Chronic Obstructive Pulmonary Disease

Nurses can help craft treatment and prevention plans tailored to each patient's needs.

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Learning Scope #373
1 contact hour
Expires Dec. 5, 2013

You can earn 1 contact hour of continuing education credit in three ways: 1) For immediate results and certificate; take the test online; grade and certificate are available immediately after taking the test. 2) Mail your completed exam (or a photocopy) along with the $8 fee (check or credit card) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. 3) Fax the completed exam to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.

Merion Matters, Inc. is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 221-3-O-09), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. Merion Matters Inc. is also approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).

The goal of this continuing education offering is to provide nurses with current information on chronic obstructive pulmonary disease (COPD) they can apply to their practice. After reading this article, you will be able to:

1. Define and discuss the stages of COPD.
2. Differentiate between short-/long-acting inhaled beta agonists and short-/long-acting anticholinergic medications for pharmacological management of COPD.
3. Discuss the goals and techniques of pulmonary rehabilitation.

Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease that has a significant impact on a patient's lifestyle. It can prove to be taxing both to the patient and the patient's support system. The natural progression of the disease is variable by individual and generally progressive in nature.

There are two major mechanisms involved in COPD: inflammation and airflow limitation. Treatment and prevention are aimed at minimizing these two components. Inflammation causes small airway disease and airway remodeling in addition to parenchymal destruction, which contributes to loss of elastic recoil and ultimately airflow limitation.1 Cough and sputum production may occur prior to the development of airflow limitation, but is not necessarily obligatory.

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) provides guidelines for staging based on pulmonary function test results. There are four stages: mild (I), moderate (II), severe (III) and very severe (IV). There are pharmacologic treatment recommendations correlating to each stage of the disease (see Table).1 However, clinicians may tailor the treatment regimen to make it specific to each individual, keeping in mind the general guidelines.

Pharmacologic Management

Pharmacologic management of the COPD patient is goal-oriented and directed at the prevention of both progression of the disease and minimizing exacerbations.

Roflumilast (Daliresp) is one of the newest medications approved by the FDA for prophylaxis of COPD exacerbations. It is dosed at 500 mcg daily with caution indicated for hepatic insufficiency. The exact mechanism of action is unknown, but it does selectively inhibit phosphodiesterase 4 (PDE4), a major cyclic AMP-metabolizing enzyme in lung tissue. The goal of therapy is a decreased rate of COPD exacerbations, improved arterial blood gases and pulmonary function tests, reduced use of rescue medication, and greater symptom relief. Common adverse effects for which nurses can educate patients to monitor include weight loss, diarrhea, nausea, loss of appetite, headache, backache, influenza and insomnia. Less commonly, patients experience suicidal thoughts; use should be avoided in patients with baseline depression.

Short-acting inhaled beta agonists (SABAs) are one of the standard classes of medications used for COPD treatment. Bronchodilators relax muscles in the airways and help increase airflow to the lungs. More commonly known as "rescue" medications, albuterol and levalbuterol are examples. Their use is prescribed on an as-needed basis and the need for increasing frequency could be indicative of an imminent exacerbation or progression of disease.

Long-acting inhaled beta agonists (LABAs) are more commonly used as maintenance medications for the management of COPD patients. Examples include arformoterol (Brovana) and formoterol (Foradil or Perforomist). They are taken twice daily and are not used as rescue medications. LABAs can also be found in combination with inhaled corticosteroids. Inhaled corticosteroids are anti-inflammatory agents that work to reduce inflammation in the airways, increase lung function, and reduce symptoms and frequency of exacerbations. Nursing implications include patient teaching as it relates to side effect monitoring. Patients often complain of feeling "jittery" after the use of SABAs or LABAs. They often experience tachycardia that most find tolerable, but they should be instructed to inform their nurse or other healthcare provider should they find the side effects to be intolerable.

Ipratropium (Atrovent) and Tiotropium (Spiriva) are examples of short- and long-acting anticholinergic agents, respectively, that are commonly used in the treatment of COPD. They act to antagonize acetylcholine receptors, thereby producing bronchodilation. Their use is usually in addition to SABAs or LABAs. The duration of shorter-acting agents is 6-8 hours, whereas the longer-acting agent lasts for 24 hours or more. Urinary retention is a side effect that requires medication cessation and intervention. Aminophylline and Theophylline (Theo-24) belong to the methylxanthine drug class, and though the mechanism of action is unclear, they have been found to be effective in decreasing exacerbations in COPD patients. However, there is a concern for toxicity with this class of drugs, the most concerning of which are tachyarrhythmias.

Use of Antibiotics

Antibiotics have shown to be beneficial in the treatment of patients with acute exacerbations of COPD who present with an increase in sputum volume, dyspnea and sputum purulence. There also was a benefit with antibiotic use for patients who had only two of the three symptoms listed above. The infectious component of COPD could be viral or bacterial in nature. The most common bacteria found in patients with COPD exacerbations are S. pneumoniae, M. catarrhalis, and H. influenzae.

Macrolide antibiotics have been shown to have anti-inflammatory properties. Azithromycin dosed at 250 mg daily in addition to usual treatment was shown to be effective in decreasing COPD exacerbations.2 Hearing loss is a possible side effect of macrolide therapy and was noted in a small percentage of the patients who participated in the study to determine the effectiveness of azithromycin in the COPD population. Nurses are integral in educating patients to monitor for potential side effects such as hearing loss, gastrointestinal symptoms or palpitations that may be indicative of dysrhythmias.

Delivery Route

The chosen method of delivery for inhaled medication is of significant importance. A nebulized medication seemingly provides more symptomatic relief for patients, likely due to the fact delivery method via nebulizer presents reduced potential for user-dependent error.

On the contrary, metered dose inhalers (MDI) have a great potential for user error, as patients are not always appropriately educated in their use. Nurses can play an integral role in educating the patient as to the appropriate technique for the use of their MDI.

Proper MDI administration includes these four steps:

1) Shake the inhaler and remove the cap, breathe out fully.

2) Use the "open mouth" method, holding the inhaler 1-2 inches from the mouth.

3) Take a deep breath in slowly while pressing down on the inhaler to release the medication.

4) Hold inspiration for a count of 10, and then breathe out slowly. Repeat as prescribed.

Improper use leads to an insufficient amount of medication delivery and subsequent inadequate relief of symptoms. Nursing care is tantamount in educating patients in the proper technique for use of MDIs to ensure adequate delivery of medication as prescribed.

Corticosteroids

Systemic corticosteroids are used in the maintenance of patients with severe COPD who cannot remain asymptomatic once they are withdrawn. Prednisone is most commonly used in various doses individualized to the patient. Intravenous corticosteroids are used to manage acute exacerbations of COPD in the hospitalized patient.

Nurses must recognize the need to provide education to patients on the chronic use of corticosteroids and to monitor for side effects. Commonly reported side effects include, but are not limited to, weight gain due to increased appetite, hyperglycemia, mood changes, "moon" face, cataracts and altered sleep patterns. Patients should monitor for signs and symptoms of osteopenia and osteoporosis and avoid activities that could potentially lead to fractures.

Patients also should be educated to supplement their diets with calcium and vitamin D in addition to performing weight-bearing and weight-lifting activities as much as possible to promote bone density. Bone density should be monitored regularly through the use of dexa scans. Patients diagnosed with osteoporosis should be placed on a medication such as alendronate to promote bone density.

Oxygen Therapy

Oxygen therapy is another form of supportive treatment for patients with COPD. It has been useful in improving breathlessness during exercise in individuals with COPD. It is hypothesized the perceived decrease in breathlessness is attributable to improved pulmonary hemodynamics.3

In spite of therapeutic benefits of oxygen therapy in decreasing patients' perceptions of breathlessness and improved oxygen delivery to peripheral tissues, there are concerns long-term therapy could cause hypercapnia in COPD patients. However, nocturnal oxygen has been shown to be superior to no oxygen therapy and continuous oxygen therapy is comparatively superior to nocturnal therapy in decreasing the rate of mortality.

Liter flow is individualized to each patient and is determined by an oxygen titration study during a 6-minute walk test. Higher-than-normal carbon dioxide levels are expected in the chronic COPD patient, and the term "permissive hypercapnia" is frequently utilized. However, hypoxemia is poorly tolerated and oxygen therapy should be appropriately utilized.

Non-Pharmacologic Interventions

Non-pharmacologic interventions also are integral in the management of patients with COPD and can prove to be as effective, if not more so, than pharmacologic measurements. They help contribute to feelings of normalcy and prevent the inadequacy often felt by those who live in chronic disease states.

Patients with COPD worry about experiencing loneliness, depression, and social isolation due to increased dyspnea and fatigue. They may lack the motivation to participate in daily activities. Patients with COPD experience a progressive deterioration from an early stage up to the end stage of the disease. Many experience a severely limited and declining performance status and increasingly sedentary lifestyle. Increased physical disability leads to muscular and cardiovascular deconditioning. Improving the quality of life of patients with COPD is a major goal of COPD management and an important health outcome to consider in managing the disease.

Pulmonary rehabilitation is a non-pharmacological treatment of COPD. Pulmonary rehabilitation is a gold standard of treatment for managing people with COPD. Pulmonary rehabilitation is defined by the American Thoracic Society as "an evidence-based, multidisciplinary and comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activities. Integrated into the individualized treatment of the patient, pulmonary rehabilitation is designed to reduce symptoms, optimize functional status, increase participation and reduce healthcare costs through stabilizing or reversing systemic manifestations of the disease." The principal goals for pulmonary rehabilitation are to improve quality of life, reduce symptoms, reduce hospitalizations and increase active participation in day-to-day activities.

Pulmonary rehabilitation varies from program to program but at Temple University Hospital's Temple Lung Center in Philadelphia, pulmonary rehabilitation consists of exercise training tailored to each patient's needs and goals, education concerning pulmonary disease and the effects on daily lifestyles, secretion clearance, nutrition counseling, and education regarding breathing techniques. It also includes energy conservation, medications, stress management and emotional support.

Patients are assessed on an individual basis regarding medical and social aspects; a plan is initiated and communicated to the medical team to promote a multidisciplinary approach to obtain optimal patient outcomes. Sessions usually are 2-3 times a week for 30-60 minutes each. The majority of insurance plans will pay for one complete program consisting of 36 sessions unless an exacerbation of COPD or hospitalization occurs.

Exercise Regimens

Exercise is a main component of pulmonary rehabilitation. A reduction in exercise tolerance is one of the chief complaints of people with chronic lung disease. Lower-extremity endurance exercise modalities consist of ground walking, treadmill walking, and stationary cycling with the initial intensity of less than 60 percent of exercise test peak work and initial duration of 10 minutes. With tolerance of the initial intensity and duration of lower extremity exercises, confirmed by limited symptoms of dyspnea and a target heart rate based on the Karvonen method, patients should progress to 20 minutes of continuous exercise with increased intensity.

Upper-extremity exercises include a combination of unsupported arm lefts and upper extremity cycle ergometry with a possible progression to free weights of 1 pound or less. Additionally, leg squats, stair climbing and flexibility exercises are integrated into the program as the sessions progress. The use of supplemental oxygen and bronchodilators, if prescribed, may allow the patient to exercise with greater intensity and less dyspnea. Patients are given written instructions about the nature of the exercises, patient safety and how to maintain them at home.

With pulmonary rehabilitation at the Temple Lung Center, there is a comprehensive educational training that involve topics such as energy conservation techniques with activities of daily living and exercising, medications, self-management of an exacerbation, breathing retraining, sexuality, and traveling, just to name a few. Weight management and nutrition can become a balancing act for the COPD patient as well as depression and anxiety due to increased breathlessness. Patients may need additional outpatient referrals to a registered dietician and/or psychiatrist for further evaluation. With classes on meal preparations and timing of meals, the use of dietary supplements, managing stress and coping with chronic illness through pulmonary rehabilitation, the patient can likely have an increase in quality of life.

Regular exercise can help decrease shortness of breath, depression, risk factors for heart disease, and some side effects of medications used to treat COPD. Exercise increases energy level, muscle strength and endurance, and the ability to fight infections.

Pulmonary rehabilitation is beneficial at any stage of COPD with improvement in exercise tolerance, breathlessness and fatigue. Pulmonary rehabilitation will not reverse damage that has occurred to the lung, but will help with coping skills, self-management of the disease, and completion of daily tasks such as dressing, walking and cooking.

Smoking Cessation

Smoking cessation is another non-pharmacologic modification that can be crucial to the management of patients with COPD. Progression of the disease can be slowed or stopped once the causative noxious stimuli are removed.

Successful withdrawal from cigarette smoking can be achieved with the help of pharmacologic aids such as nicotine replacements, Chantix or Wellbutrin. Dedicated smoking cessation clinics and support groups with the involvement of trained smoking cessation staff can also prove integral in the patient's ability to successfully overcome this addiction.

Nurses can prove integral in recognizing and identifying patients who are willing to stop smoking and would benefit from added support. The best intervention is to refer them to a specialized smoking cessation program such as the one recently implemented at Temple Lung Center. Such programs have specialized staff that can assess the needs of the patient and determine by which means smoking cessation can be achieved. They provide detailed information as to how pharmacologic agents work and what side effects could occur.

Future Approaches

There are many potential directions the treatment or prevention of COPD can take. Research is currently in progress that can significantly alter what we know about the medical management of patients with COPD. Telemedicine is being piloted to assess the outcomes of patients who report their symptoms at least once daily and are managed by nurses per physician established protocols. The effect of high levels of positive pressure ventilation and long-term oxygen use are also being studied.

Research is the key to determine how we will care for our patients in the future. Our mothers may have had more insight than we knew when they told us to eat our vegetables. Who would think that broccoli extract might have an impact on COPD? It is currently one of many trials open for enrollment at Temple Lung Center. Only time and the discoveries of current and future research will tell.

To view the Course Outline and take the test online, click here.

For a printer-friendly version of the exam you can print out, complete and mail in to ADVANCE, click here.

References
for this article can be accessed here.

Tiffaney S. Randolph is a nurse practitioner for pulmonary and critical care medicine specializing in transplant medicine and advanced lung disease at Temple University Hospital, Philadelphia. Asia Kemp is a pulmonary nurse specialist specializing in advanced lung disease at the Temple Lung Center. The authors have completed disclosure forms and report no relationships relevant to the content of this article.




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