Chronic Obstructive Pulmonary Disease (COPD)
By Marianne Belleza, R.N. - September 14, 2016
Mr. Cruz, a lawyer, smokes three packs of cigarette every day for the past 20 years. Now on his late fties, he
started to notice that his cough has been going on for more than three months. This has also occurred last year
wherein his cough lasted for almost three months. There is sputum production and he experiences di culty of
breathing whenever he performs his daily activities.
1. Description
2. Classi cation
2.1. Chronic Bronchitis
2.2. Emphysema
3. Pathophysiology
4. Epidemiology
5. Causes
6. Clinical Manifestations
7. Prevention
8. Complications
9. Assessment and Diagnostic Findings
10. Medical Management
10.1. Pharmacologic Therapy
10.2. Management of Exacerbations
11. Surgical Management
12. Nursing Management
12.1. Nursing Assessment
12.2. Diagnosis
12.3. Planning & Goals
12.4. Nursing Priorities
12.5. Nursing Interventions
12.6. Evaluation
12.7. Discharge and Home Care Guidelines
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12.8. Documentation Guidelines
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13. See Also
Description
Nurses care for patients with COPD across the spectrum of care, from outpatient to home care to
emergency department, critical care, and hospice settings.
Chronic Obstructive Pulmonary Disease (COPD) is a condition of chronic dyspnea with expiratory
air ow limitation that does not signi cantly uctuate.
Chronic Obstructive Pulmonary Disease has been de ned by The Global Initiative for Chronic Obstructive
Lung Disease as “a preventable and treatable disease with some signi cant extrapulmonary e ects
that may contribute to the severity in individual patients.”
This updated de nition is a broad description of COPD and its signs and symptoms.
Classi cation
There are two classi cations of COPD: chronic bronchitis and emphysema. These two types of COPD can be
sometimes confusing because there are patients who have overlapping signs and symptoms of these two
distinct disease processes.
Image source: medcomic.com
Chronic Bronchitis
Chronic bronchitis is a disease of the airways and is de ned as the presence of cough and sputum
production for at least 3 months in each of 2 consecutive years.
Chronic bronchitis is also termed as “blue bloaters”.
Pollutants or allergens irritate the airways and leads to the production of sputum by the mucus-secreting
glands and goblet cells.
A wide range of viral, bacterial, and mycoplasmal infections can produce acute episodes of bronchitis.
Emphysema
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Pulmonary Emphysema is a pathologic term that describes an abnormal distention of airspaces
beyond the terminal bronchioles and destruction of the walls of the alveoli.
People with emphysema are also called “pink pu ers”.
There is impaired carbon dioxide and oxygen exchange, and the exchange results from the destruction
of the walls of overdistended alveoli.
There are two main types of emphysema: panlobular and centrilobular.
In panlobular, there is destruction of the respiratory bronchiole, alveolar duct, and alveolus.
All spaces in the lobule are enlarged.
In centrilobular, pathologic changes occur mainly in the center of the secondary lobule.
Pathophysiology
In COPD, the air ow limitation is both progressive and associated with an abnormal in ammatory response
of the lungs to noxious gases or particles.
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Image source: pathophys.org
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An in ammatory response occurs throughout the proximal and peripheral airways, lung parenchyma,
and pulmonary vasculature.
Due to the chronic in ammation, changes and narrowing occur in the airways.
There is an increase in the number of goblet cells and enlarged submucosal glands leading to
hypersecretion of mucus.
Scar formation. This can cause scar formation in the long term and narrowing of the airway lumen.
Wall destruction. Alveolar wall destruction leads to loss of alveolar attachments and a decrease in
elastic recoil.
The chronic in ammatory process a ects the pulmonary vasculature and causes thickening of the vessel
lining and hypertrophy of smooth muscle.
Schematic Diagrams:
COPD Emphysema Schematic Diagram
COPD Schematic Diagram
Epidemiology
Mortality for COPD has been increasing ever since while other diseases have decreasing mortalities.
COPD is the fourth leading cause of death in the United States.
COPD also account for the death of 125, 000 Americans every year.
Mortality from COPD among women has increased, and in 2005, more women than men died of COPD.
Approximately 12 million Americans live with a diagnosis of COPD.
An additional 2 million may have COPD but remain undiagnosed.
The annual cost of COPD is approximately $42.6 billion with overall healthcare expenditures of $26.7
billion.
Causes
Causes of COPD includes environmental factors and host factors. These includes:
Smoking depresses the activity of scavenger cells and a ects the respiratory tract’s ciliary cleansing
mechanism.
Occupational exposure. Prolonged and intense exposure to occupational dust and chemicals, indoor
air pollution, and outdoor air pollution all contribute to the development of COPD.
Genetic abnormalities. The well-documented genetic risk factor is a de ciency of alpha1- antitrypsin, an
enzyme inhibitor that protects the lung parenchyma from injury.
Clinical Manifestations
The natural history of COPD is variable but is a generally progressive disease.
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Chronic cough. Chronic cough is one of the primary symptoms of COPD.
Sputum production. There is a hyperstimulation of the goblet cells and the mucus-secreting gland
leading to overproduction of sputum.
Dyspnea on exertion. Dyspnea is usually progressive, persistent, and worsens with exercise.
Dyspnea at rest. As COPD progress, dyspnea at rest may occur.
Weight loss. Dyspnea interferes with eating and the work of breathing is energy depleting.
Barrel chest. In patients with emphysema, barrel chest thorax con guration results from a more
xed position of the ribs in the inspiratory position and from loss of elasticity.
Prevention
Prevention of COPD is never impossible. Discipline and consistency are the keys to achieving freedom from
chronic pulmonary diseases.
Smoking cessation. This is the single most cost-e ective intervention to reduce the risk of developing
COPD and to stop its progression.
Healthcare providers should promote cessation by explaining the risks of smoking and personalizing the
“at-risk” message to the patient.
Complications
There are two major life-threatening complications of COPD: respiratory insu ciency and failure.
Respiratory failure. The acuity and the onset of respiratory failure depend on baseline pulmonary
function, pulse oximetry or arterial blood gas values, comorbid conditions, and the severity of other
complications of COPD.
Respiratory insu ciency. This can be acute or chronic, and may necessitate ventilator support until
other acute complications can be treated.
Assessment and Diagnostic Findings
Diagnosis and assessment of COPD must be done carefully since the three main symptoms are common
among chronic pulmonary disorders.
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Health history. The nurse should obtain a thorough health history from patients with known or
potential COPD.
Pulmonary function studies. Pulmonary function studies are used to help con rm the diagnosis of
COPD, determine disease severity, and monitor disease progression.
Spirometry. Spirometry is used to evaluate airway obstruction, which is determined by the ratio of FEV1
to forced vital capacity.
ABG. Arterial blood gas measurement is used to assess baseline oxygenation and gas exchange and is
especially important in advanced COPD.
Chest x-ray. A chest x-ray may be obtained to exclude alternative diagnoses.
CT scan. Computed tomography chest scan may help in the di erential diagnosis.
Screening for alpha1-antitrypsin de ciency. Screening can be performed for patients younger than 45
years old and for those with a strong family history of COPD.
Chest x-ray: May reveal hyperin ation of lungs, attened diaphragm, increased retrosternal air space,
decreased vascular markings/bullae (emphysema), increased bronchovascular markings (bronchitis),
normal ndings during periods of remission (asthma).
Pulmonary function tests: Done to determine cause of dyspnea, whether functional abnormality is
obstructive or restrictive, to estimate degree of dysfunction and to evaluate e ects of therapy, e.g.,
bronchodilators. Exercise pulmonary function studies may also be done to evaluate activity tolerance in
those with known pulmonary impairment/progression of disease.
The forced expiratory volume over 1 second (FEV1): Reduced FEV1 not only is the standard way of
assessing the clinical course and degree of reversibility in response to therapy, but also is an important
predictor of prognosis.
Total lung capacity (TLC), functional residual capacity (FRC), and residual volume (RV): May be increased,
indicating air-trapping. In obstructive lung disease, the RV will make up the greater portion of the TLC.
Arterial blood gases (ABGs): Determines degree and severity of disease process, e.g., most often Pao2is
decreased, and Paco2 is normal or increased in chronic bronchitis and emphysema, but is often
decreased in asthma; pH normal or acidotic, mild respiratory alkalosis secondary to hyperventilation
(moderate emphysema or asthma).
DL CO test: Assesses di usion in lungs. Carbon monoxide is used to measure gas di usion across the
alveocapillary membrane. Because carbon monoxide combines with hemoglobin 200 times more easily
than oxygen, it easily a ects the alveoli and small airways where gas exchange occurs. Emphysema is the
only obstructive disease that causes di usion dysfunction.
Bronchogram: Can show cylindrical dilation of bronchi on inspiration; bronchial collapse on forced
expiration (emphysema); enlarged mucous ducts (bronchitis).
Lung scan: Perfusion/ventilation studies may be done to di erentiate between the various pulmonary
diseases. COPD is characterized by a mismatch of perfusion and ventilation (i.e., areas of abnormal
ventilation in area of perfusion defect).
Complete blood count (CBC) and di erential: Increased hemoglobin (advanced emphysema),
increased eosinophils (asthma).
Blood chemistry: alpha1-antitrypsin is measured to verify de ciency and diagnosis of primary
emphysema.
Sputum culture: Determines presence of infection, identi es pathogen.
Cytologic examination: Rules out underlying malignancy or allergic disorder.
Electrocardiogram (ECG): Right axis deviation, peaked P waves (severe asthma); atrial dysrhythmias
(bronchitis), tall, peaked P waves in leads II, III, AVF (bronchitis, emphysema); vertical QRS axis
(emphysema).
Exercise ECG, stress uses
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of bronchodilator therapy, planning/evaluating exercise program.
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Medical Management
Healthcare providers perform medical management by considering the assessment data rst and matching
the appropriate intervention to the existing manifestation.
Pharmacologic Therapy
Bronchodilators. Bronchodilators relieve bronchospasm by altering the smooth muscle tone and
reduce airway obstruction by allowing increased oxygen distribution throughout the lungs and
improving alveolar ventilation.
Corticosteroids. A short trial course of oral corticosteroids may be prescribed for patients to determine
whether pulmonary function improves and symptoms decrease.
Other medications. Other pharmacologic treatments that may be used in COPD include alpha1-
antitrypsin augmentation therapy, antibiotic agents, mucolytic agents, antitussive agents, vasodilators,
and narcotics.
Management of Exacerbations
Optimization of bronchodilator medications is rst-line therapy and involves identifying the best
medications or combinations of medications taken on a regular schedule for a speci c patient.
Hospitalization. Indications for hospitalization for acute exacerbation of COPD include severe dyspnea
that does not respond to initial therapy, confusion or lethargy, respiratory muscle fatigue, paradoxical
chest wall movement, and peripheral edema.
Oxygen therapy. Upon arrival of the patient in the emergency room, supplemental oxygen therapy is
administered and rapid assessment is performed to determine if the exacerbation is life-threatening.
Antibiotics. Antibiotics have been shown to be of some bene t to patients with increased dyspnea,
increased sputum production, and increased sputum purulence.
Surgical Management
Patients with COPD also have options for surgery to improve their condition.
Bullectomy. Bullectomy is a surgical option for select patients with bullous emphysema and can help
reduce dyspnea and improve lung function.
Lung Volume Reduction Surgery. Lung volume reduction surgery is a palliative surgery in patients
with homogenous disease or disease that is focused in one area and not widespread throughout the
lungs.
Lung Transplantation. Lung transplantation is a viable option for de nitive surgical treatment of end-
stage emphysema.
Nursing Management
Management of patients with COPD should be incorporated with teaching and improving the respiratory
status of the patient.
Nursing Assessment
Assessment of the respiratory system should be done rapidly yet accurately.
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Assess patient’s exposure to risk factors.
Assess the patient’s past and present medical history.
Assess the signs and symptoms of COPD and their severity.
Assess the patient’s knowledge of the disease.
Assess the patient’s vital signs.
Assess breath sounds and pattern.
Diagnosis
Diagnosis of COPD would mainly depend on the assessment data gathered by the healthcare team
members.
Impaired gas exchange due to chronic inhalation of toxins.
Ine ective airway clearance related to bronchoconstriction, increased mucus production, ine ective
cough, and other complications.
Ine ective breathing pattern related to shortness of breath, mucus, bronchoconstriction, and airway
irritants.
Self-care de cit related to fatigue.
Activity intolerance related to hypoxemia and ine ective breathing patterns.
Planning & Goals
Main article: 5 Chronic Obstructive Pulmonary Disease (COPD) Nursing Care Plans
Goals to achieve in patients with COPD include:
Improvement in gas exchange.
Achievement of airway clearance.
Improvement in breathing pattern.
Independence in self-care activities.
Improvement in activity intolerance.
Ventilation/oxygenation adequate to meet self-care needs.
Nutritional intake meeting caloric needs.
Infection treated/prevented.
Disease process/prognosis and therapeutic regimen understood.
Plan in place to meet needs after discharge.
Nursing Priorities
1. Maintain airway patency.
2. Assist with measures to facilitate gas exchange.
3. Enhance nutritional intake.
4. Prevent complications, slow progression of condition.
5. Provide information about disease process/prognosis and treatment regimen.
Nursing Interventions
Patient and family teaching
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with any chronic pulmonary disorder. ACCEPT
To achieve airway clearance:
The nurse must appropriately administer bronchodilators and corticosteroids and become alert for
potential side e ects.
Direct or controlled coughing. The nurse instructs the patient in direct or controlled coughing, which is
more e ective and reduces fatigue associated with undirected forceful coughing.
To improve breathing pattern:
Inspiratory muscle training. This may help improve the breathing pattern.
Diaphragmatic breathing. Diaphragmatic breathing reduces respiratory rate, increases alveolar
ventilation, and sometimes helps expel as much air as possible during expiration.
Pursed lip breathing. Pursed lip breathing helps slow expiration, prevents collapse of small airways,
and control the rate and depth of respiration.
To improve activity intolerance:
Manage daily activities. Daily activities must be paced throughout the day and support devices can be
also used to decrease energy expenditure.
Exercise training. Exercise training can help strengthen muscles of the upper and lower extremities and
improve exercise tolerance and endurance.
Walking aids. Use of walking aids may be recommended to improve activity levels and ambulation.
To monitor and manage potential complications:
Monitor cognitive changes. The nurse should monitor for cognitive changes such as personality and
behavior changes and memory impairment.
Monitor pulse oximetry values. Pulse oximetry values are used to assess the patient’s need for oxygen
and administer supplemental oxygen as prescribed.
Prevent infection. The nurse should encourage the patient to be immunized against in uenza and S.
pneumonia because the patient is prone to respiratory infection.
Evaluation
During evaluation, the e ectiveness of the care plan would be measured if goals were achieved in the end
and the patient:
Identi es the hazards of cigarette smoking.
Identi es resources for smoking cessation.
Enrolls in smoking cessation program.
Minimizes or eliminates exposures.
Verbalizes the need for uids.
Is free of infection.
Practices breathing techniques.
Performs activities with less shortness of breath.
Discharge and Home Care Guidelines
It is important for the nurse to assess the knowledge of patient and family members about self-care and
the therapeutic regimen.
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Setting goals. If the COPD is mild, the objectives of the treatment are to increase exercise tolerance and
prevent further loss of pulmonary function, while if COPD is severe, these objectives are to preserve
current pulmonary function and relieve symptoms as much as possible.
Temperature control. The nurse should instruct the patient to avoid extremes of heat and cold because
heat increases the temperature and thereby raising oxygen requirements and high altitudes increase
hypoxemia.
Activity moderation. The patient should adapt a lifestyle of moderate activity and should avoid
emotional disturbances and stressful situations that might trigger a coughing episode.
Breathing retraining. The home care nurse must provide the education and breathing retraining
necessary to optimize the patient’s functional status.
Documentation Guidelines
Documentation is an essential part of the patient’s chart because the interventions and medications given
and done are re ected on this part.
Document assessment ndings including respiratory rate, character of breath sounds; frequency,
amount and appearance of secretions laboratory ndings and mentation level.
Document conditions that interfere with oxygen supply.
Document plan of care and speci c interventions.
Document liters of supplemental oxygen.
Document client’s responses to treatment, teaching, and actions performed.
Document teaching plan.
Document modi cations to plan of care.
Document attainment or progress towardsgoals.
Practice Quiz: Chronic Obstructive Pulmonary Disease (COPD)
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Practice Quiz: Chronic Obstructive Pulmonary Disease (COPD)
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Practice Quiz: Chronic Obstructive Pulmonary Disease (COPD)
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TEXT MODE
Text Mode: All questions and answers are given on a single page for reading and answering at your
own pace. Be sure to grab a pen and paper to write down your answers.
1. As a cause of death in the United States, COPD ranks:
A. Second.
B. Third.
C. Fourth.
D. Fifth.
2. Two diseases common to the etiology of COPD are:
A. Asthma and atelectasis.
B. Chronic bronchitis and emphysema.
C. Pneumonia and pleurisy.
D. Tuberculosis and pleural e usion.
3. The underlying pathophysiology of COPD is:
A. In amed airways that obstruct air ow.
B. Mucus secretion that blocks airways.
C. Alveolar wall destruction.
D. Characterized by variations in all of the above.
4. The abnormal in ammatory response in the lungs occurs primarily in the:
A. Airways.
B. Parenchyma.
C. Pulmonary vasculature.
D. Areas identi ed in all of the above.
5. The most important environmental risk factor in emphysema is:
A. Air pollution.
B. Allergens.
C. Infectious agents.
D. Cigarette smoking.
Answers and Rationale
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1. Answer: C. Fourth
COPD is the fourth leading cause of death in the United States.
2. Answer: B. Chronic bronchitis and emphysema
Chronic bronchitis and emphysema belong to the old classi cation of COPD.
Option A: Asthma may be one of the chronic pulmonary diseases but atelectasis is not.
Option C: Pneumonia and pleurisy are not classi ed under the COPD.
Option D: Tuberculosis and pleural e usion are not chronic pulmonary diseases.
3. Answer: D. Characterized by variations in all of the above.
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In ammation, hypersecretion of mucus, and alveolar wall destruction are included in the
pathophysiology of COPD.
Option A: In ammation occurs through the proximal and peripheral airways, lung parenchyma, and
pulmonary vasculature.
Option B: Hypersecretion occurs due to the increase in the number of goblet cells.
Option C: Alveolar wall destruction leads to loss of alveolar attachments and a decrease in elastic
recoil.
4. Answer: D. Areas identi ed in all of the above
The airways, parenchyma, and pulmonary vasculature undergo in ammation in COPD.
Option A: The airways are in amed in COPD.
Option B: The lung parenchyma undergoes an in ammatory response in COPD.
Option C: The pulmonary vasculature is a ected by in ammation in COPD.
5. Answer: D. Cigarette smoking
Cigarette smoking is the foremost factor in the development of emphysema.
Option A: Air pollution is a risk factor in the development of emphysema but it is not the primary
factor.
Option B: Allergens may contribute to the development of emphysema but it is not the main factor.
Option C: Infectious agents are part of the risk factors for emphysema but it is not the main factor.
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See Also
Posts related to Chronic Obstructive Pulmonary Disease (COPD):
10 COPD: Bronchitis Nursing Care Plans
5 Chronic Obstructive Pulmonary Disease (COPD) Nursing Care Plans
8 Pneumonia Nursing Care Plans
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Last updated on August 12, 2019
Marianne Belleza, R.N.
Marianne is a sta nurse during the day and a Nurseslabs writer at night. She is a registered nurse since 2015 and is currently working in a
regional tertiary hospital and is nishing her Master's in Nursing this June. As an outpatient department nurse, she is a seasoned nurse in
providing health teachings to her patients making her also an excellent study guide writer for student nurses. Marianne is also a mom of a
toddler going through the terrible twos and her free time is spent on reading books!
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