Chronic Obstructive Disease; types, impairments and managment

MANAGEMENT OF PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Chronic obstructive pulmonary disease is a broad term encompassing a number of chronic pulmonary conditions, all of which obstruct the flow of air in the conducting airways of the lower respiratory tract and alter ventilation and gas exchange.  Although a variety of pulmonary diseases are classified as obstructive in nature, each disease has its unique features and clinical manifestations and is distinguished by the cause of the obstruction of airflow, the onset of the disease, the location of the obstruction, and the reversibility of the obstruction

 

Chronic Obstructive

Types of Obstructive Pulmonary Disorders

Typically, peripheral airway disease, chronic bronchitis, and emphysema are classified as COPD; but other obstructive pulmonary diseases that are chronic in nature, such as asthma, bronchiectasis, cystic fibrosis, and bronchopulmonary dysplasia, also may be included under this broad descriptor. The focus of discussion and guidelines for management presented in this section of the chapter is on chronic bronchitis and emphysema because patients with these diseases commonly are seen in pulmonary rehabilitation programs.

Pathological Changes in the Pulmonary System

Changes in chronic bronchitis and emphysema that occur over time are inflammation of the mucous membranes of the airways; increased production and retention of mucus; narrowing and destruction of airways; and destruction of alveolar and bronchial walls. These structural changes are reflected in pulmonary function tests depicted in . These changes in the patient’s pulmonary status predispose the patient to frequent acute respiratory infections.

Impairments and Impact on Function

As a result of the pathophysiology of COPD, many physical impairments develop over time. Patients typically have a chronic, productive cough and are often short of breath. The characteristic impact of COPD on the pulmonary system is the inability to remove air from the lungs effectively, which in turn affects the ability of the respiratory system to transport oxygen into the lungs. Consequently, functional limitations and eventually disability occur consistent with the disablement process. Impairments such as increased respiratory rate, decreased vital capacity and forced expiratory volume, increased use of accessory muscles of inspiration, and progressive chest wall stiffness are associated with decreased tolerance to exercise, frequent episodes of dyspnea, decreased walking speed and distance, and eventual inability to perform activities of daily living at home or in the workplace or to remain an active participant in the community.

 

Chronic Obstructive

Management Guidelines: COPD

Lifelong management includes appropriate medical management to lessen disabling symptoms and prevent infection, smoking cessation, and participation in a comprehensive pulmonary rehabilitation program. Important aspects of management include breathing exercises, ongoing, airway clearance, and participation in an individually designed, graded exercise program that includes upper and lower extremity strength training and aerobic conditioning

 

Impairments

An increase in the amount and viscosity of mucus production A chronic, often productive cough

Frequent episodes of dyspnea A labored breathing pattern that results in:

• Increased respiratory rate (tachypnea)

• Use of accessory muscles of inspiration and decreased diaphragmatic excursion

• Upper chest breathing

• Increased residual volume

• Decreased vital capacity

• Decreased expiratory flow rates Decreased mobility of the chest wall; a barrel chest deformity develops Abnormal posture: forward-head and rounded and elevated shoulders Decreased general endurance during functional activities

MANAGEMENT GUIDELINES—Chronic Obstructive Pulmonary Disease (COPD)

Plan of Care Interventions

1. Decrease the amount and viscosity of secretions and prevent respiratory infections.

2. Remove or prevent the accumulation of secretions. (This is important if emphysema

is associated with chronic bronchitis or if there is an acute respiratory infection.)

3. Promote relaxation of the accessory muscles of inspiration to decrease reliance on

upper chest breathing and to decrease muscle tension associated with dyspnea.

4. Improve the patient’s breathing pattern and ventilation.

Emphasize diaphragmatic and lateral costal breathing and relaxed expiration; decrease the

work of breathing, rate of respiration, and use of accessory muscles. Carry over controlled

breathing exercises to functional activities.

5. Minimize or prevent episodes of dyspnea.

6. Improve the mobility of the lower thorax.

7. Improve posture.

8. Increase exercise tolerance.

 Intervention

1. Administration of bronchodilators, antibiotics, and humidification therapy.

If patient smokes, he or she should be strongly encouraged to stop.

2. Deep and effective cough.

Postural drainage to areas where secretions are identified.

3. Positioning for relaxation.

• Relaxed head-up position in bed: trunk, arms, and head are well supported.

• Sitting: leaning forward, resting forearms on thighs or on a table.

• Standing: leaning forward on an object, with hands on the thighs or leaning backward against a wall.

Relaxation exercises for shoulder musculature: active shoulder shrugging followed by relaxation; shoulder and arm circles; horizontal abduction and adduction of the shoulders.

4. Breathing exercises: controlled diaphragmatic breathing with minimal upper chest movement; lateral costal breathing; pursed-lip breathing (careful to avoid forced expiration). Practice controlled breathing during standing, walking, climbing stairs, and other functional activities.

5. Have a patient assume a comfortable position so the upper chest is relaxed and the lower chest is as mobile as possible. Emphasize controlled diaphragmatic breathing. Have the patient breathe out as rapidly as possible without forcing expiration.Administer supplemental oxygen during a severe episode, if needed.

6. Exercises for chest mobility, emphasizing movement of the lower rib cage during deep breathing.

7. Exercises and postural training to decrease forward-head and rounded shoulders.

8. Graded endurance and conditioning exercises .

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