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Chronic Obstructive Pulmonary Disease

Contact Hours: 4

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Contact Hours: 4

This educational activity is credited for 4 contact hours at completion of the activity.

Course Purpose

To provide healthcare professionals with an overview of chronic obstructive pulmonary disease, common causes, and potential treatment options.

Overview

Chronic obstructive pulmonary disease (COPD) is a group of diseases that are characterized by progressive and incurable airflow restriction. It has multiple clinical forms, including chronic bronchitis and emphysema, making breathing difficult. Although there is no cure available, in many instances, COPD is preventable, and can be managed. This course will discuss the causes, lung variations, and clinical presentations of COPD, along with possible treatment options.

Course Objectives

Upon completion of the independent study, the healthcare professional will be able to: 

  • Describe the anatomy and physiology of the lungs
  • Define chronic obstructive pulmonary disease (COPD)
  • Identify clinical presentations of COPD
  • Describe treatment options for COPD
  • Discuss nursing considerations for COPD patients

Policy Statement

This activity has been planned and implemented in accordance with the policies of FastCEForLess.com.

Disclosures

Fast CE For Less, Inc and its authors have no disclosures. There is no commercial support.

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Definitions
AlveoliAny of the many tiny air sacs of the lungs which allow for rapid gaseous exchange.
Arterial Blood Gas (ABG)The sampling of the blood levels of oxygen and carbon dioxide within the arteries.
BronchodilatorA drug that causes widening of the bronchi, such as any of those taken by inhalation for the alleviation of asthma.
Carbon DioxideA natural greenhouse gas, commonly produced by the air we exhale. 
Chest X-RayProduce images of your heart, lungs, blood vessels, airways, and the bones of your chest and spine
Chronic Obstructive Pulmonary Disease A group of diseases that cause airflow blockage and breathing-related problems
Computed Tomography (CT) ScanA widely used technique to image various lung pathology. 
DiaphragmThe primary muscle used in respiration, which is the process of breathing. 
DyspneaThe medical term for shortness of breath or difficulty breathing.
Forced Expiratory Volume (FEV1)Measures how much air a person can exhale during a forced breath.
Fractional Exhaled Nitric Oxide (FeNO)Measures the amount of nitric oxide, a byproduct of inflammation, in the air that is breathed out
Global Initiative for Chronic Obstructive Lung Disease (GOLD)GOLD works with healthcare professionals and public health officials around the world to raise awareness of COPD and to improve prevention and treatment of this lung disease. 
Haemophilus InfluenzaeA name for any illness caused by bacteria called H. Influenzae
Hyperinflation of the Lungs A term used to describe excessive, large, or heightened increase in lung tissues
Long-Acting Muscarinic Agonists (LAMA)A class of inhaled bronchodilators that affect the airways for at least 12 hours.
Long-Acting Beta Agonist (LABA)Inhaled medications that are used in the treatment of asthma and chronic obstructive pulmonary disease (COPD)
LungA pair of spongy, air-filled organs located on either side of the chest (thorax)
LymphocytesA type of immune cell that is made in the bone marrow and is found in the blood and in lymph tissue.
MacrophagesA large phagocytic cell found in stationary form in the tissues or as a mobile white blood cell, especially at sites of infection.
MediastinumAn area found in the midline of the thoracic cavity, that is surrounded by the left and right pleural sacs.
NeutrophilsA type of white blood cell (leukocytes) that act as the immune system’s first line of defense
Peak Expiratory Flow (PEF)A person’s maximum speed of expiration, as measured with a peak flow meter, is a small, hand-held device used to monitor a person’s ability to breathe out air. 
Phosphodiesterase InhibitorsMedications that cause blood vessels to relax and widen, improving circulation and lowering blood pressure.
Slow-Acting Beta-Agonist (SABA)Medications that are used for quick relief of asthma symptoms.
SpirometryA common test used to assess how well the lungs work by measuring how much air is inhaled, how much air is exhaled and how quickly the air is exhale.
Streptococcus PneumoniaeLancet-shaped, gram-positive, facultative anaerobic bacteria
TracheaThe main passageway through which air passes from the upper respiratory tract to the lungs.
Introduction

Chronic obstructive pulmonary disease (COPD) is a group of diseases that are characterized by progressive and incurable airflow restriction.1 It has multiple clinical forms, including chronic bronchitis and emphysema, making breathing difficult.1,2 This preventable multifactorial disease affects 380 million people worldwide and has a significant economic burden.1 In the United States, direct costs of COPD are estimated to be $32 billion, and indirect costs (incurred by lost working days) are estimated to be an additional $20.4 billion.1 Significant drivers of direct and indirect costs includes disease severity, exacerbations frequency, dyspnea severity, presence, and types of comorbidities.1

Although there is no cure available, in many instances, COPD is preventable and can be managed. This course will discuss the causes, lung variations, and clinical presentations of COPD, along with possible treatment options.

Lung Anatomy and Physiology

Before we discuss chronic obstructive pulmonary disease, let’s discuss the lungs’ anatomy and physiology. There are two lungs in the thoracic cavity, divided by the mediastinum into two sections or lobes. The right lung is further divided into three lobes, and the left is divided into two.3 A protective membrane, called pleura, covers the lung, whereas a muscular diaphragm separates the lungs from the abdominal cavity. When the diaphragm contracts, it pulls the lungs downward, expanding the thoracic cavity and allowing the lungs to inhale air through the trachea and bronchi (the lungs’ branching passageway), filling the alveoli.3,4 The alveoli are tiny sacs at the end of the bronchi and are surrounded by blood vessels called capillaries.3,4 Capillaries connect the arteries and veins and help exchange oxygen for carbon dioxide.3,4 The carbon dioxide is taken back into the lungs and released into the alveoli.3 As a person exhales, the carbon dioxide is expelled into the trachea from the bronchi.3

In the case of COPD, the bronchi and alveoli are filled with mucus and become constricted. Because of this, they are unable to expand and dilate properly, which causes the airway to block and the gases not to be exchanged.4 As a result, the lungs become stiff and nonpliable, which is a classic characteristic of COPD.4

Regarding the physiology of breathing, it is important to know the pressure difference and how it affects breathing. The thoracic cavity’s internal pressure is negative compared to the positive atmospheric pressure.4 In breathing, the diaphragm contracts and expands the thoracic cavity, allowing the lungs to inhale air until the internal pressure exceeds the external pressure, and then reverses the process for exhaling by relaxing the diaphragm.4 In COPD, the diaphragm becomes ineffective due to the trapped air in the alveoli. And since it is responsible for 80% of the breathing and expanding the thoracic cavity, the incoming airflow reduces, affecting breathing.4

What is Chronic Obstructive Pulmonary Disease (COPD)?

Chronic obstructive pulmonary disease (COPD) is a chronic lung disease caused by obstruction or airflow restriction.4,5 It is a progressive disease that worsens over time and makes breathing difficult.6 Chronic obstructive pulmonary disease is diagnosed more often in women compared to men, and according to the Center for Disease Control (CDC), it is the fourth leading cause of death in the United States.6 It is highly prevalent in smokers and people above 40.7 Moreover, the prevalence increases with age. Prolonged exposure to harmful particles and gases also causes structural changes in the lungs.7

Lung Variations in COPD

In COPD, three parts of the lungs, such as the bronchi, parenchyma, and pulmonary vessels, undergo morphological changes. Studying the relationship and interaction between these three lung parts can help simplify diagnosing COPD phenotypes and understanding the underlying pathophysiology.8 These lung variations are identifiable through CT and MRI scans.8.9

A study researched the prevalence of the most common lung variant by performing CT scans on a large group of people, 3,169 participants, to be exact.9 As a result, the following lung variations were discovered:

  • Airway branch variation (26.5%)
  • Accessory sub-superior airway (most common variant), followed by an absent right medial-basal airway.
  • Rare airway branch variants were observed in 4% of the participants, such as a tracheal or carinal airway, accessory left medial-basal airway, or combinations of the abovementioned variants.
  • The remaining 73.5% had no airway branch variants or had standard airway anatomy.9

Next, the study determined which common lung variation was associated with COPD. It included results from both the MESA Lung Study and the Subpopulations and Intermediate Outcome Measures in COPD Study (SPIROMICS), which followed the same CT methodology.9 As a result, the presence of an accessory sub-superior segmental airway variation was found to be associated with COPD.9 Moreover, in some cases, the absence of the right medial-basal segmental airway was also associated with COPD.9

If we further study the morphological imaging observed with a CT scan, the following changes are highlighted:

  • Airways
    • Bronchial wall measurements indicate remodeling of the airways or inflammatory changes. The bronchial wall was found to be thinner than normal in COPD.8
    • An airway diameter of 2-3 mm is associated with airflow obstruction in COPD.8
  • Pulmonary vessels
    • Distal vessel pruning and endothelial dysfunction of hypoxic vasoconstriction response may be related to inflammation in smokers and COPD patients.8
    • 2D and 3D images are used to measure the surface of small blood vessels. Assessment of small pulmonary vessels in mild to moderate PH secondary to COPD has shown a negative correlation with mean PAP.8

Aside from assessing different lung components, a CT scan can also be used for morphological evaluation of the chest wall or cardiovascular system.8 You can determine the size and morphology of the right and left ventricles and help diagnose COPD phenotypes.8 These parameters are useful in patients who respond to beta-blockers with an exacerbation frequency reduction.8 Whereas diaphragm changes are related to hyperinflation and emphysema. Another study focused on the coronary artery calcification score and concluded that they were correlated to mortality.8

Causes of COPD

Prolonged exposure to harmful lung irritants, such as tobacco smoke and chemicals, and damage the lungs and airway can cause chronic obstructive pulmonary disease.7,9 In the United States, cigarette smoking is the most common cause of COPD.7,10 However, 1 in 4 COPD patients have never smoked. The chemicals in cigarette smoke expose the lungs to infections, destroy air sacs by causing them to lose their elasticity, and thicken the walls of the airways.9,10

Cigarette smoke chemicals produce indentations within the fine endothelial lining of the arteries in the body, which results in open gaps in the vessels where cholesterol and fat can build up. This damages the circulatory system by narrowing the arteries, also known as atherosclerosis.4 It also hinders blood flow by blocking oxygen absorption and producing thick and sticky blood with atherosclerotic plaques that narrow the arteries.4 To conclude, smoking affects each body system, from the brain to the ischemic bowel. It is important to note that the FDA does not approve electronic cigarettes (vapes) as substitutes for cigarettes due to the production of similar adverse effects of nicotine.4

Other common causes of COPD include: 7,9

  • Air pollution – Lung functionality declines with prolonged exposure to poor air quality. If an individual is constantly exposed to factories, motor vehicle exhaust, power plants, wood burning, or wildfires, they are exposed to particulate matter PM 2.5 and nitrogen dioxide, which are common risk factors of COPD.9
  • Alpha-1 antitrypsin deficiency (AATD) – Is a genetic or inherited condition and is a rare cause of emphysema. It affects the body’s ability to produce a protein (alpha-1) that protects the lung. The lack of antiproteases and the imbalance puts the lung parenchyma at risk for protease-mediated damage. Alpha-1 antitrypsin deficiency is caused by the misfolding of the mutated protein accumulated in the liver. It primarily involves the lower lobes and can be diagnosed with a blood test.
  • Environmental and occupational exposures – Account for 10 to 20% of all COPD cases or respiratory symptoms. Long-term exposure to dust, fumes, and chemicals is a risk factor for COPD.9
  • Second-hand smoke

Common risk factors for COPD include the following:9,10

  • Family history of respiratory infections or AATD
  • History of asthma
  • Long-term exposure to air pollutants
  • People aged 40 or above
  • People with underdeveloped lungs
  • Personal history of childhood infections
Diagnosing COPD

Diagnosis of COPD is challenging as the symptoms are not apparent and thus cannot be measured. Moreover, each patient does not necessarily experience the same symptoms or intensity. It is important for the healthcare professional to create a customized treatment plan and monitor a patient’s symptoms of COPD.11

The following are some of the common symptoms and clinical presentations associated with chronic obstructive pulmonary disease: 6,7,11

These symptoms develop slowly but can worsen over time, impacting an individual’s ability to continue regular activities. In severe COPD, patients cannot cook, clean, walk, or do any basic activity.6 Patients should immediately consult a healthcare professional if they start to experience any of these symptoms, as they can have a long-term impact. COPD diagnosis involves the following steps:

History and Physical

Chronic obstructive pulmonary disease is diagnosed through inquiry about a patient’s family history, smoking habits or exposure to second-hand smoke, and exposure to environmental and occupational chemicals.7 The following are considerations when obtaining a history and physical: 7

  • Healthcare professionals should gather information about the frequency of coughing, how much sputum is produced, and when it worsens.
  • Past medical history and family history of COPD and other related diseases, such as allergies, asthma, and childhood respiratory infections.
  • Patients with a confirmed diagnosis of COPD should share information regarding inhaler usage, previous exacerbations, nighttime awakenings, and how the disease has impacted their daily routine.
  • Patients with liver disease or a family history of emphysema should be questioned on alpha-1 antitrypsin deficiency.7

In the initial examination, healthcare professionals use a stethoscope to listen to abnormal chest sounds or wheezing, which are characteristic of COPD.12 Patients with COPD may exhibit multiple physical changes in different body parts, such as:

  • Skin
    • When arterial oxygenation is low, central cyanosis occurs, causing a bluing of the skin and mucosa.
  • Chest
    • This causes barrel chest characterized by an increased anterior-posterior chest wall diameter.
  • Lungs
    • Wheezing
    • Prolonged expiration
    • Pursed-lip breathing
    • Accessory respiratory muscle use
  • Extremities
    • In the case of right heart failure, lower extremity edema occurs.
    • Digital clubbing
  • General
    • Muscle wasting
    • In acute exacerbations, there is significant respiratory distress.

Spirometry

Spirometry is the main test for confirming a diagnosis of COPD or determining how severe COPD is.12 It is a type of pulmonary function test that is performed before and after administering an inhaled bronchodilator.7 Spirometry assesses how well the lungs work by measuring how much air can be blown out using maximum effort.12 An inhaled bronchodilator is a short-acting anticholinergic, a short-acting beta2-agonist (SABA), or a combination of both.7 If the ratio of the forced expiratory volume in one second to forced vital capacity is less than 0.7, then COPD diagnosis is confirmed.7

In addition to spirometry, other lung functioning tests can be used to diagnose COPD, including:

  • Arterial blood gas (ABG) test – Blood is taken from the wrist to measure the blood’s oxygen and carbon dioxide levels.
  • Fractional exhaled nitric oxide (FeNO) test – Measures the percentage of nitric oxide in breath. Higher percentages mean the airways are inflamed. Patients must blow in a tube, and no heavy breathing is required.
  • Peak expiratory flow (PEF) test – A spirometer or a small handheld device is used to measure forced expiration using maximum effort.

Global Initiative for Chronic Obstructive Lung Disease (GOLD)

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) program is a joint initiative by the World Health Organization (WHO) and the National Heart, Lung, and Blood Institute (NHLBI).7 It provides updated information and recommendations for diagnosing and managing COPD. It is also useful in determining the severity of COPD and developing a customized treatment plan.7

According to the 2019 GOLD report, after diagnosis of COPD is confirmed with a spirometry test, the disease’s severity (GOLD classification 1-4) is determined by the forced expiratory volume (FEV1).7 The GOLD group (A-D) is then determined by the severity of symptoms, and the history of exacerbations.

Table 1: GOLD program COPD assessment

GradeSeverityFEV1
GOLD 1Mild≥ 80
GOLD 2Moderate50-79
GOLD 3Severe30-49
GOLD 4Very severe< 30

Patients must fill out the modified British Medical Research Council (mMRC) questionnaire and the COPD Assessment Test (CAT) to determine symptom severity.7

Laboratory Tests

Common laboratory tests conducted for COPD include:

  • Alpha-1 antitrypsin levels    
  • Anemia
  • Polycythemia

A 6-minute walk test is also recommended for patients with COPD to check the maximum capacity of their lungs and assess the functional damage. The test is conducted indoors on a straight, flat surface, usually around 100 feet. The healthcare professional measures the length of the walkway covered over a 6-minute period.7

Lung Imaging

COPD lung imaging involves the following two scans:

  • Chest X-ray – Used to obtain a clear image of the structures in and around the chest. It is primarily used to diagnose lung-related diseases like heart failure, lung cancer, pneumonia, etc., and can also be used to gather information on the efficacy of drug and treatment regimens.12 In the case of COPD, a chest X-ray may show a flattened diaphragm, increased anterior-posterior wall diameter, or hyperinflation. In contrast, bronchial wall thickening may be observed in chronic bronchitis.7 
  • Computed tomography (CT) scan – Used to take pictures of the lungs or structures inside the chest. It combines multiple images to create 3D models that help improve diagnosis by showing the accurate size, proportion, and position of the lungs and structures.12 An iodine-based contrast dye is injected into the vein before imaging. It helps in determining symptom severity and lung disease progression.12 A CT scan may show centrilobular emphysema or bullae in the subpleural regions.7
Common COPD Treatment Options

Daily Medications

Evidence shows that pharmacotherapy is effective against COPD and helps dilate the airways, decrease resting lung volumes and severe symptoms, and increase exercise tolerance and quality of life.16 With such benefits, implementation becomes necessary. Medication therapy should be based on the patient’s disease severity, response to drugs, and potential side effects.16 

Medications are prescribed based on the patient’s clinical and phenotypic characteristics. For instance, patients with asthma features and a history of wheezes, allergies, and eosinophilia may respond better to a long-acting beta agonist  and inhaled cortical steroid (LABA/ICS) combination.16 On the other hand, long-acting bronchodilators are better for patients with emphysema features, lung hyperinflation with low diffusion capacity, low BMI, and low eosinophils.16

Daily medications are divided into two categories; one that is administered orally and the other that is inhaled.

Inhaled Medications

  • Bronchodilators
    • Anticholinergic – These drugs block the muscarinic receptors and reduce exacerbation recurrence and dyspnea. The appropriate dosage of the short-acting ipratropium bromide is two to four puffs three or four times per day.16Beta-agonists – Long-acting beta agonist (LABA) are most commonly recommended for patients with persistent symptoms and result in increased exercise endurance and quality of life. For patients with mild symptoms, a slow-acting beta-agonist (SABA) is sufficient for symptom relief.16
    • Combinations of LABA/LAMA – The combination of long-acting beta agonists and long-acting muscarinic agonists (LAMA) are useful for patients with lung hyperinflation and dyspnea.16
  • Corticosteroids – as a result of the TORCH (towards a revolution in COPD health) trial, that studied the effects of combination therapy with salmeterol and fluticasone propionate on mortality, the treatment with corticosteroids alone is not recommended for COPD due to increased side effects.16 However, many studies have shown that budesonide and beclomethasone carry a lower risk of side effects.16 Despite the precautions, corticosteroids in combination with LABAs are considered effective for patients with severe COPD and frequent exacerbations.16

Oral Medications

  • Antibiotics – The antibiotic choice depends on the sputum culture and infection type.16 Macrolides such as azithromycin are most used.16
  • Biologicals – The use of systemic monoclonal antibodies has shown positive results on exacerbation frequency.  A trial evaluating monoclonal antibody against IL-5, mepolizumab, significantly reduced moderate and severe exacerbations in patients already on triple (LABA/ LAMA/ICS) inhaled treatment.16
  • Parenteral medication – Alpha-1 antitrypsin enzyme supplement is given weekly, biweekly, or monthly in non-smoking emphysema diagnosed patients.16
  • Phosphodiesterase Inhibitors – Patients that cannot tolerate aerosol therapy are recommended theophylline. It is a nonspecific and weak bronchodilator that is only effective in high doses; however, it is associated with toxicity.16 Side effects can be reduced by combining theophylline with an inhaled bronchodilator.16
  • Systemic corticosteroids – Only recommended for hospitalized patients on bronchodilator therapy or patients already treated with systemic corticosteroids.16

Oxygen Therapy

Among the many pharmacological treatment options available, long-term oxygen therapy is widely used and recommended.17 COPD treatment is focused on relieving symptoms. In severe cases of COPD, patients suffer from dyspnea, and families often request oxygen therapy as palliative care to offer some semblance of relief.17

Oxygen therapy in combination with non-invasive ventilation has been found to be effective in COPD treatment.17

Surgical Interventions

Surgery for COPD is a last resort and is only considered for patients in the very severe stage.18 The following three types of surgical interventions are considered for advanced COPD:

  • Lung volume reduction – In this procedure, the hyperinflated parts of the lungs are removed to offer more room for healthy parts and make it easier to supply the blood with oxygen. It can be done either through surgery or bronchoscopy procedures.18 However, not every patient is suitable for surgery, and it is only recommended for patients who are younger than 75 years of age, nonsmokers, not underweight, and those who do not have any other serious medical conditions.18
  • Bullectomy – In this procedure, bullae, large air-filled spaces, are removed. It is similar to a lung volume reduction surgery done through small cuts in the chest area.18
  • Lung transplant – When all treatment options fail, a lung transplant is only considered in patients with advanced emphysema.18 It has multiple risks and is only recommended for patients whose condition is continuing to worsen despite treatment efforts, is in a hypoxic and hypercapnic state, and whose FEV1 is less than 25%.18
COPD Exacerbation

There is no single definition used to describe exacerbation. However, the simplest and commonly used definition states it as worsening respiratory symptoms with a variable degree of physiological deterioration.14 It can also be defined as worsening respiratory symptoms which require treatment by corticosteroids or antibiotics, or both.13

According to WHO and US National Heart Lung and Blood Institute Global Initiative for Chronic Obstructive Lung Disease (GOLD), exacerbation can be defined as “an event in the natural course of the disease characterized by a change in the patient’s baseline dyspnea, cough, and/or sputum that is beyond normal day-to-day variations, is acute in onset, and may warrant a change in regular medication in a patient with underlying COPD.”14

COPD exacerbation is quite unpredictable. For instance, some studies have shown patients to return to baseline symptoms within 7 days, while they are still exacerbation after 35 days of onset. Moreover, in a few cases, patients never return to baseline symptoms.14

The following are some of the plausible pathophysiological changes observed during a COPD exacerbation:

  • Increase in the CD8+ lymphocytes and macrophages in the bronchial mucosa and an increase in neutrophils with more severe disease.
  • Increased systemic inflammation – There is a direct relation between the airway inflammation degree and the systemic acute-phase response. If exacerbation is associated with viral and bacterial infection, system inflammation increases.14
  • Increased upper and lower airway inflammation.
  • Pronounced airway neutrophilia, neutrophil elastase expression, and upregulation of neutrophil chemokine expression.14

Airway inflammation during COPD exacerbation results in increased sputum production, airway edema, bronchospasm, worsening airflow limitation, and the development of dynamic hyperinflation.14 Hyperinflation leads to dyspnea, which is a common cause of exacerbations.14

Moderate-to-severe COPD patients are prone to frequent exacerbation episodes, often, more than 3 in a year.13 This significantly impacts the quality of life and increases hospital admission and readmission.13 Patients with frequent exacerbations have increased airway bacterial colonization in the stable state with bacteria such as Haemophilus influenzae and Streptococcus pneumoniae.13 in addition, patients may suffer from a faster decline in lung function, greater airway inflammation, and higher mortality.14

Causes of COPD Exacerbation

COPD exacerbation consists of complex interactions between the host, airway bacteria, respiratory viruses, and environmental pollution. All this together leads to increased respiratory burden. The following are some of the most common viral and bacterial pathogens found in COPD exacerbation:14

  • Viruses
    • Adenovirus
    • Coronavirus
    • Influenza
    • Parainfluenza
    • Respiratory syncytial virus
    • Rhinovirus
  • Bacteria
    • Haemophilus influenzae
    • Moraxella catarrhalis
    • Pseudomonas aeruginosa
    • Streptococcus pneumoniae

Exacerbation Treatment Options

Acute exacerbation is a heterogenous event that is unpredictable and has a higher chance of recurrence. Treatment is focused on improving host responses and targeting causative agents.15 Exacerbations have different phenotypes, each requiring a unique approach to treatment. The following are some of the most common management and treatment techniques for exacerbations:

Corticosteroids for Inflammation

Corticosteroids are commonly used for systemic and airway inflammation during COPD exacerbation.15 Steroids offer multiple benefits, such as reduced hospital stays and admissions, reduced treatment failure, and quicker improvement in lung function and symptoms during exacerbation.15 However, there are some drawbacks to steroid use as well, such as an increased risk of osteoporotic fracture or sepsis.15

Steroid use should be based on the patient’s COPD phenotype; for example, patients with eosinophilic inflammation show positive responses to treatment.15 Generally, shorter courses of treatment have the same result as longer ones, and there is no difference between the oral and intravenous routes of administration.15

Antibiotics and Antivirals for Infection

Antibiotic therapy is often recommended for patients hospitalized with COPD exacerbation, as a bacterial infection is the cause in many of the cases.15 Antibiotic therapy reduces hospital stays and treatment failure rates; however, it is not required in all patients.15 Healthcare professionals use the GOLD guidelines, a system-based approach to determine which patients should receive antibiotics. The guidelines use a combination of severity and symptoms and use the following markers for antibiotic use: 15

  • Increased sputum volume
  • Sputum purulence is present together with dyspnea
  • Symptoms severe enough to require ventilation

For viruses, several antivirals are used, but the clinical benefits are limited. A study evaluating remdesivir and dexamethasone for COPD patients concluded that remdesivir has an improved recovery time compared to placebo for patients with lower respiratory tract involvement. On the other hand, dexamethasone results in reduced mortality in patients requiring ventilation or oxygen.15

Immunostimulants

Immunostimulatory agents also reduce COPD exacerbation frequency. A study evaluating the immunostimulant OM-85, a detoxified oral immunoreactive bacterial extract, showed positive results and reduced hospital admissions and severe symptoms of exacerbation.14

Other pharmacological treatment options include long-acting bronchodilators, anticholinergic agents, phosphodiesterase inhibitors, and mucolytic agents.14

Home Oxygen Therapy

As a non-pharmacological treatment option, home oxygen therapy has many benefits, especially for chronically hypoxemic patients.14 Home oxygen therapy helps in reducing anxiety, depression, and mortality.14 Many researchers, such as Garcia-Aymerich and colleagues, concluded that hypoxemic patients not treated with long-term oxygen therapy have a higher risk of hospital admission.14

Self-Management of COPD

COPD patients are often recommended to include physical activity in their daily routine as it has multiple benefits.14 For instance, studies have shown that patients who join a pulmonary rehabilitation program with physical activity and awareness education benefit from shorter hospital stays than patients who are not part of pulmonary rehabilitation program.14 For some COPD patients, self-management can be difficult, and as such, community support should be provided.14

Nursing Considerations

The following are some of the nursing interventions effective for COPD patients:

  • Nurses play a major role in symptom management by being involved in emergency action plans, including exacerbation management, teaching patients how to maintain a healthy environment, and educating patients on breathing and coughing techniques, physical activity, and smoking cessation.
  • Nurses should also be well-versed in managing the psychological consequences of the disease and help patients deal with anxiety, depression, and intense emotions.
  • Nurses should create individualized nutrition plans based on the patient’s needs, socioeconomic status, weight, and dietary habits.
  • To reduce the risk of infection, patients should be taught proper hand hygiene, limit visitors, and assist the patient in the disposal of waste, tissues, and sputum.
  • Nurses should also educate patients and discuss the importance of follow-up care, routine sputum cultures and chest X-rays., and advise smoking cessation.19,20
Conclusion

Chronic obstructive pulmonary disease presents major challenges for patients and healthcare professionals. In addition to optimal management of symptoms, the economic burden of direct and indirect costs is considerable.1 Moreover, the prognosis of COPD patients varies based on their adherence to treatment and making significant lifestyle changes, such as smoking cessation, avoiding second-hand smoking, including exercise, etc.7

Management of COPD is only possible through a personalized treatment plan and requires a multidisciplinary team involving nurses, a pulmonologist, a thoracic surgeon if surgery is indicated, an intensivist, a respiratory therapist, and specialists in palliative care.7 Nurses play a major role in pulmonary rehabilitation and management, including providing education on maintaining a healthy lifestyle, and providing treatment and management once an exacerbation occurs. Nurses are involved in every part of the treatment process. According to a review, there is a tendency for reductions in anxiety, unscheduled physician visits, and increases in self-efficacy amongst patients who participate in nurse-led self-management programs.19

To prevent frequent exacerbations, patients should be educated about smoking cessation, the importance of physical activity, and adherence to treatment plans. Patients should also be encouraged regarding pulmonary rehabilitation as it improves the quality of life and reduces symptoms.7

References
  1. Iheanacho I, Zhang S, King D, Rizzo M, Ismaila AS. Economic burden of Chronic Obstructive Pulmonary Disease (COPD): A systematic literature review. International Journal of Chronic Obstructive Pulmonary Disease. 2020;Volume 15:439-460. doi:https://doi.org/10.2147/copd.s234942
  2. CDC. Chronic Obstructive Pulmonary Disease (COPD) | CDC. www.cdc.gov. Published March 29, 2021. https://www.cdc.gov/copd/index.html#:~:text=What%20is%20COPD%3F
  3. Anatomy of the Lung | SEER Training. training.seer.cancer.gov. https://training.seer.cancer.gov/lung/anatomy/#:~:text=The%20lungs%20are%20the%20major
  4. Anatomy and Physiology of Breathing | ATrain Education. www.atrainceu.com. https://www.atrainceu.com/content/3-anatomy-and-physiology-breathing#:~:text=COPD%20is%20caused%20by%20a
  5. American Lung Association. Learn About COPD | American Lung Association. Lung.org. Published 2019. https://www.lung.org/lung-health-diseases/lung-disease-lookup/copd/learn-about-copd
  6. National Heart, Lung, and Blood Institute. COPD – What Is COPD? | NHLBI, NIH. www.nhlbi.nih.gov. Published March 24, 2022. https://www.nhlbi.nih.gov/health/copd
  7. Agarwal AK, Raja A, Brown BD. Chronic obstructive pulmonary disease (COPD). PubMed. Published August 8, 2022. https://www.ncbi.nlm.nih.gov/books/NBK559281/
  8. Benlala I, Laurent F, Dournes G. Structural and functional changes in COPD : What we have learned from imaging. Respirology. Published online April 7, 2021. doi:https://doi.org/10.1111/resp.14047
  9. American Lung Association. COPD causes and risk factors | American Lung Association. Lung.org. Published 2021. https://www.lung.org/lung-health-diseases/lung-disease-lookup/copd/what-causes-copd
  10. COPD – Causes and Risk Factors | NHLBI, NIH. www.nhlbi.nih.gov. Published March 24, 2022. https://www.nhlbi.nih.gov/health/copd/causes
  11. Association AL. COPD Symptoms. www.lung.org. https://www.lung.org/lung-health-diseases/lung-disease-lookup/copd/symptoms-diagnosis/symptoms
  12. COPD – Diagnosis | NHLBI, NIH. www.nhlbi.nih.gov. https://www.nhlbi.nih.gov/health/copd/diagnosis#:~:text=The%20main%20test%20for%20COPD
  13. Burge S, Wedzicha JA. COPD exacerbations: definitions and classifications. European Respiratory Journal. 2003;21(Supplement 41):46S53s. doi:https://doi.org/10.1183/09031936.03.00078002
  14. Wedzicha JA, Seemungal TAR. COPD exacerbations: defining their cause and prevention. Lancet (London, England). 2007;370(9589):786-796. doi:https://doi.org/10.1016/S0140-6736(07)61382-8
  15. MacLeod M, Papi A, Contoli M, et al. Chronic obstructive pulmonary disease exacerbation fundamentals: Diagnosis, treatment, prevention, and disease impact. Respirology. 2021;26(6):532-551. doi:https://doi.org/10.1111/resp.14041
  16. Celli BR. Pharmacological Therapy of COPD. Chest. 2018;154(6):1404-1415. doi:https://doi.org/10.1016/j.chest.2018.07.005
  17. Branson RD. Oxygen Therapy in COPD. Respiratory Care. 2018;63(6):734-748. doi:https://doi.org/10.4187/respcare.06312
  18. Information NC for B, Pike USNL of M 8600 R, MD B, Usa 20894. Chronic Obstructive Pulmonary Disease (COPD): Surgical Procedures for the Treatment of COPD. Institute for Quality and Efficiency in Health Care (IQWiG); 2019. https://www.ncbi.nlm.nih.gov/books/NBK543216/
  19. Baker E, Fatoye F. Clinical and cost effectiveness of nurse-led self-management interventions for patients with copd in primary care: A systematic review. International Journal of Nursing Studies. 2017;71:125-138. doi:https://doi.org/10.1016/j.ijnurstu.2017.03.010
  20. R.N MVB. 7 Chronic Obstructive Pulmonary Disease (COPD) Nursing Care Plans. Nurseslabs. Published September 28, 2019. Accessed April 19, 2023. https://nurseslabs.com/chronic-obstructive-pulmonary-disease-copd-nursing-care-plans/#h-imbalanced-nutrition-less-than-body-requirements
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