Respiratory disorder in Elderly

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อ. หนงฤทย โพธศรDyspneaDyspnea 2

My Philosophy of teaching:

Me: make it as simple as you can. No simpler.

You: Interact, ask questions. You will stay awake ;).

No question is dumb, and the answer will be just in front of you.

วตถประสงค การผนแปรออกซเจนในผสงอายคออะไร ? แตกตางจากวยอนอยางไร อบตการณในผสงอาย? การผนแปรออกซเจนชนดตาง ๆ ปอดอกเสบ (Pneumonia) โรคถงลมโปงพองเรอรง (COPD) ภาวะหายใจลาบาก (Dyspnea)การพยาบาลผปวยสงอายทมภาวะผนแปรออกซเจนได

Aging in America

• Adults aged 65+ is a fast growing population– 55 million in 2010– 80 million by 2040

• Importance of managing care transitions– chronic illness and falls

• increases acute and long-term institutional stays• decreases independence in the home setting

ปรามดประชากรของประเทศไทย ป พ.ศ. 2503-2573

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Age of Workers

Percent Growth in U.S. Workforce by Age: 2000-2020

Source: U.S. Census Bureau

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AS WE AGE Maximal Strength Muscle Mass Bone density Visual and Auditory Acuity Fitness Aerobic Capacity Cognitive Speed/Function

Obesity Arthritis High BP Diabetes Depression/Heart Disease Menopausal/Post Menopausal Issues

Impact of Aging

• Nearly one-fifth of Medicare beneficiaries discharged from a hospital return within 30 days– 2 million per year

• Reducing avoidable readmissions– improves patient safety– enhances quality of care– lowers health care spending

Structure and Function Lung Anatomy

Gas exchange Blood Transports Gases Between Lungs & Tissues

Respiratory Changes in AgingPhysiologic changes Clinical correlationkyphoscoliosis, costal ↓ chest wall compliance

cartilage calcification ↑ work of breathing, ↑ diaphargm and abdominal muscle dependency

↓respiratory m.strength ↓ maximal inspiratory & expiratory pressure

↓ elastin in alveolar wall ↓alveolar elasticity recoil↓ distal bronchiole diameter, ↑ closing volume

rearrangement in collagen↑ residual volume ↓ vital capacity, tidal

volume

Respiratory Changes in AgingPhysiologic changes Clinical correlation

thinning of alveolar wall, ↓ alveolar surface areaenlagement of terminal lung unitventilation-perfusion ↓PaO2 =(100-0.32x age)

mismatching↓ FEV1, FVC inadequate coughless effective ciliary action↓ventilatory response to prolonged hypercapniahypercapnia

Changes associated to Aging ↓ recoil and compliance

AP diameter

↓ functional alveoli

↓ in Pa02

Respiratory defense mechanisms less effective

Altered respiratory controls More gradual response to

changes in O2 and Co2 levels in blood

PneumoniaPathophysiology

ปอดอกเสบ (Pneumonia)Acute inflammation of lung (lower respiratory tract) caused by microorganism, comes with fever, focal chest symptomsshadowing on CXR

Epidemiology in Older Age• Incidence of pneumonia increases with aging

and frailty– hospitalisations per year for pneumonia

1.1 / 1000 community-dwelling elderly 33 / 1,000 nursing home residents per year

• Morbidity and mortality from pneumonia increases with aging

Pneumonia

• Nearly half of all cases of pneumonia involve patients > 65 years of age.

• Among nursing home residents, pneumonia is the second most common cause of infection.

• It is also the second most common cause of bacteremia in a nursing home.

Adedipe A, Lowenstein R. Emerg Med Clin N Am 2006; 24(2):433-448.

–‘Physiology’ of ageing–Multi-morbidity–Undernutrition–Reduced functional and

cognitive reserve–Non-specific presentation of

disease

Epidemiology in Older Age

Risk factorspneumonia in older people

• Community dwelling– ‘Silent’ aspiration in 71% of patients

with CAP compared to 10% in controls • Residents of long-term care facilities

– Difficulty swallowing food and medication

– aspiration– Sedative medicines

Pneumonia: Etiology Cause

bacteria (75%) viruses fungi Mycoplasma Parasites chemicals

Pneumonia: Classifications Community-acquired pneumonia (CAP)

Onset in community or during 1st 2 days of hospitalization (Strep. pneumonia most common)

Hospital-acquired Pneumonia(HAP/nosocomial) Occurring 48 hrs or longer after hospitalization

Aspiration pneumonia

Pneumonia caused by opportunistic organisms Pneumocystis Carinii

Pneumonia: Risk FactorsCAP

Older adult Chronic/coexisting

condition Recent history or

exposure to viral or influenza infections

History of tobacco or alcohol use

HAP Older adult Chronic lung disease Aspiration ET, Trach, NG / GT Immunocompromised Mechanical ventilation

Pneumonia: Pathophysiology

NEJM 2000;342:1334-1349

Observed Changes in the Lungs Combine less functional alveoli with slightly

thickened capillaries decreased surface area available for O2-CO2 exchange lower O2 to supply vital organs, especially in setting of acute respiratory illness.

Observed Changes in Aging The respiratory muscles lose strength &

endurance. There is increased stiffness of chest wall (ie,

decreased compliance). Pulmonary vasculature becomes less elastic,

pulm artery thickens & enlarges increased resistance to blood flow in lungs increased pulmonary artery pressure.

Pneumonia: Sign and symptom

Fevers, chills, anorexia Pleuritic chest pain Crackles/wheezes Cough, sputum production Tachypnea

Pneumonia: Clinical Manifestations-Cont.

Mycoplasma (Atypical) feeling tired or weak,

headaches, sore throat, or diarrhea.

Eventually, most develop a dry cough. They can, also, develop fever, chills, earaches, chest pain

“walking pneumonia”

Pneumonia: Complications

Hypoxemia

Pleural effusion

Atelectasis

Pleurisy

Atelectasis Pleurisy

Pleural Effusion

Diagnostics Pulse Oximetry

Chest X-Ray

Computed Tomography (CT scan)

Bronchoscopy

Thoracentesis

Pulmonary Function Tests

Sputum Specimen and Cultures

Diagnostics: Chest X-Ray Cont.

Posterior Anterior View Left Lateral View

Nodule

Infiltrates

Diagnostics: Sputum Specimen

To diagnose; evaluate treatment Specimen: ID organisms or abnormal

cells Culture & Sensitivity (C&S) Cytology Gram stains

(e.g. Acid Fast Bacilli)

Diagnostics: Bronchoscopy

Diagnose problems and assess changes in bronchi/bronchioles

Performed to remove foreign body, secretions, or to obtain specimens of tissue or mucus for further study

Procedure Care/Instructions:NPO 6 -8 hrs priorSedation during procedurePost Procedure:HOB elevatedObserve for hemorrhageNPO until gag reflex returns

Pneumonia: Diagnosis

Diagnosis → Physical exam →

crackles, rhonchi/wheezes

CXR →area of increased density (infiltrates/ consolidation)

Sputum specimen – Gram stain

LUL Infiltrates

Pneumonia :Interventions/Tx Treatment

Antibiotics → choose based on age, suspected cause & immune status

Supportive care → IV fluids, supplemental oxygen therapy, respiratory monitoring, cough enhancement

*may take 6-8 weeks for CXR to normalize

chronic obstructive pulmonary disease : COPD

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COPDChronic obstructive pulmonary disease is a slowly progressive disease that is characterized by a gradual loss of lung functionCOPD includes chronic bronchitis, chronic obstructive bronchitis, or emphysema, or combinations of these conditions

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Epidemiology

20.3 million Americans report having asthma5,000 deaths annually from asthma12.1 million Aging Americans reported being diagnosed with COPD119,000 deaths annually from COPDCOPD is the 4th leading cause of death in the U.S.

Two Major Causes of COPD

Chronic Bronchitis is characterized by– Chronic inflammation and excess mucus

production– Presence of chronic productive cough

Emphysema is characterized by– Damage to the small, sac-like units of the lung

that deliver oxygen into the lung and remove the carbon dioxide

– Chronic cough

*Source: Braman, S. Update on the ATS Guidelines for COPD. Medscape Pulmonary Medicine. 2005;9(1):1.

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Signs and symptoms

WheezingCoughingSputum productionShortness of breath Chest tightness

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Diagnosis

Clinical symptomsChest x-rayLung function testsABGs

Physical Exam

RR, HR, O2 saturation Gen: Barrel-chest, accessory muscle

use CV: Quiet heart sounds Resp: Decreased breath sounds,

wheezing, rhonchi, crackles

Labs

CBC: Hgb/Hct ABG: pH, pCO2

Chemistry: HCO3

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Clinical Features of COPD Patients

Mild COPD: no abnormal signs, smokers cough, little or no breathlessnessModerate COPD: breathlessness with/without wheezing, cough with/without sputumSevere COPD: breathlessness on any exertion/at rest, wheeze and cough prominent, lung inflation usual, cyanosis, peripheral edema, and polycythemia in advanced disease

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DiagnosisSpirometry

Breathing test which measures the amount and rate at which air can pass through the airways

Bronchodilator Reversibility TestingRelaxing tightened muscles around the airways and opening up airways quickly to ease breathing

Other pulmonary function testingDiffusion capacity

Chest X-rayArterial Blood Gas

Shows oxygen level in blood

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Medical Management of COPD Patient

Smoking cessation and elimination of environmental pollutantsPalliative measure such as regular exercise, good nutrition, flu and pneumonia vaccinesBronchodilators, corticosteroids, anticholinergics, and NSAIDs

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Management of COPD PatientReview historyAvoid treatment if upper respiratory tract infection is presentTreat in upright positionAvoid rubber dam in severe casesUse pulse oximetry (if pulse ox <91%, use low flow 2-3L/min)Avoid barbiturates, narcotics, antihistamines, and anticholinergicsIf patient is on steroid regimen, supplement as neededDrug interactions with COPD medication

Respiratory Function COPD

Maintain Adequate Oxygenation and Ventilation

:drive :pump:gas exchange

การใหออกซเจนในผปวย COPD• COPD คอ มการคงของคารบอนไดออกไซดเรอรง (chronic CO2

retention) ทาใหศนยควบคมการหายใจในสมองไมตอบสนองตอการเพมขนของปรมาณคารบอนไดออกไซดแตจะถกกระตนการหายใจดวยภาวะพรองออกซเจน (Hypoxic respiratory drive) เทานน

• ถาไดรบออกซเจนจน PaO2 มากกวา 60 mmHg (SaO2 90 %) อาจทาใหขาดตวกระตนการหายใจ (Cut off hypoxemic ventilator drive)

• ทาใหผปวยหายใจชาลงๆ (hypoventilation) และปรมาณ CO2 ในเลอดแดงจะคงมากขน เรยกวา CO2 narcosis อาจทาใหหยดหายใจ (apnea) และเสยชวต

• การใหออกซเจนในผปวยกลมนควรใหออกซเจนอยางระมดระวงและใหขนาดความเขมขนตาๆโดย FiO2 ไมเกน 0.28 (ถาให nasal cannula ไมเกน 2 LPM) เพอรกษาระดบ PaO2 ใหอยในชวง 55-60 mmHg หรอ SpO2 ประมาณ 85-90%

การใหออกซเจนในผปวย COPD DyspneaBreathing increases in rateDifficulty coughing up secretionsIncreases susceptibility to infections such as a cold or pneumonia

DyspneaDyspnea 55

Respiratory Definitions

Eupnea - normal breathing Bradypnea - decreased breathing rate Tachypnea – breathing very fast. Pt not

always aware of it. Apnea – not breathing at all Hyperpnea - faster and/or deeper

breathing Hyperventilation - rapid breathing with

hypocarbia

Positional Changes• Orthopnea : left-sided heart failure, COPD, or

neuromuscular disorders

• Paroxysmal nocturnal dyspnea : left-sided heart failure, COPD

• Exertional dyspnea : COPD, poor cardiac reserve and abdominal loading, caused by ascites, obesity, or pregnancy, leads to elevation of the diaphragm, resulting in less effective ventilation and dyspnea.

DyspneaEtiologies

A&E(VINAYAKA)

Cause Acute

Bronchial asthma Pneumonia Pneumothorax thromboembolic disease Cardiac Pulmonary oedema Non cardiac pulmonary oedema psychogenic

Chronic

Pulmonary Cause1. COPD Chronic Bronchial Asthma Emphysema Chronic Bronchitis 2. Restrictive Lung Disease Sarcoidosis Rheumatoid lung fibrosing alveolitis Pneumoconosis

DyspneaPhysical Examination: Pulmonary

Inspection Use of accessory muscles Splinting Intercostal retractions

Percussion Hyper-resonance vs. dullness Unilateral vs. bilateral

DyspneaPhysical Examination: Pulmonary

Auscultation Air entry

Stridor = upper airway obstruction Breath sounds

Normal Abnormal

Wheezing, rales, rhonchi, etc. Unilateral vs. bilateral

A&E(VINAYAKA)

AUSCULTATION

CREPTS/CRACKLES

Fever, Cough, s/o of infection

PNEUMONIA/ARDS

SUDDEN ONSET

PUL.EDEMA

WHEEZE

SUDDEN ONSET

MAYBE A F.B OR

ANAPHYLAXIS

KNOWN ASTHMATIC/COP

D

ACUTE EXACERBATION

DyspneaDyspnea 64

What other tools?

PEF ABG Other blood tests CXR EKG CT UltraSound

DyspneaDiagnostic Adjuncts

What lab tests might be useful in dyspnea workup? ABG

If any question about ventilatory or acid-base status Beware of interpretation of (A–a)O2

Troponin How would it be helpful in our patient?

B-type natriuretic protein (BNP) Laboratory studies based on suspected etiology of

dyspnea

DyspneaTreatment

Assuring oxygenation/ventilation Supplemental O2

PaO2 > 60 mm Hg; SpO2 > 90%

Specific Rx depends on working diagnosis

Comfortable Positions if short of breathBreathing Techniques• Start with position of ease• Relax shoulders / upper chest• Diaphragmatic ‘tummy’ breathing

• Breath out twice as long as breath in• Pursed lips on breathing out if needed•

Nursing Process

Nursing Diagnoses…

Impaired gas exchange R/T inflammatory exudate in alveolar space

Pain R/T infection in lung Hyperthermia r/t infection Anxiety r/t dyspnea

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Nursing diagnosis

Ineffective airway clearance r/t thick secretionsImpaired gas exchange r/t altered supply O2Altered health maintenance r/t ineffective individual copingRisk for infection r/t inadequate defense systemAltered role performance r/t changes in role

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Nursing DX

Ineffective breathing pattern r/t musculoskeletal impairment , decreased energyInability to sustain spontaneous ventilation r/t muscle fatigueActivity intolerance r/t imbalance of O2 supply

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PlanningPlanning

Goals: Patient will haveClear breath soundsNormal breathing patternsNo signs of hypoxiaNormal chest x-rayNo complications related to pneumonia

Goals: Patient will haveClear breath soundsNormal breathing patternsNo signs of hypoxiaNormal chest x-rayNo complications related to pneumonia

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Nursing ImplementationNursing Implementation

Teach nutrition, hygiene, rest, regular exercise to maintain natural resistance

Prompt treatment of URIs

Teach nutrition, hygiene, rest, regular exercise to maintain natural resistance

Prompt treatment of URIs

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Nursing ImplementationNursing Implementation

Encourage those at risk to obtain influenza and pneumococcal vaccinationsReposition patient q 2 hAssist patients at risk for aspiration with eating, drinking, and taking meds

Encourage those at risk to obtain influenza and pneumococcal vaccinationsReposition patient q 2 hAssist patients at risk for aspiration with eating, drinking, and taking meds

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Nursing ImplementationNursing Implementation

Assist immobile patients with turning and deep breathingStrict asepsisEmphasize need to take course of medication(s)Teach drug-drug interactions

Assist immobile patients with turning and deep breathingStrict asepsisEmphasize need to take course of medication(s)Teach drug-drug interactions

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EvaluationEvaluation

Dyspnea not presentFree of adventitious breath soundsClears sputum from airwayReports pain controlledVerbalizes causal factorsAdequate fluid and caloric intakePerforms ADLs

Dyspnea not presentFree of adventitious breath soundsClears sputum from airwayReports pain controlledVerbalizes causal factorsAdequate fluid and caloric intakePerforms ADLs

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