EMPHYSEMA
It is the non-uniform pattern of abnormal permanent distension of the air spaces, distal to the terminal bronchioles.
Classification
Panilobular type, there is destruction of the respiratory bronchiole, alveolar duct and alveoli. All air spaces within the lobule are more or less enlarged. This patient has a hyperinflated chest and marked dyspnoea on exertion referred as a pink puffer. The patient remains "pink" or well-oxygenated, until the disease becomes terminal.
Centrilobular form, the pathologic changes take place mainly in the centre of the secondary lobule while the peripheral portions of the acinus are preserved. There is chronic hypoxia, hypercapnea and polycythemia which causes cyanosis, peripheral edema and respiratory failure. Patient is called 'Blue bloater'.
Causes
1. Smoking
2. Infection-recurring.
3. Inhaled irritants / air pollution-bronchospasm and mucosal edema.
4. Hereditary.
Pathophysiology
Recurrent infection
Increase production and stimulation of neutrophils and macrophages.
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Release of proteolytic enzymes.
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Destroys alveolar tissue
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Air goes into the lungs easily, but is unable to come out on its own and remains in the lung (air trapping)
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Bronchioles collapse.
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Hyperinflation and over-distention of alveoli.
Clinical Manifestations
- Dyspnea-First on exertion and later on rest
- Minimal coughing with no sputum.
- Increase anteroposterior diameter of chest - Barrel chest appearance.
- Thin and underweight increased energy expenditure depends on increase breathing.
- Hypoxemia (especially during exercise)
- Protein energy malnutrition with loss of lean muscle mass and subcutaneous fat.
- Advanced stages-clubbing of fingers present
Diagnostic Evaluation
- Patient's symptoms
- Physical examination!
- Chest X-ray
- Pulmonary function test
- Blood gas studies.
- Complete blood count, ABG Analysis
Medical Management
1. Cessation of smoking Health education, use of nicotine gum, nicotine transdermal patch-minimizes effect of nicotine withdrawal hypnosis.
2. Avoid/Control environmental irritants.
3. Vaccinate COPD patients with influenza virus vaccine yearly and pneumococcal vaccine once in a lifetime.
4. Treat-respiratory infection
5. Administer antibiotics.
6. Administer bronchodilators through nebulizer.
7. Oxygen Therapy
8.Surgical Therapy
a. Thorascopic bullectomy: Thorascope inserted into pleura at affected sites and bullae (air spaces in lung parenchyma) removed by laser.
b. Pneumoplasty: requires median sternotomy to remove bullae
9. Breathing techniques (Diaphragmatic breathing, Pursed Lip Breathing)
10. Effective coughing conserves energy, reduces fatigue and facilitates remove secretion.
11. Chest Physiotherapy: (Postural Drainage, Percussion, Vibration)
12. Aerosol nebulization therapy rapid acting form of administration with side effects.
13. Bronchodilators.
14. Nutritional Management
Rest-30 minutes before eating - decrease dyspnea and conserves energy.
Exercise and treatment avoided 1 hr. before and after eating
Full stomach puts pressure on diaphragm and decreases lung movement li diet helps.
Avoid foods that requires chewing (use grated/pureed foodstuffs)
High calorie, high protein diet in divided 5-6 heals/day offered between meals.
Avoid gas forming foods.
Fluids to be taken between meals to avoid stomach distension
Take medication with milk/meals and perform bronchial drainage approximately 1 hr. before meals.
Nursing Management
- Provide supportive care and help patient to adjust to life-style changes.
- Encourage the patient to express his fears and concerns about the illness. Remain v the patient during periods of stress and anxiety. Answer the patient's questions about illness
- Include the patient and family in care.
- If ordered, perform chest physiotherapy including postural drainage, chest percussion vibration several times daily.
- Provide a high-calorie, protein-rich diet promotes health and healing Give sm frequent meals-conserves energy and prevents fatigue.
- Schedule respiratory treatment atleast 1 hour before or after meals. Provide mouth ca after bronchodilator therapy.
- Provide adequate fluids (3 litre/day) - loosens secretions
- Assist patient to alternate periods of rest and activity to conserve energy and preve fatigue.
- Administer medications as ordered. Record patient's response to these medications
- Watch for complications, respiratory tract infections; cor pulmonale, spontaneous pneumothorax, respiratory failure and peptic ulcer disease.
Patient Education
Advise the patient avoid crowds and people with known infectious an to obtain influenza and pneumococcus immunizations.
Explain rationales for home Oxygen therapy and proper use of equipment.
Teach the patient and family members perform postural drainage and chest percussion. Instruct them to maintain each position for 10 minutes and then perform percussion and cough.
Teach coughing and deep ventilation and mobilizes secretions. breathing techniques promotes good
Review patient's medications and explain rationale, dosage and adverse effects.
Advise the patient to report to doctor immediately if any adverse effects occurs. Teach the use of inhaler correctly.
Encourage high-calorie, protein-rich foods, plenty of fluids.
Encourage patient to stop smoking.
Advise to avoid respiratory irritants automobile exhaust fumes, aerosol sprays, and industrial pollutants.
Avoid cold, windy weather can precipitate broncho-spasm.
Notify doctors if sudden, sharp pleuritic pain that's exacerbated by chest movement, breathing or coughing.
