

bull TiotropiumExample

Combination Anticholinergics amp 2-agonists

bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects

bull Albuterol and Ipratropium available as an MDI Combiventreg

Methylxanthines

bull Produce bronchodilation by

bull Inhibition of PDE increasing cAMP levels

bull Inhibition of calcium ion influx intosmooth muscle

bull Prostaglandin antagonism

bull Stimulation of endogenouscatecholamines

bull Inhibition of release of mediators frommast cells and leukocytes

MOA

bull 8-12 mcgmlTherapeutic

Serum Levels

Methylxanthines

bull Minor side effects

ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia

bull Serious toxic effects

ndash arrhythmias and seizures

bull Considered in patients who donot respond well to bronchodilators

Corticosteroids

bull Mechanism of Action

ndash Reduction in capillary permeability to decrease mucus

ndash Inhibition of release of proteolytic enzymes from leukocytes

ndash Inhibition of prostaglandins

bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone

bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone

Corticosteroids

bull Inhaled CS

ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy

bull Systemic CS

ndashShort term use for acute exacerbations

ndashNot used in chronic management because of high risk of toxicity

Combination ICS amp Bronchodilators

bull Effective in reducing the rate of COPD exacerbations

bull Reduces the number of total inhalations needed more patient compliance

bull Available combination

ndash Beclomethasone with salbutamol (Clenil Compositumreg)

ndash Budesonide with formeterol

ndash Fluticasone with salmeterol

AAT Replacement Therapy

bull Considered for patients with AAT deficiency

bull Life time treatment

bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma

bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week

Indacaterol

bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist

bull Approved by FDA on July 1 2011

bull Requires once daily dosing unlike other long-acting

bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea

bull Recommended dose is one capsule (75mcg) per day

Devices used in COPDbull Inhalers

bull Small handheld devices that

deliver a puff of medicine into the airways

bull Metered-dose inhalers (MDIs)

bull Dry powder inhalers (DPIs) or

breath activated inhalers

bull Inhalers with spacer devices

Metered-dose Inhalersbull Contains a liquid

medication delivered as an aerosol spray

bull Quick to use small and convenient to carry

bull Needs good co-ordination to press the canister and breathe in fully at the same time

Breath-activated inhalersor DPI

bull It releases a puff of drypowder instead of aliquid mist

bull Require less co-ordination than thestandard MDI

bull Slightly bigger than thestandard MDI

bull Example Rotahaler

Inhalers with spacer devices

bull Spacer devices are used with pressurised MDIs

bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed

Nebulizers

bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol

bull Useful in people whoare very breathless egIn severe attack ofCOPD

bull They are not portable

Nanda Nursing Diagnosis for COPD

1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection

2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants

3 Impaired gas exchange related to ventilation perfusion inequality

4 Activity intolerance related to imbalance between oxygen supply with demand

5 Imbalanced Nutrition less than body requirements related to anorexia

Smoking Cessationbull Only proven intervention to affect long term

decline in FEV1 amp slow the progression of COPD

ndash Nicotine replacement therapy

bull Transdermal patch

bull Chewing gum

bull Inhaler

bull Nasal spray

bull Lozenges

ndash Non-nicotine pharmacotherapy

bull Bupropion

bull Varenicline

Smoking Cessation

Product Side effectsPrecautions

Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision

Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors

Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness

Immunizationbull Influenza vaccination

ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients

ndash Patients with serious allergy to eggs should not be given this vaccine

ndash Brand available Fluarixreg

ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects

ndash Available brand Tamiflureg

Immunizationbull Polyvalent pnuemococcal vaccine

ndash Recommended for all COPD patients

bull 65 years and older

bull Less than 65 years only if the FEV1 is less than 40 predicted

ndash Dosage 05ml IM

ndash Available brand Pneumovaxreg (05ml pre-filled syringes)

Long-term Oxygen Therapy

bull Should be started if

ndash Resting PaO2 is less than 55 mm Hg

ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg

Pulmonary Rehabilitation

bull Improves symptoms and quality of life

bull Reduces frequency of exacerbations

bull Components include

ndash Exercise training

ndash Nutritional counselling

ndash Psychosocial support

Pharmacologic Treatment

Bronchodilators

Long-acting

2-agonists

Anticholinergics

Methylxanthines

Short-acting

2-agonists

Anticholinergics

Short-acting 2-agonists

bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation

bull Improve mucociliary clearance

MOA

bull 4 to 6 hoursDuration of action

bull Albuterol (Ventolinreg) levalbuterol pirbuterol

Selective 2-agonists

bull Metaproterenol isoetharine isoproterenol epinephrine

Less selective 2-agonists

Short-acting Anticholinergics

bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle

MOA

bull 4 to 6 hours slower onset of action in comparison to -agonists

Duration of action

bull Ipratropium (Atroventreg Atemreg)

bull AtropineExamples

Long-acting 2-agonists

bull Same as that of short-acting 2-agonistsMOA

bull 12 hoursDuration of action

bull Salmeterol (Sereventreg)

bull Formoterol

bull ArformoterolExamples

Long-acting Anticholinergics

bull Same as that of short-acting anticholinergicsMOA

bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing

Duration of action

bull TiotropiumExample

Combination Anticholinergics amp 2-agonists

bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects

bull Albuterol and Ipratropium available as an MDI Combiventreg

Methylxanthines

bull Produce bronchodilation by

bull Inhibition of PDE increasing cAMP levels

bull Inhibition of calcium ion influx intosmooth muscle

bull Prostaglandin antagonism

bull Stimulation of endogenouscatecholamines

bull Inhibition of release of mediators frommast cells and leukocytes

MOA

bull 8-12 mcgmlTherapeutic

Serum Levels

Methylxanthines

bull Minor side effects

ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia

bull Serious toxic effects

ndash arrhythmias and seizures

bull Considered in patients who donot respond well to bronchodilators

Corticosteroids

bull Mechanism of Action

ndash Reduction in capillary permeability to decrease mucus

ndash Inhibition of release of proteolytic enzymes from leukocytes

ndash Inhibition of prostaglandins

bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone

bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone

Corticosteroids

bull Inhaled CS

ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy

bull Systemic CS

ndashShort term use for acute exacerbations

ndashNot used in chronic management because of high risk of toxicity

Combination ICS amp Bronchodilators

bull Effective in reducing the rate of COPD exacerbations

bull Reduces the number of total inhalations needed more patient compliance

bull Available combination

ndash Beclomethasone with salbutamol (Clenil Compositumreg)

ndash Budesonide with formeterol

ndash Fluticasone with salmeterol

AAT Replacement Therapy

bull Considered for patients with AAT deficiency

bull Life time treatment

bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma

bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week

Indacaterol

bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist

bull Approved by FDA on July 1 2011

bull Requires once daily dosing unlike other long-acting

bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea

bull Recommended dose is one capsule (75mcg) per day

Devices used in COPDbull Inhalers

bull Small handheld devices that

deliver a puff of medicine into the airways

bull Metered-dose inhalers (MDIs)

bull Dry powder inhalers (DPIs) or

breath activated inhalers

bull Inhalers with spacer devices

Metered-dose Inhalersbull Contains a liquid

medication delivered as an aerosol spray

bull Quick to use small and convenient to carry

bull Needs good co-ordination to press the canister and breathe in fully at the same time

Breath-activated inhalersor DPI

bull It releases a puff of drypowder instead of aliquid mist

bull Require less co-ordination than thestandard MDI

bull Slightly bigger than thestandard MDI

bull Example Rotahaler

Inhalers with spacer devices

bull Spacer devices are used with pressurised MDIs

bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed

Nebulizers

bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol

bull Useful in people whoare very breathless egIn severe attack ofCOPD

bull They are not portable

Nanda Nursing Diagnosis for COPD

1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection

2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants

3 Impaired gas exchange related to ventilation perfusion inequality

4 Activity intolerance related to imbalance between oxygen supply with demand

5 Imbalanced Nutrition less than body requirements related to anorexia

Smoking Cessation

Product Side effectsPrecautions

Nicotine replacement therapy Headache insomnia nightmares nausea dizziness blurred vision

Bupropion Headache insomnia nausea dizziness xerostomia hypertension seizureAvoid monoamine oxidase inhibitors

Varenicline Nausea vomiting headache insomnia abnormal dreamsWorsening of underlying psychiatric illness

Immunizationbull Influenza vaccination

ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients

ndash Patients with serious allergy to eggs should not be given this vaccine

ndash Brand available Fluarixreg

ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects

ndash Available brand Tamiflureg

Immunizationbull Polyvalent pnuemococcal vaccine

ndash Recommended for all COPD patients

bull 65 years and older

bull Less than 65 years only if the FEV1 is less than 40 predicted

ndash Dosage 05ml IM

ndash Available brand Pneumovaxreg (05ml pre-filled syringes)

Long-term Oxygen Therapy

bull Should be started if

ndash Resting PaO2 is less than 55 mm Hg

ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg

Pulmonary Rehabilitation

bull Improves symptoms and quality of life

bull Reduces frequency of exacerbations

bull Components include

ndash Exercise training

ndash Nutritional counselling

ndash Psychosocial support

Pharmacologic Treatment

Bronchodilators

Long-acting

2-agonists

Anticholinergics

Methylxanthines

Short-acting

2-agonists

Anticholinergics

Short-acting 2-agonists

bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation

bull Improve mucociliary clearance

MOA

bull 4 to 6 hoursDuration of action

bull Albuterol (Ventolinreg) levalbuterol pirbuterol

Selective 2-agonists

bull Metaproterenol isoetharine isoproterenol epinephrine

Less selective 2-agonists

Short-acting Anticholinergics

bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle

MOA

bull 4 to 6 hours slower onset of action in comparison to -agonists

Duration of action

bull Ipratropium (Atroventreg Atemreg)

bull AtropineExamples

Long-acting 2-agonists

bull Same as that of short-acting 2-agonistsMOA

bull 12 hoursDuration of action

bull Salmeterol (Sereventreg)

bull Formoterol

bull ArformoterolExamples

Long-acting Anticholinergics

bull Same as that of short-acting anticholinergicsMOA

bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing

Duration of action

bull TiotropiumExample

Combination Anticholinergics amp 2-agonists

bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects

bull Albuterol and Ipratropium available as an MDI Combiventreg

Methylxanthines

bull Produce bronchodilation by

bull Inhibition of PDE increasing cAMP levels

bull Inhibition of calcium ion influx intosmooth muscle

bull Prostaglandin antagonism

bull Stimulation of endogenouscatecholamines

bull Inhibition of release of mediators frommast cells and leukocytes

MOA

bull 8-12 mcgmlTherapeutic

Serum Levels

Methylxanthines

bull Minor side effects

ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia

bull Serious toxic effects

ndash arrhythmias and seizures

bull Considered in patients who donot respond well to bronchodilators

Corticosteroids

bull Mechanism of Action

ndash Reduction in capillary permeability to decrease mucus

ndash Inhibition of release of proteolytic enzymes from leukocytes

ndash Inhibition of prostaglandins

bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone

bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone

Corticosteroids

bull Inhaled CS

ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy

bull Systemic CS

ndashShort term use for acute exacerbations

ndashNot used in chronic management because of high risk of toxicity

Combination ICS amp Bronchodilators

bull Effective in reducing the rate of COPD exacerbations

bull Reduces the number of total inhalations needed more patient compliance

bull Available combination

ndash Beclomethasone with salbutamol (Clenil Compositumreg)

ndash Budesonide with formeterol

ndash Fluticasone with salmeterol

AAT Replacement Therapy

bull Considered for patients with AAT deficiency

bull Life time treatment

bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma

bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week

Indacaterol

bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist

bull Approved by FDA on July 1 2011

bull Requires once daily dosing unlike other long-acting

bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea

bull Recommended dose is one capsule (75mcg) per day

Devices used in COPDbull Inhalers

bull Small handheld devices that

deliver a puff of medicine into the airways

bull Metered-dose inhalers (MDIs)

bull Dry powder inhalers (DPIs) or

breath activated inhalers

bull Inhalers with spacer devices

Metered-dose Inhalersbull Contains a liquid

medication delivered as an aerosol spray

bull Quick to use small and convenient to carry

bull Needs good co-ordination to press the canister and breathe in fully at the same time

Breath-activated inhalersor DPI

bull It releases a puff of drypowder instead of aliquid mist

bull Require less co-ordination than thestandard MDI

bull Slightly bigger than thestandard MDI

bull Example Rotahaler

Inhalers with spacer devices

bull Spacer devices are used with pressurised MDIs

bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed

Nebulizers

bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol

bull Useful in people whoare very breathless egIn severe attack ofCOPD

bull They are not portable

Nanda Nursing Diagnosis for COPD

1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection

2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants

3 Impaired gas exchange related to ventilation perfusion inequality

4 Activity intolerance related to imbalance between oxygen supply with demand

5 Imbalanced Nutrition less than body requirements related to anorexia

Immunizationbull Influenza vaccination

ndash Reduces the incidence of influenza-related acute respiratory illness in COPD patients

ndash Patients with serious allergy to eggs should not be given this vaccine

ndash Brand available Fluarixreg

ndash An oral antiinfluenza agent (Oseltamivir) can be given to such patients but its less effective and causes more side effects

ndash Available brand Tamiflureg

Immunizationbull Polyvalent pnuemococcal vaccine

ndash Recommended for all COPD patients

bull 65 years and older

bull Less than 65 years only if the FEV1 is less than 40 predicted

ndash Dosage 05ml IM

ndash Available brand Pneumovaxreg (05ml pre-filled syringes)

Long-term Oxygen Therapy

bull Should be started if

ndash Resting PaO2 is less than 55 mm Hg

ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg

Pulmonary Rehabilitation

bull Improves symptoms and quality of life

bull Reduces frequency of exacerbations

bull Components include

ndash Exercise training

ndash Nutritional counselling

ndash Psychosocial support

Pharmacologic Treatment

Bronchodilators

Long-acting

2-agonists

Anticholinergics

Methylxanthines

Short-acting

2-agonists

Anticholinergics

Short-acting 2-agonists

bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation

bull Improve mucociliary clearance

MOA

bull 4 to 6 hoursDuration of action

bull Albuterol (Ventolinreg) levalbuterol pirbuterol

Selective 2-agonists

bull Metaproterenol isoetharine isoproterenol epinephrine

Less selective 2-agonists

Short-acting Anticholinergics

bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle

MOA

bull 4 to 6 hours slower onset of action in comparison to -agonists

Duration of action

bull Ipratropium (Atroventreg Atemreg)

bull AtropineExamples

Long-acting 2-agonists

bull Same as that of short-acting 2-agonistsMOA

bull 12 hoursDuration of action

bull Salmeterol (Sereventreg)

bull Formoterol

bull ArformoterolExamples

Long-acting Anticholinergics

bull Same as that of short-acting anticholinergicsMOA

bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing

Duration of action

bull TiotropiumExample

Combination Anticholinergics amp 2-agonists

bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects

bull Albuterol and Ipratropium available as an MDI Combiventreg

Methylxanthines

bull Produce bronchodilation by

bull Inhibition of PDE increasing cAMP levels

bull Inhibition of calcium ion influx intosmooth muscle

bull Prostaglandin antagonism

bull Stimulation of endogenouscatecholamines

bull Inhibition of release of mediators frommast cells and leukocytes

MOA

bull 8-12 mcgmlTherapeutic

Serum Levels

Methylxanthines

bull Minor side effects

ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia

bull Serious toxic effects

ndash arrhythmias and seizures

bull Considered in patients who donot respond well to bronchodilators

Corticosteroids

bull Mechanism of Action

ndash Reduction in capillary permeability to decrease mucus

ndash Inhibition of release of proteolytic enzymes from leukocytes

ndash Inhibition of prostaglandins

bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone

bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone

Corticosteroids

bull Inhaled CS

ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy

bull Systemic CS

ndashShort term use for acute exacerbations

ndashNot used in chronic management because of high risk of toxicity

Combination ICS amp Bronchodilators

bull Effective in reducing the rate of COPD exacerbations

bull Reduces the number of total inhalations needed more patient compliance

bull Available combination

ndash Beclomethasone with salbutamol (Clenil Compositumreg)

ndash Budesonide with formeterol

ndash Fluticasone with salmeterol

AAT Replacement Therapy

bull Considered for patients with AAT deficiency

bull Life time treatment

bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma

bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week

Indacaterol

bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist

bull Approved by FDA on July 1 2011

bull Requires once daily dosing unlike other long-acting

bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea

bull Recommended dose is one capsule (75mcg) per day

Devices used in COPDbull Inhalers

bull Small handheld devices that

deliver a puff of medicine into the airways

bull Metered-dose inhalers (MDIs)

bull Dry powder inhalers (DPIs) or

breath activated inhalers

bull Inhalers with spacer devices

Metered-dose Inhalersbull Contains a liquid

medication delivered as an aerosol spray

bull Quick to use small and convenient to carry

bull Needs good co-ordination to press the canister and breathe in fully at the same time

Breath-activated inhalersor DPI

bull It releases a puff of drypowder instead of aliquid mist

bull Require less co-ordination than thestandard MDI

bull Slightly bigger than thestandard MDI

bull Example Rotahaler

Inhalers with spacer devices

bull Spacer devices are used with pressurised MDIs

bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed

Nebulizers

bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol

bull Useful in people whoare very breathless egIn severe attack ofCOPD

bull They are not portable

Nanda Nursing Diagnosis for COPD

1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection

2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants

3 Impaired gas exchange related to ventilation perfusion inequality

4 Activity intolerance related to imbalance between oxygen supply with demand

5 Imbalanced Nutrition less than body requirements related to anorexia

Immunizationbull Polyvalent pnuemococcal vaccine

ndash Recommended for all COPD patients

bull 65 years and older

bull Less than 65 years only if the FEV1 is less than 40 predicted

ndash Dosage 05ml IM

ndash Available brand Pneumovaxreg (05ml pre-filled syringes)

Long-term Oxygen Therapy

bull Should be started if

ndash Resting PaO2 is less than 55 mm Hg

ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg

Pulmonary Rehabilitation

bull Improves symptoms and quality of life

bull Reduces frequency of exacerbations

bull Components include

ndash Exercise training

ndash Nutritional counselling

ndash Psychosocial support

Pharmacologic Treatment

Bronchodilators

Long-acting

2-agonists

Anticholinergics

Methylxanthines

Short-acting

2-agonists

Anticholinergics

Short-acting 2-agonists

bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation

bull Improve mucociliary clearance

MOA

bull 4 to 6 hoursDuration of action

bull Albuterol (Ventolinreg) levalbuterol pirbuterol

Selective 2-agonists

bull Metaproterenol isoetharine isoproterenol epinephrine

Less selective 2-agonists

Short-acting Anticholinergics

bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle

MOA

bull 4 to 6 hours slower onset of action in comparison to -agonists

Duration of action

bull Ipratropium (Atroventreg Atemreg)

bull AtropineExamples

Long-acting 2-agonists

bull Same as that of short-acting 2-agonistsMOA

bull 12 hoursDuration of action

bull Salmeterol (Sereventreg)

bull Formoterol

bull ArformoterolExamples

Long-acting Anticholinergics

bull Same as that of short-acting anticholinergicsMOA

bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing

Duration of action

bull TiotropiumExample

Combination Anticholinergics amp 2-agonists

bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects

bull Albuterol and Ipratropium available as an MDI Combiventreg

Methylxanthines

bull Produce bronchodilation by

bull Inhibition of PDE increasing cAMP levels

bull Inhibition of calcium ion influx intosmooth muscle

bull Prostaglandin antagonism

bull Stimulation of endogenouscatecholamines

bull Inhibition of release of mediators frommast cells and leukocytes

MOA

bull 8-12 mcgmlTherapeutic

Serum Levels

Methylxanthines

bull Minor side effects

ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia

bull Serious toxic effects

ndash arrhythmias and seizures

bull Considered in patients who donot respond well to bronchodilators

Corticosteroids

bull Mechanism of Action

ndash Reduction in capillary permeability to decrease mucus

ndash Inhibition of release of proteolytic enzymes from leukocytes

ndash Inhibition of prostaglandins

bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone

bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone

Corticosteroids

bull Inhaled CS

ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy

bull Systemic CS

ndashShort term use for acute exacerbations

ndashNot used in chronic management because of high risk of toxicity

Combination ICS amp Bronchodilators

bull Effective in reducing the rate of COPD exacerbations

bull Reduces the number of total inhalations needed more patient compliance

bull Available combination

ndash Beclomethasone with salbutamol (Clenil Compositumreg)

ndash Budesonide with formeterol

ndash Fluticasone with salmeterol

AAT Replacement Therapy

bull Considered for patients with AAT deficiency

bull Life time treatment

bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma

bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week

Indacaterol

bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist

bull Approved by FDA on July 1 2011

bull Requires once daily dosing unlike other long-acting

bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea

bull Recommended dose is one capsule (75mcg) per day

Devices used in COPDbull Inhalers

bull Small handheld devices that

deliver a puff of medicine into the airways

bull Metered-dose inhalers (MDIs)

bull Dry powder inhalers (DPIs) or

breath activated inhalers

bull Inhalers with spacer devices

Metered-dose Inhalersbull Contains a liquid

medication delivered as an aerosol spray

bull Quick to use small and convenient to carry

bull Needs good co-ordination to press the canister and breathe in fully at the same time

Breath-activated inhalersor DPI

bull It releases a puff of drypowder instead of aliquid mist

bull Require less co-ordination than thestandard MDI

bull Slightly bigger than thestandard MDI

bull Example Rotahaler

Inhalers with spacer devices

bull Spacer devices are used with pressurised MDIs

bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed

Nebulizers

bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol

bull Useful in people whoare very breathless egIn severe attack ofCOPD

bull They are not portable

Nanda Nursing Diagnosis for COPD

1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection

2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants

3 Impaired gas exchange related to ventilation perfusion inequality

4 Activity intolerance related to imbalance between oxygen supply with demand

5 Imbalanced Nutrition less than body requirements related to anorexia

Long-term Oxygen Therapy

bull Should be started if

ndash Resting PaO2 is less than 55 mm Hg

ndash Evidence of right-sided heart failure polycythemia or impaired neuropsychiatric function with a PaO2 of less than 60 mm Hg

Pulmonary Rehabilitation

bull Improves symptoms and quality of life

bull Reduces frequency of exacerbations

bull Components include

ndash Exercise training

ndash Nutritional counselling

ndash Psychosocial support

Pharmacologic Treatment

Bronchodilators

Long-acting

2-agonists

Anticholinergics

Methylxanthines

Short-acting

2-agonists

Anticholinergics

Short-acting 2-agonists

bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation

bull Improve mucociliary clearance

MOA

bull 4 to 6 hoursDuration of action

bull Albuterol (Ventolinreg) levalbuterol pirbuterol

Selective 2-agonists

bull Metaproterenol isoetharine isoproterenol epinephrine

Less selective 2-agonists

Short-acting Anticholinergics

bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle

MOA

bull 4 to 6 hours slower onset of action in comparison to -agonists

Duration of action

bull Ipratropium (Atroventreg Atemreg)

bull AtropineExamples

Long-acting 2-agonists

bull Same as that of short-acting 2-agonistsMOA

bull 12 hoursDuration of action

bull Salmeterol (Sereventreg)

bull Formoterol

bull ArformoterolExamples

Long-acting Anticholinergics

bull Same as that of short-acting anticholinergicsMOA

bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing

Duration of action

bull TiotropiumExample

Combination Anticholinergics amp 2-agonists

bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects

bull Albuterol and Ipratropium available as an MDI Combiventreg

Methylxanthines

bull Produce bronchodilation by

bull Inhibition of PDE increasing cAMP levels

bull Inhibition of calcium ion influx intosmooth muscle

bull Prostaglandin antagonism

bull Stimulation of endogenouscatecholamines

bull Inhibition of release of mediators frommast cells and leukocytes

MOA

bull 8-12 mcgmlTherapeutic

Serum Levels

Methylxanthines

bull Minor side effects

ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia

bull Serious toxic effects

ndash arrhythmias and seizures

bull Considered in patients who donot respond well to bronchodilators

Corticosteroids

bull Mechanism of Action

ndash Reduction in capillary permeability to decrease mucus

ndash Inhibition of release of proteolytic enzymes from leukocytes

ndash Inhibition of prostaglandins

bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone

bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone

Corticosteroids

bull Inhaled CS

ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy

bull Systemic CS

ndashShort term use for acute exacerbations

ndashNot used in chronic management because of high risk of toxicity

Combination ICS amp Bronchodilators

bull Effective in reducing the rate of COPD exacerbations

bull Reduces the number of total inhalations needed more patient compliance

bull Available combination

ndash Beclomethasone with salbutamol (Clenil Compositumreg)

ndash Budesonide with formeterol

ndash Fluticasone with salmeterol

AAT Replacement Therapy

bull Considered for patients with AAT deficiency

bull Life time treatment

bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma

bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week

Indacaterol

bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist

bull Approved by FDA on July 1 2011

bull Requires once daily dosing unlike other long-acting

bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea

bull Recommended dose is one capsule (75mcg) per day

Devices used in COPDbull Inhalers

bull Small handheld devices that

deliver a puff of medicine into the airways

bull Metered-dose inhalers (MDIs)

bull Dry powder inhalers (DPIs) or

breath activated inhalers

bull Inhalers with spacer devices

Metered-dose Inhalersbull Contains a liquid

medication delivered as an aerosol spray

bull Quick to use small and convenient to carry

bull Needs good co-ordination to press the canister and breathe in fully at the same time

Breath-activated inhalersor DPI

bull It releases a puff of drypowder instead of aliquid mist

bull Require less co-ordination than thestandard MDI

bull Slightly bigger than thestandard MDI

bull Example Rotahaler

Inhalers with spacer devices

bull Spacer devices are used with pressurised MDIs

bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed

Nebulizers

bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol

bull Useful in people whoare very breathless egIn severe attack ofCOPD

bull They are not portable

Nanda Nursing Diagnosis for COPD

1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection

2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants

3 Impaired gas exchange related to ventilation perfusion inequality

4 Activity intolerance related to imbalance between oxygen supply with demand

5 Imbalanced Nutrition less than body requirements related to anorexia

Pulmonary Rehabilitation

bull Improves symptoms and quality of life

bull Reduces frequency of exacerbations

bull Components include

ndash Exercise training

ndash Nutritional counselling

ndash Psychosocial support

Pharmacologic Treatment

Bronchodilators

Long-acting

2-agonists

Anticholinergics

Methylxanthines

Short-acting

2-agonists

Anticholinergics

Short-acting 2-agonists

bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation

bull Improve mucociliary clearance

MOA

bull 4 to 6 hoursDuration of action

bull Albuterol (Ventolinreg) levalbuterol pirbuterol

Selective 2-agonists

bull Metaproterenol isoetharine isoproterenol epinephrine

Less selective 2-agonists

Short-acting Anticholinergics

bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle

MOA

bull 4 to 6 hours slower onset of action in comparison to -agonists

Duration of action

bull Ipratropium (Atroventreg Atemreg)

bull AtropineExamples

Long-acting 2-agonists

bull Same as that of short-acting 2-agonistsMOA

bull 12 hoursDuration of action

bull Salmeterol (Sereventreg)

bull Formoterol

bull ArformoterolExamples

Long-acting Anticholinergics

bull Same as that of short-acting anticholinergicsMOA

bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing

Duration of action

bull TiotropiumExample

Combination Anticholinergics amp 2-agonists

bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects

bull Albuterol and Ipratropium available as an MDI Combiventreg

Methylxanthines

bull Produce bronchodilation by

bull Inhibition of PDE increasing cAMP levels

bull Inhibition of calcium ion influx intosmooth muscle

bull Prostaglandin antagonism

bull Stimulation of endogenouscatecholamines

bull Inhibition of release of mediators frommast cells and leukocytes

MOA

bull 8-12 mcgmlTherapeutic

Serum Levels

Methylxanthines

bull Minor side effects

ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia

bull Serious toxic effects

ndash arrhythmias and seizures

bull Considered in patients who donot respond well to bronchodilators

Corticosteroids

bull Mechanism of Action

ndash Reduction in capillary permeability to decrease mucus

ndash Inhibition of release of proteolytic enzymes from leukocytes

ndash Inhibition of prostaglandins

bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone

bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone

Corticosteroids

bull Inhaled CS

ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy

bull Systemic CS

ndashShort term use for acute exacerbations

ndashNot used in chronic management because of high risk of toxicity

Combination ICS amp Bronchodilators

bull Effective in reducing the rate of COPD exacerbations

bull Reduces the number of total inhalations needed more patient compliance

bull Available combination

ndash Beclomethasone with salbutamol (Clenil Compositumreg)

ndash Budesonide with formeterol

ndash Fluticasone with salmeterol

AAT Replacement Therapy

bull Considered for patients with AAT deficiency

bull Life time treatment

bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma

bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week

Indacaterol

bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist

bull Approved by FDA on July 1 2011

bull Requires once daily dosing unlike other long-acting

bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea

bull Recommended dose is one capsule (75mcg) per day

Devices used in COPDbull Inhalers

bull Small handheld devices that

deliver a puff of medicine into the airways

bull Metered-dose inhalers (MDIs)

bull Dry powder inhalers (DPIs) or

breath activated inhalers

bull Inhalers with spacer devices

Metered-dose Inhalersbull Contains a liquid

medication delivered as an aerosol spray

bull Quick to use small and convenient to carry

bull Needs good co-ordination to press the canister and breathe in fully at the same time

Breath-activated inhalersor DPI

bull It releases a puff of drypowder instead of aliquid mist

bull Require less co-ordination than thestandard MDI

bull Slightly bigger than thestandard MDI

bull Example Rotahaler

Inhalers with spacer devices

bull Spacer devices are used with pressurised MDIs

bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed

Nebulizers

bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol

bull Useful in people whoare very breathless egIn severe attack ofCOPD

bull They are not portable

Nanda Nursing Diagnosis for COPD

1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection

2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants

3 Impaired gas exchange related to ventilation perfusion inequality

4 Activity intolerance related to imbalance between oxygen supply with demand

5 Imbalanced Nutrition less than body requirements related to anorexia

Pharmacologic Treatment

Bronchodilators

Long-acting

2-agonists

Anticholinergics

Methylxanthines

Short-acting

2-agonists

Anticholinergics

Short-acting 2-agonists

bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation

bull Improve mucociliary clearance

MOA

bull 4 to 6 hoursDuration of action

bull Albuterol (Ventolinreg) levalbuterol pirbuterol

Selective 2-agonists

bull Metaproterenol isoetharine isoproterenol epinephrine

Less selective 2-agonists

Short-acting Anticholinergics

bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle

MOA

bull 4 to 6 hours slower onset of action in comparison to -agonists

Duration of action

bull Ipratropium (Atroventreg Atemreg)

bull AtropineExamples

Long-acting 2-agonists

bull Same as that of short-acting 2-agonistsMOA

bull 12 hoursDuration of action

bull Salmeterol (Sereventreg)

bull Formoterol

bull ArformoterolExamples

Long-acting Anticholinergics

bull Same as that of short-acting anticholinergicsMOA

bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing

Duration of action

bull TiotropiumExample

Combination Anticholinergics amp 2-agonists

bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects

bull Albuterol and Ipratropium available as an MDI Combiventreg

Methylxanthines

bull Produce bronchodilation by

bull Inhibition of PDE increasing cAMP levels

bull Inhibition of calcium ion influx intosmooth muscle

bull Prostaglandin antagonism

bull Stimulation of endogenouscatecholamines

bull Inhibition of release of mediators frommast cells and leukocytes

MOA

bull 8-12 mcgmlTherapeutic

Serum Levels

Methylxanthines

bull Minor side effects

ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia

bull Serious toxic effects

ndash arrhythmias and seizures

bull Considered in patients who donot respond well to bronchodilators

Corticosteroids

bull Mechanism of Action

ndash Reduction in capillary permeability to decrease mucus

ndash Inhibition of release of proteolytic enzymes from leukocytes

ndash Inhibition of prostaglandins

bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone

bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone

Corticosteroids

bull Inhaled CS

ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy

bull Systemic CS

ndashShort term use for acute exacerbations

ndashNot used in chronic management because of high risk of toxicity

Combination ICS amp Bronchodilators

bull Effective in reducing the rate of COPD exacerbations

bull Reduces the number of total inhalations needed more patient compliance

bull Available combination

ndash Beclomethasone with salbutamol (Clenil Compositumreg)

ndash Budesonide with formeterol

ndash Fluticasone with salmeterol

AAT Replacement Therapy

bull Considered for patients with AAT deficiency

bull Life time treatment

bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma

bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week

Indacaterol

bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist

bull Approved by FDA on July 1 2011

bull Requires once daily dosing unlike other long-acting

bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea

bull Recommended dose is one capsule (75mcg) per day

Devices used in COPDbull Inhalers

bull Small handheld devices that

deliver a puff of medicine into the airways

bull Metered-dose inhalers (MDIs)

bull Dry powder inhalers (DPIs) or

breath activated inhalers

bull Inhalers with spacer devices

Metered-dose Inhalersbull Contains a liquid

medication delivered as an aerosol spray

bull Quick to use small and convenient to carry

bull Needs good co-ordination to press the canister and breathe in fully at the same time

Breath-activated inhalersor DPI

bull It releases a puff of drypowder instead of aliquid mist

bull Require less co-ordination than thestandard MDI

bull Slightly bigger than thestandard MDI

bull Example Rotahaler

Inhalers with spacer devices

bull Spacer devices are used with pressurised MDIs

bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed

Nebulizers

bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol

bull Useful in people whoare very breathless egIn severe attack ofCOPD

bull They are not portable

Nanda Nursing Diagnosis for COPD

1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection

2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants

3 Impaired gas exchange related to ventilation perfusion inequality

4 Activity intolerance related to imbalance between oxygen supply with demand

5 Imbalanced Nutrition less than body requirements related to anorexia

Short-acting 2-agonists

bull Stimulate adenyl cyclase toincrease the formation of cAMPwhich causes bronchodilation

bull Improve mucociliary clearance

MOA

bull 4 to 6 hoursDuration of action

bull Albuterol (Ventolinreg) levalbuterol pirbuterol

Selective 2-agonists

bull Metaproterenol isoetharine isoproterenol epinephrine

Less selective 2-agonists

Short-acting Anticholinergics

bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle

MOA

bull 4 to 6 hours slower onset of action in comparison to -agonists

Duration of action

bull Ipratropium (Atroventreg Atemreg)

bull AtropineExamples

Long-acting 2-agonists

bull Same as that of short-acting 2-agonistsMOA

bull 12 hoursDuration of action

bull Salmeterol (Sereventreg)

bull Formoterol

bull ArformoterolExamples

Long-acting Anticholinergics

bull Same as that of short-acting anticholinergicsMOA

bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing

Duration of action

bull TiotropiumExample

Combination Anticholinergics amp 2-agonists

bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects

bull Albuterol and Ipratropium available as an MDI Combiventreg

Methylxanthines

bull Produce bronchodilation by

bull Inhibition of PDE increasing cAMP levels

bull Inhibition of calcium ion influx intosmooth muscle

bull Prostaglandin antagonism

bull Stimulation of endogenouscatecholamines

bull Inhibition of release of mediators frommast cells and leukocytes

MOA

bull 8-12 mcgmlTherapeutic

Serum Levels

Methylxanthines

bull Minor side effects

ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia

bull Serious toxic effects

ndash arrhythmias and seizures

bull Considered in patients who donot respond well to bronchodilators

Corticosteroids

bull Mechanism of Action

ndash Reduction in capillary permeability to decrease mucus

ndash Inhibition of release of proteolytic enzymes from leukocytes

ndash Inhibition of prostaglandins

bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone

bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone

Corticosteroids

bull Inhaled CS

ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy

bull Systemic CS

ndashShort term use for acute exacerbations

ndashNot used in chronic management because of high risk of toxicity

Combination ICS amp Bronchodilators

bull Effective in reducing the rate of COPD exacerbations

bull Reduces the number of total inhalations needed more patient compliance

bull Available combination

ndash Beclomethasone with salbutamol (Clenil Compositumreg)

ndash Budesonide with formeterol

ndash Fluticasone with salmeterol

AAT Replacement Therapy

bull Considered for patients with AAT deficiency

bull Life time treatment

bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma

bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week

Indacaterol

bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist

bull Approved by FDA on July 1 2011

bull Requires once daily dosing unlike other long-acting

bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea

bull Recommended dose is one capsule (75mcg) per day

Devices used in COPDbull Inhalers

bull Small handheld devices that

deliver a puff of medicine into the airways

bull Metered-dose inhalers (MDIs)

bull Dry powder inhalers (DPIs) or

breath activated inhalers

bull Inhalers with spacer devices

Metered-dose Inhalersbull Contains a liquid

medication delivered as an aerosol spray

bull Quick to use small and convenient to carry

bull Needs good co-ordination to press the canister and breathe in fully at the same time

Breath-activated inhalersor DPI

bull It releases a puff of drypowder instead of aliquid mist

bull Require less co-ordination than thestandard MDI

bull Slightly bigger than thestandard MDI

bull Example Rotahaler

Inhalers with spacer devices

bull Spacer devices are used with pressurised MDIs

bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed

Nebulizers

bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol

bull Useful in people whoare very breathless egIn severe attack ofCOPD

bull They are not portable

Nanda Nursing Diagnosis for COPD

1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection

2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants

3 Impaired gas exchange related to ventilation perfusion inequality

4 Activity intolerance related to imbalance between oxygen supply with demand

5 Imbalanced Nutrition less than body requirements related to anorexia

Short-acting Anticholinergics

bull Competitively inhibit cholinergicreceptors in bronchial smoothmuscle block Ach with the neteffect of reduction in cGMP whichnormally constrict bronchial smoothmuscle

MOA

bull 4 to 6 hours slower onset of action in comparison to -agonists

Duration of action

bull Ipratropium (Atroventreg Atemreg)

bull AtropineExamples

Long-acting 2-agonists

bull Same as that of short-acting 2-agonistsMOA

bull 12 hoursDuration of action

bull Salmeterol (Sereventreg)

bull Formoterol

bull ArformoterolExamples

Long-acting Anticholinergics

bull Same as that of short-acting anticholinergicsMOA

bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing

Duration of action

bull TiotropiumExample

Combination Anticholinergics amp 2-agonists

bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects

bull Albuterol and Ipratropium available as an MDI Combiventreg

Methylxanthines

bull Produce bronchodilation by

bull Inhibition of PDE increasing cAMP levels

bull Inhibition of calcium ion influx intosmooth muscle

bull Prostaglandin antagonism

bull Stimulation of endogenouscatecholamines

bull Inhibition of release of mediators frommast cells and leukocytes

MOA

bull 8-12 mcgmlTherapeutic

Serum Levels

Methylxanthines

bull Minor side effects

ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia

bull Serious toxic effects

ndash arrhythmias and seizures

bull Considered in patients who donot respond well to bronchodilators

Corticosteroids

bull Mechanism of Action

ndash Reduction in capillary permeability to decrease mucus

ndash Inhibition of release of proteolytic enzymes from leukocytes

ndash Inhibition of prostaglandins

bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone

bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone

Corticosteroids

bull Inhaled CS

ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy

bull Systemic CS

ndashShort term use for acute exacerbations

ndashNot used in chronic management because of high risk of toxicity

Combination ICS amp Bronchodilators

bull Effective in reducing the rate of COPD exacerbations

bull Reduces the number of total inhalations needed more patient compliance

bull Available combination

ndash Beclomethasone with salbutamol (Clenil Compositumreg)

ndash Budesonide with formeterol

ndash Fluticasone with salmeterol

AAT Replacement Therapy

bull Considered for patients with AAT deficiency

bull Life time treatment

bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma

bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week

Indacaterol

bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist

bull Approved by FDA on July 1 2011

bull Requires once daily dosing unlike other long-acting

bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea

bull Recommended dose is one capsule (75mcg) per day

Devices used in COPDbull Inhalers

bull Small handheld devices that

deliver a puff of medicine into the airways

bull Metered-dose inhalers (MDIs)

bull Dry powder inhalers (DPIs) or

breath activated inhalers

bull Inhalers with spacer devices

Metered-dose Inhalersbull Contains a liquid

medication delivered as an aerosol spray

bull Quick to use small and convenient to carry

bull Needs good co-ordination to press the canister and breathe in fully at the same time

Breath-activated inhalersor DPI

bull It releases a puff of drypowder instead of aliquid mist

bull Require less co-ordination than thestandard MDI

bull Slightly bigger than thestandard MDI

bull Example Rotahaler

Inhalers with spacer devices

bull Spacer devices are used with pressurised MDIs

bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed

Nebulizers

bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol

bull Useful in people whoare very breathless egIn severe attack ofCOPD

bull They are not portable

Nanda Nursing Diagnosis for COPD

1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection

2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants

3 Impaired gas exchange related to ventilation perfusion inequality

4 Activity intolerance related to imbalance between oxygen supply with demand

5 Imbalanced Nutrition less than body requirements related to anorexia

Long-acting 2-agonists

bull Same as that of short-acting 2-agonistsMOA

bull 12 hoursDuration of action

bull Salmeterol (Sereventreg)

bull Formoterol

bull ArformoterolExamples

Long-acting Anticholinergics

bull Same as that of short-acting anticholinergicsMOA

bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing

Duration of action

bull TiotropiumExample

Combination Anticholinergics amp 2-agonists

bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects

bull Albuterol and Ipratropium available as an MDI Combiventreg

Methylxanthines

bull Produce bronchodilation by

bull Inhibition of PDE increasing cAMP levels

bull Inhibition of calcium ion influx intosmooth muscle

bull Prostaglandin antagonism

bull Stimulation of endogenouscatecholamines

bull Inhibition of release of mediators frommast cells and leukocytes

MOA

bull 8-12 mcgmlTherapeutic

Serum Levels

Methylxanthines

bull Minor side effects

ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia

bull Serious toxic effects

ndash arrhythmias and seizures

bull Considered in patients who donot respond well to bronchodilators

Corticosteroids

bull Mechanism of Action

ndash Reduction in capillary permeability to decrease mucus

ndash Inhibition of release of proteolytic enzymes from leukocytes

ndash Inhibition of prostaglandins

bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone

bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone

Corticosteroids

bull Inhaled CS

ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy

bull Systemic CS

ndashShort term use for acute exacerbations

ndashNot used in chronic management because of high risk of toxicity

Combination ICS amp Bronchodilators

bull Effective in reducing the rate of COPD exacerbations

bull Reduces the number of total inhalations needed more patient compliance

bull Available combination

ndash Beclomethasone with salbutamol (Clenil Compositumreg)

ndash Budesonide with formeterol

ndash Fluticasone with salmeterol

AAT Replacement Therapy

bull Considered for patients with AAT deficiency

bull Life time treatment

bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma

bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week

Indacaterol

bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist

bull Approved by FDA on July 1 2011

bull Requires once daily dosing unlike other long-acting

bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea

bull Recommended dose is one capsule (75mcg) per day

Devices used in COPDbull Inhalers

bull Small handheld devices that

deliver a puff of medicine into the airways

bull Metered-dose inhalers (MDIs)

bull Dry powder inhalers (DPIs) or

breath activated inhalers

bull Inhalers with spacer devices

Metered-dose Inhalersbull Contains a liquid

medication delivered as an aerosol spray

bull Quick to use small and convenient to carry

bull Needs good co-ordination to press the canister and breathe in fully at the same time

Breath-activated inhalersor DPI

bull It releases a puff of drypowder instead of aliquid mist

bull Require less co-ordination than thestandard MDI

bull Slightly bigger than thestandard MDI

bull Example Rotahaler

Inhalers with spacer devices

bull Spacer devices are used with pressurised MDIs

bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed

Nebulizers

bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol

bull Useful in people whoare very breathless egIn severe attack ofCOPD

bull They are not portable

Nanda Nursing Diagnosis for COPD

1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection

2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants

3 Impaired gas exchange related to ventilation perfusion inequality

4 Activity intolerance related to imbalance between oxygen supply with demand

5 Imbalanced Nutrition less than body requirements related to anorexia

Long-acting Anticholinergics

bull Same as that of short-acting anticholinergicsMOA

bull Cause bronchodilation within 30 minutes which persists for 24 hours allowing once daily dosing

Duration of action

bull TiotropiumExample

Combination Anticholinergics amp 2-agonists

bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects

bull Albuterol and Ipratropium available as an MDI Combiventreg

Methylxanthines

bull Produce bronchodilation by

bull Inhibition of PDE increasing cAMP levels

bull Inhibition of calcium ion influx intosmooth muscle

bull Prostaglandin antagonism

bull Stimulation of endogenouscatecholamines

bull Inhibition of release of mediators frommast cells and leukocytes

MOA

bull 8-12 mcgmlTherapeutic

Serum Levels

Methylxanthines

bull Minor side effects

ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia

bull Serious toxic effects

ndash arrhythmias and seizures

bull Considered in patients who donot respond well to bronchodilators

Corticosteroids

bull Mechanism of Action

ndash Reduction in capillary permeability to decrease mucus

ndash Inhibition of release of proteolytic enzymes from leukocytes

ndash Inhibition of prostaglandins

bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone

bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone

Corticosteroids

bull Inhaled CS

ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy

bull Systemic CS

ndashShort term use for acute exacerbations

ndashNot used in chronic management because of high risk of toxicity

Combination ICS amp Bronchodilators

bull Effective in reducing the rate of COPD exacerbations

bull Reduces the number of total inhalations needed more patient compliance

bull Available combination

ndash Beclomethasone with salbutamol (Clenil Compositumreg)

ndash Budesonide with formeterol

ndash Fluticasone with salmeterol

AAT Replacement Therapy

bull Considered for patients with AAT deficiency

bull Life time treatment

bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma

bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week

Indacaterol

bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist

bull Approved by FDA on July 1 2011

bull Requires once daily dosing unlike other long-acting

bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea

bull Recommended dose is one capsule (75mcg) per day

Devices used in COPDbull Inhalers

bull Small handheld devices that

deliver a puff of medicine into the airways

bull Metered-dose inhalers (MDIs)

bull Dry powder inhalers (DPIs) or

breath activated inhalers

bull Inhalers with spacer devices

Metered-dose Inhalersbull Contains a liquid

medication delivered as an aerosol spray

bull Quick to use small and convenient to carry

bull Needs good co-ordination to press the canister and breathe in fully at the same time

Breath-activated inhalersor DPI

bull It releases a puff of drypowder instead of aliquid mist

bull Require less co-ordination than thestandard MDI

bull Slightly bigger than thestandard MDI

bull Example Rotahaler

Inhalers with spacer devices

bull Spacer devices are used with pressurised MDIs

bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed

Nebulizers

bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol

bull Useful in people whoare very breathless egIn severe attack ofCOPD

bull They are not portable

Nanda Nursing Diagnosis for COPD

1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection

2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants

3 Impaired gas exchange related to ventilation perfusion inequality

4 Activity intolerance related to imbalance between oxygen supply with demand

5 Imbalanced Nutrition less than body requirements related to anorexia

Combination Anticholinergics amp 2-agonists

bull Combining bronchodilators with different MOA allows reduced doses to be administored reducing side effects

bull Albuterol and Ipratropium available as an MDI Combiventreg

Methylxanthines

bull Produce bronchodilation by

bull Inhibition of PDE increasing cAMP levels

bull Inhibition of calcium ion influx intosmooth muscle

bull Prostaglandin antagonism

bull Stimulation of endogenouscatecholamines

bull Inhibition of release of mediators frommast cells and leukocytes

MOA

bull 8-12 mcgmlTherapeutic

Serum Levels

Methylxanthines

bull Minor side effects

ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia

bull Serious toxic effects

ndash arrhythmias and seizures

bull Considered in patients who donot respond well to bronchodilators

Corticosteroids

bull Mechanism of Action

ndash Reduction in capillary permeability to decrease mucus

ndash Inhibition of release of proteolytic enzymes from leukocytes

ndash Inhibition of prostaglandins

bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone

bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone

Corticosteroids

bull Inhaled CS

ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy

bull Systemic CS

ndashShort term use for acute exacerbations

ndashNot used in chronic management because of high risk of toxicity

Combination ICS amp Bronchodilators

bull Effective in reducing the rate of COPD exacerbations

bull Reduces the number of total inhalations needed more patient compliance

bull Available combination

ndash Beclomethasone with salbutamol (Clenil Compositumreg)

ndash Budesonide with formeterol

ndash Fluticasone with salmeterol

AAT Replacement Therapy

bull Considered for patients with AAT deficiency

bull Life time treatment

bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma

bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week

Indacaterol

bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist

bull Approved by FDA on July 1 2011

bull Requires once daily dosing unlike other long-acting

bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea

bull Recommended dose is one capsule (75mcg) per day

Devices used in COPDbull Inhalers

bull Small handheld devices that

deliver a puff of medicine into the airways

bull Metered-dose inhalers (MDIs)

bull Dry powder inhalers (DPIs) or

breath activated inhalers

bull Inhalers with spacer devices

Metered-dose Inhalersbull Contains a liquid

medication delivered as an aerosol spray

bull Quick to use small and convenient to carry

bull Needs good co-ordination to press the canister and breathe in fully at the same time

Breath-activated inhalersor DPI

bull It releases a puff of drypowder instead of aliquid mist

bull Require less co-ordination than thestandard MDI

bull Slightly bigger than thestandard MDI

bull Example Rotahaler

Inhalers with spacer devices

bull Spacer devices are used with pressurised MDIs

bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed

Nebulizers

bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol

bull Useful in people whoare very breathless egIn severe attack ofCOPD

bull They are not portable

Nanda Nursing Diagnosis for COPD

1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection

2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants

3 Impaired gas exchange related to ventilation perfusion inequality

4 Activity intolerance related to imbalance between oxygen supply with demand

5 Imbalanced Nutrition less than body requirements related to anorexia

Methylxanthines

bull Produce bronchodilation by

bull Inhibition of PDE increasing cAMP levels

bull Inhibition of calcium ion influx intosmooth muscle

bull Prostaglandin antagonism

bull Stimulation of endogenouscatecholamines

bull Inhibition of release of mediators frommast cells and leukocytes

MOA

bull 8-12 mcgmlTherapeutic

Serum Levels

Methylxanthines

bull Minor side effects

ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia

bull Serious toxic effects

ndash arrhythmias and seizures

bull Considered in patients who donot respond well to bronchodilators

Corticosteroids

bull Mechanism of Action

ndash Reduction in capillary permeability to decrease mucus

ndash Inhibition of release of proteolytic enzymes from leukocytes

ndash Inhibition of prostaglandins

bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone

bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone

Corticosteroids

bull Inhaled CS

ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy

bull Systemic CS

ndashShort term use for acute exacerbations

ndashNot used in chronic management because of high risk of toxicity

Combination ICS amp Bronchodilators

bull Effective in reducing the rate of COPD exacerbations

bull Reduces the number of total inhalations needed more patient compliance

bull Available combination

ndash Beclomethasone with salbutamol (Clenil Compositumreg)

ndash Budesonide with formeterol

ndash Fluticasone with salmeterol

AAT Replacement Therapy

bull Considered for patients with AAT deficiency

bull Life time treatment

bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma

bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week

Indacaterol

bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist

bull Approved by FDA on July 1 2011

bull Requires once daily dosing unlike other long-acting

bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea

bull Recommended dose is one capsule (75mcg) per day

Devices used in COPDbull Inhalers

bull Small handheld devices that

deliver a puff of medicine into the airways

bull Metered-dose inhalers (MDIs)

bull Dry powder inhalers (DPIs) or

breath activated inhalers

bull Inhalers with spacer devices

Metered-dose Inhalersbull Contains a liquid

medication delivered as an aerosol spray

bull Quick to use small and convenient to carry

bull Needs good co-ordination to press the canister and breathe in fully at the same time

Breath-activated inhalersor DPI

bull It releases a puff of drypowder instead of aliquid mist

bull Require less co-ordination than thestandard MDI

bull Slightly bigger than thestandard MDI

bull Example Rotahaler

Inhalers with spacer devices

bull Spacer devices are used with pressurised MDIs

bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed

Nebulizers

bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol

bull Useful in people whoare very breathless egIn severe attack ofCOPD

bull They are not portable

Nanda Nursing Diagnosis for COPD

1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection

2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants

3 Impaired gas exchange related to ventilation perfusion inequality

4 Activity intolerance related to imbalance between oxygen supply with demand

5 Imbalanced Nutrition less than body requirements related to anorexia

Methylxanthines

bull Minor side effects

ndash dyspepsia nausea vomiting diarrhea headache dizziness tachycardia

bull Serious toxic effects

ndash arrhythmias and seizures

bull Considered in patients who donot respond well to bronchodilators

Corticosteroids

bull Mechanism of Action

ndash Reduction in capillary permeability to decrease mucus

ndash Inhibition of release of proteolytic enzymes from leukocytes

ndash Inhibition of prostaglandins

bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone

bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone

Corticosteroids

bull Inhaled CS

ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy

bull Systemic CS

ndashShort term use for acute exacerbations

ndashNot used in chronic management because of high risk of toxicity

Combination ICS amp Bronchodilators

bull Effective in reducing the rate of COPD exacerbations

bull Reduces the number of total inhalations needed more patient compliance

bull Available combination

ndash Beclomethasone with salbutamol (Clenil Compositumreg)

ndash Budesonide with formeterol

ndash Fluticasone with salmeterol

AAT Replacement Therapy

bull Considered for patients with AAT deficiency

bull Life time treatment

bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma

bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week

Indacaterol

bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist

bull Approved by FDA on July 1 2011

bull Requires once daily dosing unlike other long-acting

bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea

bull Recommended dose is one capsule (75mcg) per day

Devices used in COPDbull Inhalers

bull Small handheld devices that

deliver a puff of medicine into the airways

bull Metered-dose inhalers (MDIs)

bull Dry powder inhalers (DPIs) or

breath activated inhalers

bull Inhalers with spacer devices

Metered-dose Inhalersbull Contains a liquid

medication delivered as an aerosol spray

bull Quick to use small and convenient to carry

bull Needs good co-ordination to press the canister and breathe in fully at the same time

Breath-activated inhalersor DPI

bull It releases a puff of drypowder instead of aliquid mist

bull Require less co-ordination than thestandard MDI

bull Slightly bigger than thestandard MDI

bull Example Rotahaler

Inhalers with spacer devices

bull Spacer devices are used with pressurised MDIs

bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed

Nebulizers

bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol

bull Useful in people whoare very breathless egIn severe attack ofCOPD

bull They are not portable

Nanda Nursing Diagnosis for COPD

1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection

2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants

3 Impaired gas exchange related to ventilation perfusion inequality

4 Activity intolerance related to imbalance between oxygen supply with demand

5 Imbalanced Nutrition less than body requirements related to anorexia

Corticosteroids

bull Mechanism of Action

ndash Reduction in capillary permeability to decrease mucus

ndash Inhibition of release of proteolytic enzymes from leukocytes

ndash Inhibition of prostaglandins

bull ICS Beclomethasone (Bekson Clenil-A Clenil Forte Rinoclenil) flunisolide budesonide fluticasone mometasone

bull Systemic CS Prednisolone (Deltacortil) Methylprednisolone Prednisone

Corticosteroids

bull Inhaled CS

ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy

bull Systemic CS

ndashShort term use for acute exacerbations

ndashNot used in chronic management because of high risk of toxicity

Combination ICS amp Bronchodilators

bull Effective in reducing the rate of COPD exacerbations

bull Reduces the number of total inhalations needed more patient compliance

bull Available combination

ndash Beclomethasone with salbutamol (Clenil Compositumreg)

ndash Budesonide with formeterol

ndash Fluticasone with salmeterol

AAT Replacement Therapy

bull Considered for patients with AAT deficiency

bull Life time treatment

bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma

bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week

Indacaterol

bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist

bull Approved by FDA on July 1 2011

bull Requires once daily dosing unlike other long-acting

bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea

bull Recommended dose is one capsule (75mcg) per day

Devices used in COPDbull Inhalers

bull Small handheld devices that

deliver a puff of medicine into the airways

bull Metered-dose inhalers (MDIs)

bull Dry powder inhalers (DPIs) or

breath activated inhalers

bull Inhalers with spacer devices

Metered-dose Inhalersbull Contains a liquid

medication delivered as an aerosol spray

bull Quick to use small and convenient to carry

bull Needs good co-ordination to press the canister and breathe in fully at the same time

Breath-activated inhalersor DPI

bull It releases a puff of drypowder instead of aliquid mist

bull Require less co-ordination than thestandard MDI

bull Slightly bigger than thestandard MDI

bull Example Rotahaler

Inhalers with spacer devices

bull Spacer devices are used with pressurised MDIs

bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed

Nebulizers

bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol

bull Useful in people whoare very breathless egIn severe attack ofCOPD

bull They are not portable

Nanda Nursing Diagnosis for COPD

1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection

2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants

3 Impaired gas exchange related to ventilation perfusion inequality

4 Activity intolerance related to imbalance between oxygen supply with demand

5 Imbalanced Nutrition less than body requirements related to anorexia

Corticosteroids

bull Inhaled CS

ndashConsidered for symptomatic stage III or IV disease who experience repeated exacerbation despite bronchodilator therapy

bull Systemic CS

ndashShort term use for acute exacerbations

ndashNot used in chronic management because of high risk of toxicity

Combination ICS amp Bronchodilators

bull Effective in reducing the rate of COPD exacerbations

bull Reduces the number of total inhalations needed more patient compliance

bull Available combination

ndash Beclomethasone with salbutamol (Clenil Compositumreg)

ndash Budesonide with formeterol

ndash Fluticasone with salmeterol

AAT Replacement Therapy

bull Considered for patients with AAT deficiency

bull Life time treatment

bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma

bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week

Indacaterol

bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist

bull Approved by FDA on July 1 2011

bull Requires once daily dosing unlike other long-acting

bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea

bull Recommended dose is one capsule (75mcg) per day

Devices used in COPDbull Inhalers

bull Small handheld devices that

deliver a puff of medicine into the airways

bull Metered-dose inhalers (MDIs)

bull Dry powder inhalers (DPIs) or

breath activated inhalers

bull Inhalers with spacer devices

Metered-dose Inhalersbull Contains a liquid

medication delivered as an aerosol spray

bull Quick to use small and convenient to carry

bull Needs good co-ordination to press the canister and breathe in fully at the same time

Breath-activated inhalersor DPI

bull It releases a puff of drypowder instead of aliquid mist

bull Require less co-ordination than thestandard MDI

bull Slightly bigger than thestandard MDI

bull Example Rotahaler

Inhalers with spacer devices

bull Spacer devices are used with pressurised MDIs

bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed

Nebulizers

bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol

bull Useful in people whoare very breathless egIn severe attack ofCOPD

bull They are not portable

Nanda Nursing Diagnosis for COPD

1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection

2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants

3 Impaired gas exchange related to ventilation perfusion inequality

4 Activity intolerance related to imbalance between oxygen supply with demand

5 Imbalanced Nutrition less than body requirements related to anorexia

Combination ICS amp Bronchodilators

bull Effective in reducing the rate of COPD exacerbations

bull Reduces the number of total inhalations needed more patient compliance

bull Available combination

ndash Beclomethasone with salbutamol (Clenil Compositumreg)

ndash Budesonide with formeterol

ndash Fluticasone with salmeterol

AAT Replacement Therapy

bull Considered for patients with AAT deficiency

bull Life time treatment

bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma

bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week

Indacaterol

bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist

bull Approved by FDA on July 1 2011

bull Requires once daily dosing unlike other long-acting

bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea

bull Recommended dose is one capsule (75mcg) per day

Devices used in COPDbull Inhalers

bull Small handheld devices that

deliver a puff of medicine into the airways

bull Metered-dose inhalers (MDIs)

bull Dry powder inhalers (DPIs) or

breath activated inhalers

bull Inhalers with spacer devices

Metered-dose Inhalersbull Contains a liquid

medication delivered as an aerosol spray

bull Quick to use small and convenient to carry

bull Needs good co-ordination to press the canister and breathe in fully at the same time

Breath-activated inhalersor DPI

bull It releases a puff of drypowder instead of aliquid mist

bull Require less co-ordination than thestandard MDI

bull Slightly bigger than thestandard MDI

bull Example Rotahaler

Inhalers with spacer devices

bull Spacer devices are used with pressurised MDIs

bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed

Nebulizers

bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol

bull Useful in people whoare very breathless egIn severe attack ofCOPD

bull They are not portable

Nanda Nursing Diagnosis for COPD

1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection

2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants

3 Impaired gas exchange related to ventilation perfusion inequality

4 Activity intolerance related to imbalance between oxygen supply with demand

5 Imbalanced Nutrition less than body requirements related to anorexia

AAT Replacement Therapy

bull Considered for patients with AAT deficiency

bull Life time treatment

bull Therapy consists of giving a concentrated form of AAT derivedfrom human plasma

bull The recommended dosing regimen for replacing AAT is 60mgkg administered IV once a week

Indacaterol

bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist

bull Approved by FDA on July 1 2011

bull Requires once daily dosing unlike other long-acting

bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea

bull Recommended dose is one capsule (75mcg) per day

Devices used in COPDbull Inhalers

bull Small handheld devices that

deliver a puff of medicine into the airways

bull Metered-dose inhalers (MDIs)

bull Dry powder inhalers (DPIs) or

breath activated inhalers

bull Inhalers with spacer devices

Metered-dose Inhalersbull Contains a liquid

medication delivered as an aerosol spray

bull Quick to use small and convenient to carry

bull Needs good co-ordination to press the canister and breathe in fully at the same time

Breath-activated inhalersor DPI

bull It releases a puff of drypowder instead of aliquid mist

bull Require less co-ordination than thestandard MDI

bull Slightly bigger than thestandard MDI

bull Example Rotahaler

Inhalers with spacer devices

bull Spacer devices are used with pressurised MDIs

bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed

Nebulizers

bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol

bull Useful in people whoare very breathless egIn severe attack ofCOPD

bull They are not portable

Nanda Nursing Diagnosis for COPD

1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection

2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants

3 Impaired gas exchange related to ventilation perfusion inequality

4 Activity intolerance related to imbalance between oxygen supply with demand

5 Imbalanced Nutrition less than body requirements related to anorexia

Indacaterol

bull Indacaterol is an ultra-long-acting beta-adrenoceptor agonist

bull Approved by FDA on July 1 2011

bull Requires once daily dosing unlike other long-acting

bull In clinical trials the most common adverse events were runny nose cough sore throat headache and nausea

bull Recommended dose is one capsule (75mcg) per day

Devices used in COPDbull Inhalers

bull Small handheld devices that

deliver a puff of medicine into the airways

bull Metered-dose inhalers (MDIs)

bull Dry powder inhalers (DPIs) or

breath activated inhalers

bull Inhalers with spacer devices

Metered-dose Inhalersbull Contains a liquid

medication delivered as an aerosol spray

bull Quick to use small and convenient to carry

bull Needs good co-ordination to press the canister and breathe in fully at the same time

Breath-activated inhalersor DPI

bull It releases a puff of drypowder instead of aliquid mist

bull Require less co-ordination than thestandard MDI

bull Slightly bigger than thestandard MDI

bull Example Rotahaler

Inhalers with spacer devices

bull Spacer devices are used with pressurised MDIs

bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed

Nebulizers

bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol

bull Useful in people whoare very breathless egIn severe attack ofCOPD

bull They are not portable

Nanda Nursing Diagnosis for COPD

1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection

2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants

3 Impaired gas exchange related to ventilation perfusion inequality

4 Activity intolerance related to imbalance between oxygen supply with demand

5 Imbalanced Nutrition less than body requirements related to anorexia

Devices used in COPDbull Inhalers

bull Small handheld devices that

deliver a puff of medicine into the airways

bull Metered-dose inhalers (MDIs)

bull Dry powder inhalers (DPIs) or

breath activated inhalers

bull Inhalers with spacer devices

Metered-dose Inhalersbull Contains a liquid

medication delivered as an aerosol spray

bull Quick to use small and convenient to carry

bull Needs good co-ordination to press the canister and breathe in fully at the same time

Breath-activated inhalersor DPI

bull It releases a puff of drypowder instead of aliquid mist

bull Require less co-ordination than thestandard MDI

bull Slightly bigger than thestandard MDI

bull Example Rotahaler

Inhalers with spacer devices

bull Spacer devices are used with pressurised MDIs

bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed

Nebulizers

bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol

bull Useful in people whoare very breathless egIn severe attack ofCOPD

bull They are not portable

Nanda Nursing Diagnosis for COPD

1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection

2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants

3 Impaired gas exchange related to ventilation perfusion inequality

4 Activity intolerance related to imbalance between oxygen supply with demand

5 Imbalanced Nutrition less than body requirements related to anorexia

Metered-dose Inhalersbull Contains a liquid

medication delivered as an aerosol spray

bull Quick to use small and convenient to carry

bull Needs good co-ordination to press the canister and breathe in fully at the same time

Breath-activated inhalersor DPI

bull It releases a puff of drypowder instead of aliquid mist

bull Require less co-ordination than thestandard MDI

bull Slightly bigger than thestandard MDI

bull Example Rotahaler

Inhalers with spacer devices

bull Spacer devices are used with pressurised MDIs

bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed

Nebulizers

bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol

bull Useful in people whoare very breathless egIn severe attack ofCOPD

bull They are not portable

Nanda Nursing Diagnosis for COPD

1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection

2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants

3 Impaired gas exchange related to ventilation perfusion inequality

4 Activity intolerance related to imbalance between oxygen supply with demand

5 Imbalanced Nutrition less than body requirements related to anorexia

Breath-activated inhalersor DPI

bull It releases a puff of drypowder instead of aliquid mist

bull Require less co-ordination than thestandard MDI

bull Slightly bigger than thestandard MDI

bull Example Rotahaler

Inhalers with spacer devices

bull Spacer devices are used with pressurised MDIs

bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed

Nebulizers

bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol

bull Useful in people whoare very breathless egIn severe attack ofCOPD

bull They are not portable

Nanda Nursing Diagnosis for COPD

1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection

2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants

3 Impaired gas exchange related to ventilation perfusion inequality

4 Activity intolerance related to imbalance between oxygen supply with demand

5 Imbalanced Nutrition less than body requirements related to anorexia

Inhalers with spacer devices

bull Spacer devices are used with pressurised MDIs

bull The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed

Nebulizers

bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol

bull Useful in people whoare very breathless egIn severe attack ofCOPD

bull They are not portable

Nanda Nursing Diagnosis for COPD

1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection

2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants

3 Impaired gas exchange related to ventilation perfusion inequality

4 Activity intolerance related to imbalance between oxygen supply with demand

5 Imbalanced Nutrition less than body requirements related to anorexia

Nebulizers

bull Nebulisers aremachines that turn theliquid medicines into afine mist like anaerosol

bull Useful in people whoare very breathless egIn severe attack ofCOPD

bull They are not portable

Nanda Nursing Diagnosis for COPD

1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection

2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants

3 Impaired gas exchange related to ventilation perfusion inequality

4 Activity intolerance related to imbalance between oxygen supply with demand

5 Imbalanced Nutrition less than body requirements related to anorexia

Nanda Nursing Diagnosis for COPD

1 Ineffective airway clearance related to bronchoconstriction increased sputum production ineffective cough fatigue lack of energy broncho pulmonary infection

2 Ineffective breathing pattern related to shortness of breath mucus bronchoconstriction airway irritants

3 Impaired gas exchange related to ventilation perfusion inequality

4 Activity intolerance related to imbalance between oxygen supply with demand

5 Imbalanced Nutrition less than body requirements related to anorexia

6 Disturbed sleep pattern related to discomfort sleeping position

7 (Bathing Hygiene) Self-care deficit related to fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency

8 Anxiety related to threat to self-concept threat of death purposes that are not being met

9 Ineffective individual coping related to lack of socialization anxietydepression low activity levels and an inability to work

10 Deficient Knowledge related to lack of information do not know the source of information

bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD

In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status

bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest

bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study

Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3

Author information

bull BACKGROUND

Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established

bull CONCLUSION

Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease

bull Frequent sputum production is associated with disturbed nights rest and impaired sleep quality in patients withCOPD

In this study we measured nights rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD Furthermore our aim was to investigate the association between nights rest parameters and clinical variables and the association between sleep quality and quality of life or health status

bull find an association between frequent sputum production and disturbances during nights rest and sleep quality Future studies should investigate whether the treatment of mucus hypersecretion leads to improved nights rest

bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study

Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3

Author information

bull BACKGROUND

Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established

bull CONCLUSION

Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease

bull Pneumonia in Childhood and Impaired Lung Function in Adults A Longitudinal Study

Chan JY1 Stern DA2 Guerra S2 Wright AL2 Morgan WJ2 Martinez FD3

Author information

bull BACKGROUND

Diminished lung function and increased prevalence of asthma have been reported in children with a history of early lower respiratory illnesses (LRIs) including pneumonia Whether these associations persist up to adulthood has not been established

bull CONCLUSION

Early pneumonia is associated with asthma and impaired airway function which is partially reversible with bronchodilators and persists into adulthood Early pneumonia may be a major risk factor for adult chronic obstructive pulmonary disease

References

bull BMJ Best Practices

bull American Thoracic Society COPD guidelines

bull The Washingtonrsquos manual of medical therapeutics

bull Pharmacotherapy A pathophysiologic approach Joseph T DiPiro

bull Respiratory care pharmacology Rau Joseph