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Chronic Obstructive Pulmonary Disease (COPD)

Chronic obstructive pulmonary disease (COPD) is a progressive condition that affects a

person’s ability to breathe well. It encompasses several medical conditions,
including emphysema and chronic bronchitis.

In addition to a reduced ability to breathe in and out fully, symptoms can include a chronic
cough and increased sputum production.

Signs and symptoms of end-stage COPD

End-stage COPD is marked by severe shortness of breath (dyspnea), even when at rest. At
this stage, medications typically don’t work as well as they had in the past. Everyday tasks will
leave you more breathless.

End-stage COPD also means increased visits to the emergency department or

hospitalizations for breathing complications, lung infections, or respiratory failure.

Pulmonary hypertension is also common in end-stage COPD, which can lead to right-
sided heart failure. You may experience an accelerated resting heart rate (tachycardia) of more
than 100 beats per minute. Another symptom of end-stage COPD is ongoing weight loss.

Living with end-stage COPD

If you smoke tobacco products, quitting is one of the best things you can do at any stage of
COPD.

Your doctor can prescribe medications to treat COPD that may also relieve your symptoms.
These include bronchodilators, which help to widen your airways.
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There are two types of bronchodilators. The short-acting (rescue) bronchodilator is used
for the sudden onset of shortness of breath. The long-acting bronchodilator can be used every day
to help control symptoms.

Glucocorticosteroids may help reduce inflammation. These medications can be delivered

to your airways and lungs with an inhaler or a nebulizer. A glucocorticosteroid is commonly given
in combination with a long-acting bronchodilator for treatment of COPD.

An inhaler is a pocket-sized portable device, while a nebulizer is larger and meant primarily
for home use. While an inhaler is easier to carry around with you, it’s sometimes harder to use
correctly.

If you have a difficult time using an inhaler, adding a spacer can help. A spacer is a small
plastic tube that attaches to your inhaler.

Spraying your inhaler medication into the spacer allows for the medication to mist and fill
the spacer prior to breathing it in. A spacer may help more medicine to get into your lungs and less
to be trapped on the back of your throat.

A nebulizer is a machine that turns a liquid medicine into a continuous mist that you inhale
for around 5 to 10 minutes at a time through a mask or mouthpiece connected by tube to the
machine.

Supplemental oxygen is typically needed if you have end-stage COPD (stage 4).

The use of any of these treatments is likely to increase significantly from stage 1 (mild
COPD) to stage 4.

Diet and exercise

You may also benefit from exercise training programs. Therapists for these programs can teach
you breathing techniques that reduce how hard you have to work to breathe. This step can help
enhance your quality of life.
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You may be encouraged to eat small, high-protein meals at each sitting, such as protein shakes.
A high-protein diet can improve your well-being and prevent excess weight loss.

 6-min walk
 Sit-stand

Prepare for the weather

In addition to taking these steps, you should avoid or minimize known COPD triggers. For
example, you may have greater difficulty breathing during extreme weather conditions, such as
high heat and humidity or cold, dry temperatures.

Although you can’t change the weather, you can be prepared by limiting the time you spend
outdoors during temperature extremes. Other steps you can take include the following:

 Always keeping an emergency inhaler with you but not in your car. Many inhalers operate most
effectively when kept at room temperature.

 Wearing a scarf or mask when going outside in cold temperatures can help warm the air you
breathe in.

 Avoid going outdoors on days when the air quality is poor and smog and pollution levels are
high.

Palliative care

Palliative care or hospice care can greatly enhance your life when you’re living with end-
stage COPD. A common misconception about palliative care is that it’s for someone who will be
passing away soon. This isn’t always the case.

Instead, palliative care involves identifying treatments that can enhance your quality of life
and help caregivers provide you with more effective care. The main goal of palliative and hospice
care is to ease your pain and control your symptoms as much as possible.
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You’ll work with a team of doctors and nurses in planning your treatment goals and caring
for your physical and emotional health as much as possible.

Stages (or grades) of COPD

COPD has four stages, and your airflow becomes more limited with each passing stage.

Various organizations may define each stage differently. However, most of their
classifications are based in part on a lung function test known as the FEV1 test. This is the forced
expiratory volume of air from your lungs in one second.

The result of this test is expressed as a percentage and measures how much air you can let
out during the first second of a forced breath. It’s compared to what is expected from healthy lungs
of similar age.

According to the Lung Institute, the criteria for each COPD grade (stage) are as follows:

Grade Name FEV1 (%)

1 mild COPD ≥ 80

2 moderate COPD 50 to 79

3 severe COPD 30 to 49

4 very severe COPD or end-stage COPD < 30

The lower grades may or may not be accompanied by chronic symptoms, such as excess
sputum, noticeable shortness of breath with exertion, and chronic cough. These symptoms tend to
be more prevalent as COPD severity increases.

In addition, new Global Initiative for Chronic Obstructive Lung Disease

(GOLD) guidelines further categorize people with COPD into groups labelled A, B, C, or D.
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The groups are defined by the seriousness of problems such as dyspnea, fatigue, and
interference with daily living, as well as acute exacerbations.

Exacerbations are periods when symptoms get noticeably worse. Exacerbation symptoms
can include a worsening cough, increased yellow or green mucus production, more wheezing, and
lower oxygen levels in the bloodstream.

Groups A and B include people who’ve had no exacerbations in the past year or only a
minor one that didn’t require hospitalization. Minimal to mild dyspnea and other symptoms would
put you in Group A, while more serious dyspnea and symptoms would place you in Group B.

Groups C and D indicate that you’ve either had at least one exacerbation that required
hospital admission in the past year or at least two exacerbations that did or didn’t require
hospitalization.

Milder breathing difficulty and symptoms put you in Group C, while having more
breathing troubles means a Group D designation.

People with a stage 4, Group D label have the most serious outlook.

Treatments can’t reverse damage that’s already been done, but they can be used to try to
slow

Outlook

In end-stage COPD, you’ll likely need supplemental oxygen to breathe, and you may not
be able to complete activities of daily living without becoming very winded and tired. Sudden
worsening of COPD at this stage can be life-threatening.

While determining the stage and grade of COPD will help your doctor choose the right
treatments for you, these aren’t the only factors that affect your outlook. Your doctor will also take
into account the following:
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Weight

Although being overweight can make breathing more difficult if you have COPD, people
with end-stage COPD are often underweight. This is partly because even the act of eating can
cause you to become too winded.

Additionally, at this stage, your body uses up a lot of energy just to keep up with breathing.
This can result in extreme weight loss that affects your overall health.

Shortness of breath with activity

This is the degree to which you get short of breath when walking or other physical
activities. It can help determine the severity of your COPD.

Distance walked in six minutes

The farther you can walk in six minutes, the better outcome you will likely have with
COPD.

Age

With age, COPD will progress in severity, and the outlook tends to become poorer with
passing years, especially in seniors.

Proximity to air pollution

Exposure to air pollution and second-hand tobacco smoke can further damage your lungs
and airways.
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Smoking can also affect outlook. According to a 2009 study that looked at 65-year-old
Caucasian males, smoking reduced life expectancy for those with end-stage COPD by almost 6
years.

Frequency of doctor’s visits

Your prognosis is likely to be better if you adhere to your recommended medical therapy,
follow through with all of your scheduled doctor’s visits, and keep your doctor up to date on any
changes in your symptoms or condition. You should make monitoring your lung symptoms and
function a top priority.
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Coping with COPD

Dealing with COPD can be challenging enough without feeling lonely and scared about
this disease. Even if your caregiver and the people closest to you are supportive and encouraging,
you may still benefit from spending time with others who have COPD.

Hearing from someone going through the same situation may be helpful. They might be
able to provide some valuable insight, such as feedback about various medications you’re using
and what to expect.

Maintaining your quality of life is very important at this stage. There are lifestyle steps you
can take, such as checking air quality and practicing breathing exercises. However, when your
COPD has progressed in severity, you may benefit from additional palliative or hospice care.

COPD and Heart Failure

COPD and congestive heart failure are two different conditions that may present with
similar symptoms. However, there are two other forms of heart failure, left-sided and right-sided,
which may be directly related to or exacerbated by the presence of COPD. Here’s how:

COPD and Left-Sided Heart Failure

There is not a direct connection between COPD and left-sided heart failure. However, the
two conditions can exist together and exacerbate one another. COPD can cause low oxygen levels
in the blood, thereby placing additional stress on the heart and worsening symptoms of left-sided
heart failure. On the other hand, left-sided heart failure can contribute to fluid buildup in the lungs,
aggravating the symptoms of COPD.

COPD and Right-Sided Heart Failure

In severe cases of COPD, the condition can actually cause the development of right-sided
heart failure. This occurs when low oxygen levels due to COPD cause a rise in blood pressure in
the arteries of the lungs, a condition known as pulmonary hypertension. This increase in pressure
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places excess strain on the heart’s right ventricle as it works to pump blood through the lungs. As
a result, the heart muscle weakens and right-sided heart failure can occur.

COPD and heart failure are both dangerous health conditions, and while they often occur
independently, it is also important to understand the connections between the two. If you have
previously been diagnosed with COPD, you should be aware of the increased risk of heart
failure. And, if you are a smoker, you need to understand that you are at a higher risk for
developing both of these diseases. In any case, the medical expertise of a cardiologist should be
sought in order to monitor existing conditions and help ensure heart health.
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Case Study of Patient with

Chronic Obstructive Pulmonary disease (COPD)

Information:

Patient X is a 74 year old man who presents to your family medicine office with his wife
complaining of shortness of breath and fever. They just moved to the area and had been planning
to come to your office next week to establish care as new patients. Due to the onset of symptoms,
JS called and was given a walk-in slot today. His wife did bring records from his last physician’s
office.

Past Medical/Surgical History

 Heart failure following myocardial infarction at age 68 years

 COPD (on 2 L home oxygen)
 Hypertension
 Appendectomy

Family History

 Father died of myocardial infarction at age 59 years (diabetes, hypertension, smoker)

 Mother alive (atrial fibrillation, heart failure)
 Healthy siblings

Social History

 Married, 3 children
 30 pack year smoking history (quit after MI)
 Worked on a farm
 No alcohol or illicit drug use

Medications / Allergies

 Lisinopril 20 mg twice daily

 Metoprolol 50 mg twice daily
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 Spironolactone 25 mg daily
 Furosemide 40 mg daily
 Salmeterol/fluticasone 50/500 dry powdered inhaler (DPI) one puff inhaled twice daily
 Tiotropium DPI one cap inhaled daily
 Albuterol/ipratropium metered dose inhaler (MDI) or solution for nebulization every 6
hours as needed
 Levalbuterol MDI two puffs every 4 to 6 hours as needed
 Home oxygen
 He is confused about what to use when, so you are not sure which medications he actually
takes.
 No known allergies
 JS Past Record Review (brought by wife)
o Echocardiogram with EF of 25%
o Spirometry with FEV1 35% predicted that does not change significantly after
inhaled bronchodilator

Patient’s symptoms include the following:

 Unable to speak in full sentences for the past several hours per wife
 Cough productive but unknown color of sputum
 Audible wheezing since last night per wife
 Mild chest tightness
 Dyspnea
 His wife has noted no change in his alertness or mental status
 When you inquire, the wife states that JS usually has a cough, worse in the morning,
productive of gray sputum, gets short of breath if he walks more then 10 feet, and has
episodes of wheezing if he gets sick (e.g. with an upper respiratory infection).
 He usually is able to help around the house with light work and fixing things.

Physical Examination

 Vital Signs: BP 128/74; P 68, reg; RR 32; Ht 5ft 6 in; Wt 122 lbs; T 101.5 °F oral
 Unable to speak in full sentences, audible wheezing, alert and oriented
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 Pertinent positives:
 General: audible wheezing, no accessory muscle use
 Nails: tar stains, clubbing
 Chest: increased anteroposterior (AP) diameter; diffuse wheezing to auscultation
 Heart: regular, no murmurs

Study Results

 Pulse oximetry 86%

 Chest x-ray shows hyperinflation and right lower lobe pneumonia
 You continue his heart failure medications as per his home regimen
 No need to discontinue the cardioselective beta-blocker
 ABG Normal Range Other bloods Normal Range
o PH 7.236 7.35-7.45 Digoxin Level 0.5 1.0-2.0 nmol/L
o PO2 4.7 11-15 kPa
o PCO2 8 4.6-6 kPa
o HCO3 30.0 22-26
o BE +5 -2.4-+2.3
o SaO2 70 95-98%
o Glucose 10.0 3.7-5.2

Factors that increase the risk if severe COPD exacerbation

 Altered mental status

 At least three exacerbations in the previous 12 months
 Body mass index of 20 kg per m2 or less
 Marked increase in symptoms or change in vital signs
 Medical comorbidities (especially cardiac ischemia, heart failure, pneumonia, diabetes
mellitus, or renal or hepatic failure)
 Poor physical activity levels
 Poor social support
 Severe baseline COPD (FEV1/FVC ratio less than 0.70 and FEV1 less than 50 percent of
predicted)
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 Underutilization of home oxygen therapy

Indications for hospitalization

 Risk of death from an exacerbation increases with:

o Development of respiratory acidosis
o Presence of significant comorbidities,
o Need for ventilatory support

History of Exacerbation

 Upon questioning his wife, you find out that he has had 5 exacerbations in the past year,
three of which were treated with antibiotics and oral steroids
 Amoxicillin x2 courses, doxycycline x1 course
 Most recent course 6 weeks ago
 No hospitalizations within the last 6 months
 Based on this information, and his chest x-ray findings, you initiate treatment for
community acquired pneumonia.

Preparation for discharge

 Over 3 days, JS has significantly improved and has weaned back to his home oxygen
regimen.
 He is taking the albuterol/ipratropium nebulized treatments every 6 hours, and is ready to
switch back to bronchodilators via inhaler device.
 Along with antibiotics for a total of 7 days, you need to determine the dose and duration of
treatment for oral corticosteroids.

Discharge Medication

 Streamline regimen
 No need for levalbuterol
 Continue salmeterol/fluticasone 50/500 DPI and/or tiotropium DPI
 Short-acting bronchodilator MDI as needed
 Patient given pneumococcal vaccine prior to discharge
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Nursing Management

 he nurse plays a key role in identifying potential candidates for pulmonary rehabilitation
and in facilitating and reinforcing the material learned in the rehabilitation program

PATIENT EDUCATION

 Breathing Exercises
 Inspiratory Muscle Trainin
 Activity Pacing
 Self-Care Activities
 Physical Conditioning.
o Oxygen Therapy
o Nutritional Therapy
o Coping Measures.
 Achieving Airway Clearance
 Monitor the patient for dyspnea and hypoxemia.
 If bronchodilators or corticosteroids are prescribed, administer the medications properly
and be alert for potential side effects.
 Confirm relief of bronchospasm by measuring improvement in expiratory flow rates and
volumes (the force of expiration, how long it takes to exhale, and the amount of air exhaled)
as well as by assessing the dyspnea and making sure that it has lessened.
 Encourage patient to eliminate or reduce all pulmonary irritants, particularly cigarette
smoking.
 Instruct the patient in directed or controlled coughing.
 Chest physiotherapy with postural drainage, intermittent positive-pressure breathing,
increased fluid intake, and bland aerosol mists (with normal saline solution or water) may
be useful for some patients with COPD.
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Monitoring and Managing Complications

 Assess patient for complications (respiratory insufficiency and failure, respiratory

infection, and atelectasis).
 Monitor for cognitive changes, increasing dyspnea, tachypnea, and tachycardia.
 Monitor pulse oximeter values and administer oxygen as prescribed.
 Instruct patient and family about signs and symptoms of infection or other complications
and to report changes in physical or cognitive status.
 Encourage patient to be immunized against influenza and Streptococcus pneumonia
 Caution patient to avoid going outdoors if the pollen count is high or if there is significant
air pollution and to avoid exposure to high outdoor temperatures with high humidity.
 If a rapid onset of shortness of breath occurs, quickly evaluate the patient for potential
pneumothorax by assessing the symmetry of chest movement, differences in breath sounds,
and pulse oximeter.