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DOS CME Course 2011
Breathe in then out What was so hard about that
Catherine Skowronsky MSN ACNS RNClinical Nurse Specialist Adult Health
Medicine Institute
1
DOS CME Course 20112
DOS CME Course 2011
Objectives
bull Discuss the anatomy and physiology of the pulmonary system
bull Discuss the proper assessment of the pulmonary system
bull Explain the pathophysiology of asthma and smoking related illnesses
bull Describe nursing interventions for the patient with chronic respiratory illness
3
DOS CME Course 2011
General structure
bull Cartilage maintains patent trachea
bull Upper airways warm and moisten
bull Mucous maintains moisture traps irritants
bull Cilia brush away damaging items
4
DOS CME Course 2011
Structure of the airways
bull Rigid cartilage maintains patency of the trachea
bull Bronchi contain no cartilage but smooth muscle
ndashAir pressure keeps them open
bull Smaller airways bronchioles also held open by air pressure
bull Smooth muscle may constrict or dilate with neurological or physical stimuli
ndashMore on that later
5
DOS CME Course 2011
Thorax bull Pleura
ndashSlippery lining of the pleural cavity
ndashPleural lines the inside of the thorax
ndashVisceral covers the lungs
bull Purpose is to ease friction as lungs rub against thorax
bull Pleural cavity filled with fluid
ndashConstantly produced then drained
ndashMaintains constant volume
ndashLymphatics exert constant suction as fluid is drained
6
DOS CME Course 2011
Functions
bull Ventilation refers to the inflow and outflow of air
ndashInhalation and expiration
bull Gas exchange is the diffusion of oxygen and carbon dioxide across the alveolar walls
bull Oxygen transport relies on a continuous supply of blood between the lungs and tissues
Guyton amp Hall 2006
7
DOS CME Course 2011
Ventilation
bull Relies on patency of the upper airways and coordination of the thoracic musculature
bull Inspiration
ndashRib cage moves up and out as the diaphragm drops
ndashIncreases negative thoracic pressure
ndashElasticity of the lung parenchyma allows them to expand as the alveoli fill
bull Exhalation
ndashRib cage moves down and in
Guyton amp Hall 2006
8
DOS CME Course 2011
Lungs
bull Right lung
ndashUpper
ndashMiddle
ndashLower
bull Left
ndashUpper
ndashLower
ndashCardiac notch
9
DOS CME Course 2011
Breathe in then out
(Modified from McCance KL Huether SE editors Pathophysiology the biologic basis for disease in adults and children ed 5 St Louis 2006 Mosby)
Active
Passive
10
DOS CME Course 2011
Alveoli
11
DOS CME Course 2011
Alveoli
12
DOS CME Course 2011
Surfactant
bull Produced by type-II pneumocytes within the alveoli
bull Composed of cholesterol and phospholipids
bull Decreases surface tension to facilitate oxygen transport across the alveolar membrane
bull Removal is associated with respiratory failure
bull May be removed byndash Fluid (aspiration)
ndash Inhaled irritants
13
DOS CME Course 2011
Gas exchange
bull Movement of oxygen into the blood
bull Exchanged with carbon dioxide from the capillaries to the alveoli
Merckmanual 2006
14
DOS CME Course 2011
The brains of the outfitbull Medulla oblongata and pons control respiration
bull The smooth muscle of the airways is controlled by the autonomic nervous system
ndashParasympathetic
ndashrelaxed
ndashbronchoconstriction
ndashSympathetic
ndashfight or flight
ndashbronchodilation
ndashIncreased respiratory rate
15
DOS CME Course 2011
Assessment Inspection
bull Use your powers of observation
bull Respiratory raterhythm and quality of breathing
ndashRetracting use of accessory muscles
bull Chest diameter
ndashbarrel pigeon and funnel chest kyphosis scoliosis
bull Symmetry of chest movement
ndashanterior and posterior
bull Sound of breathing without a stethoscope
ndashCan you hear wheezing or moisture as they walk in
16
DOS CME Course 2011
Assessment Inspection
bull Color of skin nails lips
ndashCyanosis ashen
ndashClubbed fingernails
17
DOS CME Course 2011
Let the patient be your guide
bull Good history
bull Pain
bull Are you sometimes uncomfortably aware of your breathing
bull How many pillows do you usendash Recliner chair
bull How far can you walk before you need to rest
bull Do you ever pass up activities because of lack of energy
18
DOS CME Course 2011
Landmarks
19
DOS CME Course 2011
Assessment Palpation
bull Thoracic Expansion
ndashThumbs at 10th rib
ndashUnequal indicating pneumonia pleural effusion bronchial obstruction on one side
bull Crepitus
ndashFree air indicating pneumothorax
20
DOS CME Course 2011
Assessment Palpationbull Tactile fremitus
ndash Palpable vibration of sound waves
ndash Place palms or sides of hands on landmarks while the patient repeats a phrase
ndash Ninety nine toy boat
bull Increased over areas of consolidation
bull Decreased over areas which are fluid filledndash Pneumonia
ndash Pleural effusion
21
DOS CME Course 2011
Assessment percussion
Percussion Technique
Place the middle finger over the intercostal spaceTap it briskly with the middle finger of your dominant hand
22
DOS CME Course 2011
Assessmentbull Percussion
bull Resonantndash Over areas of normal lung inflation
bull Flatndash Soft high short
bull Dullndash loud low long
bull Tympanicndash Loud high
bull Hyperresonantndash Loud low long
23
DOS CME Course 2011
Crackles (Rales)
bull Adventitious
bull Noise produced by fluid-filled alveoli opening
bull Typically occur during inspirationndashmay be described as early middle late
ndashdiscontinuous sound
bull Sounds like velcro pulling pulled or when you rub your hair together
bull May be present in elderly bedridden or can be a normal finding in some people
24
DOS CME Course 2011
Crackles
bull Air bubbling through fluid or secretionsndash typically coarse low-pitched sounds longer in duration
ndash may clear with coughing or suctioning
bull Sudden opening of airwaysndash produced by rapid equalization of pressure between patent and
collapsed airways
ndash softer high-pitched sounds short duration
bull Associated withndash Atelectasis
ndash Lobar Pneumonia
ndash Pulmonary Edema
ndash Interstitial Fibrosis
25
DOS CME Course 2011
Wheezes
bull Continuous musical sounds
bull May be produced on inspiration or exhalation
bull More often heard on exhalationndash classified as high or low pitched
bull Associated with obstruction of airways
bull Pitch of the wheeze depends on severity of airway obstruction
bull Sudden cessation of wheezing may be an ominous sign
bull Associated withndash Asthmandash Chronic Bronchitisndash Cystic Fibrosis
26
DOS CME Course 2011
Rhonchi
bull Low pitched continuous coarse sounds
bull Sounds like snoring
bull May be heard on inspiration or exhalation
bull Frequently associated with smokers
bull Caused by mucus moving in large airways
bull Upon auscultation appear and disappear in a disorganized pattern
bull Associated with ndash Pneumonia
ndash Bronchitis or bronchiectasis
ndash Atelectasis
27
DOS CME Course 2011
Bronchial
bull Location - heard over trachea amp bronchus
bull Intensity - loud harsh and high pitched
28
DOS CME Course 2011
Objectives
bull Discuss the anatomy and physiology of the pulmonary system
bull Discuss the proper assessment of the pulmonary system
bull Explain the pathophysiology of asthma and smoking related illnesses
bull Describe nursing interventions for the patient with chronic respiratory illness
3
DOS CME Course 2011
General structure
bull Cartilage maintains patent trachea
bull Upper airways warm and moisten
bull Mucous maintains moisture traps irritants
bull Cilia brush away damaging items
4
DOS CME Course 2011
Structure of the airways
bull Rigid cartilage maintains patency of the trachea
bull Bronchi contain no cartilage but smooth muscle
ndashAir pressure keeps them open
bull Smaller airways bronchioles also held open by air pressure
bull Smooth muscle may constrict or dilate with neurological or physical stimuli
ndashMore on that later
5
DOS CME Course 2011
Thorax bull Pleura
ndashSlippery lining of the pleural cavity
ndashPleural lines the inside of the thorax
ndashVisceral covers the lungs
bull Purpose is to ease friction as lungs rub against thorax
bull Pleural cavity filled with fluid
ndashConstantly produced then drained
ndashMaintains constant volume
ndashLymphatics exert constant suction as fluid is drained
6
DOS CME Course 2011
Functions
bull Ventilation refers to the inflow and outflow of air
ndashInhalation and expiration
bull Gas exchange is the diffusion of oxygen and carbon dioxide across the alveolar walls
bull Oxygen transport relies on a continuous supply of blood between the lungs and tissues
Guyton amp Hall 2006
7
DOS CME Course 2011
Ventilation
bull Relies on patency of the upper airways and coordination of the thoracic musculature
bull Inspiration
ndashRib cage moves up and out as the diaphragm drops
ndashIncreases negative thoracic pressure
ndashElasticity of the lung parenchyma allows them to expand as the alveoli fill
bull Exhalation
ndashRib cage moves down and in
Guyton amp Hall 2006
8
DOS CME Course 2011
Lungs
bull Right lung
ndashUpper
ndashMiddle
ndashLower
bull Left
ndashUpper
ndashLower
ndashCardiac notch
9
DOS CME Course 2011
Breathe in then out
(Modified from McCance KL Huether SE editors Pathophysiology the biologic basis for disease in adults and children ed 5 St Louis 2006 Mosby)
Active
Passive
10
DOS CME Course 2011
Alveoli
11
DOS CME Course 2011
Alveoli
12
DOS CME Course 2011
Surfactant
bull Produced by type-II pneumocytes within the alveoli
bull Composed of cholesterol and phospholipids
bull Decreases surface tension to facilitate oxygen transport across the alveolar membrane
bull Removal is associated with respiratory failure
bull May be removed byndash Fluid (aspiration)
ndash Inhaled irritants
13
DOS CME Course 2011
Gas exchange
bull Movement of oxygen into the blood
bull Exchanged with carbon dioxide from the capillaries to the alveoli
Merckmanual 2006
14
DOS CME Course 2011
The brains of the outfitbull Medulla oblongata and pons control respiration
bull The smooth muscle of the airways is controlled by the autonomic nervous system
ndashParasympathetic
ndashrelaxed
ndashbronchoconstriction
ndashSympathetic
ndashfight or flight
ndashbronchodilation
ndashIncreased respiratory rate
15
DOS CME Course 2011
Assessment Inspection
bull Use your powers of observation
bull Respiratory raterhythm and quality of breathing
ndashRetracting use of accessory muscles
bull Chest diameter
ndashbarrel pigeon and funnel chest kyphosis scoliosis
bull Symmetry of chest movement
ndashanterior and posterior
bull Sound of breathing without a stethoscope
ndashCan you hear wheezing or moisture as they walk in
16
DOS CME Course 2011
Assessment Inspection
bull Color of skin nails lips
ndashCyanosis ashen
ndashClubbed fingernails
17
DOS CME Course 2011
Let the patient be your guide
bull Good history
bull Pain
bull Are you sometimes uncomfortably aware of your breathing
bull How many pillows do you usendash Recliner chair
bull How far can you walk before you need to rest
bull Do you ever pass up activities because of lack of energy
18
DOS CME Course 2011
Landmarks
19
DOS CME Course 2011
Assessment Palpation
bull Thoracic Expansion
ndashThumbs at 10th rib
ndashUnequal indicating pneumonia pleural effusion bronchial obstruction on one side
bull Crepitus
ndashFree air indicating pneumothorax
20
DOS CME Course 2011
Assessment Palpationbull Tactile fremitus
ndash Palpable vibration of sound waves
ndash Place palms or sides of hands on landmarks while the patient repeats a phrase
ndash Ninety nine toy boat
bull Increased over areas of consolidation
bull Decreased over areas which are fluid filledndash Pneumonia
ndash Pleural effusion
21
DOS CME Course 2011
Assessment percussion
Percussion Technique
Place the middle finger over the intercostal spaceTap it briskly with the middle finger of your dominant hand
22
DOS CME Course 2011
Assessmentbull Percussion
bull Resonantndash Over areas of normal lung inflation
bull Flatndash Soft high short
bull Dullndash loud low long
bull Tympanicndash Loud high
bull Hyperresonantndash Loud low long
23
DOS CME Course 2011
Crackles (Rales)
bull Adventitious
bull Noise produced by fluid-filled alveoli opening
bull Typically occur during inspirationndashmay be described as early middle late
ndashdiscontinuous sound
bull Sounds like velcro pulling pulled or when you rub your hair together
bull May be present in elderly bedridden or can be a normal finding in some people
24
DOS CME Course 2011
Crackles
bull Air bubbling through fluid or secretionsndash typically coarse low-pitched sounds longer in duration
ndash may clear with coughing or suctioning
bull Sudden opening of airwaysndash produced by rapid equalization of pressure between patent and
collapsed airways
ndash softer high-pitched sounds short duration
bull Associated withndash Atelectasis
ndash Lobar Pneumonia
ndash Pulmonary Edema
ndash Interstitial Fibrosis
25
DOS CME Course 2011
Wheezes
bull Continuous musical sounds
bull May be produced on inspiration or exhalation
bull More often heard on exhalationndash classified as high or low pitched
bull Associated with obstruction of airways
bull Pitch of the wheeze depends on severity of airway obstruction
bull Sudden cessation of wheezing may be an ominous sign
bull Associated withndash Asthmandash Chronic Bronchitisndash Cystic Fibrosis
26
DOS CME Course 2011
Rhonchi
bull Low pitched continuous coarse sounds
bull Sounds like snoring
bull May be heard on inspiration or exhalation
bull Frequently associated with smokers
bull Caused by mucus moving in large airways
bull Upon auscultation appear and disappear in a disorganized pattern
bull Associated with ndash Pneumonia
ndash Bronchitis or bronchiectasis
ndash Atelectasis
27
DOS CME Course 2011
Bronchial
bull Location - heard over trachea amp bronchus
bull Intensity - loud harsh and high pitched
28
DOS CME Course 2011
Structure of the airways
bull Rigid cartilage maintains patency of the trachea
bull Bronchi contain no cartilage but smooth muscle
ndashAir pressure keeps them open
bull Smaller airways bronchioles also held open by air pressure
bull Smooth muscle may constrict or dilate with neurological or physical stimuli
ndashMore on that later
5
DOS CME Course 2011
Thorax bull Pleura
ndashSlippery lining of the pleural cavity
ndashPleural lines the inside of the thorax
ndashVisceral covers the lungs
bull Purpose is to ease friction as lungs rub against thorax
bull Pleural cavity filled with fluid
ndashConstantly produced then drained
ndashMaintains constant volume
ndashLymphatics exert constant suction as fluid is drained
6
DOS CME Course 2011
Functions
bull Ventilation refers to the inflow and outflow of air
ndashInhalation and expiration
bull Gas exchange is the diffusion of oxygen and carbon dioxide across the alveolar walls
bull Oxygen transport relies on a continuous supply of blood between the lungs and tissues
Guyton amp Hall 2006
7
DOS CME Course 2011
Ventilation
bull Relies on patency of the upper airways and coordination of the thoracic musculature
bull Inspiration
ndashRib cage moves up and out as the diaphragm drops
ndashIncreases negative thoracic pressure
ndashElasticity of the lung parenchyma allows them to expand as the alveoli fill
bull Exhalation
ndashRib cage moves down and in
Guyton amp Hall 2006
8
DOS CME Course 2011
Lungs
bull Right lung
ndashUpper
ndashMiddle
ndashLower
bull Left
ndashUpper
ndashLower
ndashCardiac notch
9
DOS CME Course 2011
Breathe in then out
(Modified from McCance KL Huether SE editors Pathophysiology the biologic basis for disease in adults and children ed 5 St Louis 2006 Mosby)
Active
Passive
10
DOS CME Course 2011
Alveoli
11
DOS CME Course 2011
Alveoli
12
DOS CME Course 2011
Surfactant
bull Produced by type-II pneumocytes within the alveoli
bull Composed of cholesterol and phospholipids
bull Decreases surface tension to facilitate oxygen transport across the alveolar membrane
bull Removal is associated with respiratory failure
bull May be removed byndash Fluid (aspiration)
ndash Inhaled irritants
13
DOS CME Course 2011
Gas exchange
bull Movement of oxygen into the blood
bull Exchanged with carbon dioxide from the capillaries to the alveoli
Merckmanual 2006
14
DOS CME Course 2011
The brains of the outfitbull Medulla oblongata and pons control respiration
bull The smooth muscle of the airways is controlled by the autonomic nervous system
ndashParasympathetic
ndashrelaxed
ndashbronchoconstriction
ndashSympathetic
ndashfight or flight
ndashbronchodilation
ndashIncreased respiratory rate
15
DOS CME Course 2011
Assessment Inspection
bull Use your powers of observation
bull Respiratory raterhythm and quality of breathing
ndashRetracting use of accessory muscles
bull Chest diameter
ndashbarrel pigeon and funnel chest kyphosis scoliosis
bull Symmetry of chest movement
ndashanterior and posterior
bull Sound of breathing without a stethoscope
ndashCan you hear wheezing or moisture as they walk in
16
DOS CME Course 2011
Assessment Inspection
bull Color of skin nails lips
ndashCyanosis ashen
ndashClubbed fingernails
17
DOS CME Course 2011
Let the patient be your guide
bull Good history
bull Pain
bull Are you sometimes uncomfortably aware of your breathing
bull How many pillows do you usendash Recliner chair
bull How far can you walk before you need to rest
bull Do you ever pass up activities because of lack of energy
18
DOS CME Course 2011
Landmarks
19
DOS CME Course 2011
Assessment Palpation
bull Thoracic Expansion
ndashThumbs at 10th rib
ndashUnequal indicating pneumonia pleural effusion bronchial obstruction on one side
bull Crepitus
ndashFree air indicating pneumothorax
20
DOS CME Course 2011
Assessment Palpationbull Tactile fremitus
ndash Palpable vibration of sound waves
ndash Place palms or sides of hands on landmarks while the patient repeats a phrase
ndash Ninety nine toy boat
bull Increased over areas of consolidation
bull Decreased over areas which are fluid filledndash Pneumonia
ndash Pleural effusion
21
DOS CME Course 2011
Assessment percussion
Percussion Technique
Place the middle finger over the intercostal spaceTap it briskly with the middle finger of your dominant hand
22
DOS CME Course 2011
Assessmentbull Percussion
bull Resonantndash Over areas of normal lung inflation
bull Flatndash Soft high short
bull Dullndash loud low long
bull Tympanicndash Loud high
bull Hyperresonantndash Loud low long
23
DOS CME Course 2011
Crackles (Rales)
bull Adventitious
bull Noise produced by fluid-filled alveoli opening
bull Typically occur during inspirationndashmay be described as early middle late
ndashdiscontinuous sound
bull Sounds like velcro pulling pulled or when you rub your hair together
bull May be present in elderly bedridden or can be a normal finding in some people
24
DOS CME Course 2011
Crackles
bull Air bubbling through fluid or secretionsndash typically coarse low-pitched sounds longer in duration
ndash may clear with coughing or suctioning
bull Sudden opening of airwaysndash produced by rapid equalization of pressure between patent and
collapsed airways
ndash softer high-pitched sounds short duration
bull Associated withndash Atelectasis
ndash Lobar Pneumonia
ndash Pulmonary Edema
ndash Interstitial Fibrosis
25
DOS CME Course 2011
Wheezes
bull Continuous musical sounds
bull May be produced on inspiration or exhalation
bull More often heard on exhalationndash classified as high or low pitched
bull Associated with obstruction of airways
bull Pitch of the wheeze depends on severity of airway obstruction
bull Sudden cessation of wheezing may be an ominous sign
bull Associated withndash Asthmandash Chronic Bronchitisndash Cystic Fibrosis
26
DOS CME Course 2011
Rhonchi
bull Low pitched continuous coarse sounds
bull Sounds like snoring
bull May be heard on inspiration or exhalation
bull Frequently associated with smokers
bull Caused by mucus moving in large airways
bull Upon auscultation appear and disappear in a disorganized pattern
bull Associated with ndash Pneumonia
ndash Bronchitis or bronchiectasis
ndash Atelectasis
27
DOS CME Course 2011
Bronchial
bull Location - heard over trachea amp bronchus
bull Intensity - loud harsh and high pitched
28
DOS CME Course 2011
Functions
bull Ventilation refers to the inflow and outflow of air
ndashInhalation and expiration
bull Gas exchange is the diffusion of oxygen and carbon dioxide across the alveolar walls
bull Oxygen transport relies on a continuous supply of blood between the lungs and tissues
Guyton amp Hall 2006
7
DOS CME Course 2011
Ventilation
bull Relies on patency of the upper airways and coordination of the thoracic musculature
bull Inspiration
ndashRib cage moves up and out as the diaphragm drops
ndashIncreases negative thoracic pressure
ndashElasticity of the lung parenchyma allows them to expand as the alveoli fill
bull Exhalation
ndashRib cage moves down and in
Guyton amp Hall 2006
8
DOS CME Course 2011
Lungs
bull Right lung
ndashUpper
ndashMiddle
ndashLower
bull Left
ndashUpper
ndashLower
ndashCardiac notch
9
DOS CME Course 2011
Breathe in then out
(Modified from McCance KL Huether SE editors Pathophysiology the biologic basis for disease in adults and children ed 5 St Louis 2006 Mosby)
Active
Passive
10
DOS CME Course 2011
Alveoli
11
DOS CME Course 2011
Alveoli
12
DOS CME Course 2011
Surfactant
bull Produced by type-II pneumocytes within the alveoli
bull Composed of cholesterol and phospholipids
bull Decreases surface tension to facilitate oxygen transport across the alveolar membrane
bull Removal is associated with respiratory failure
bull May be removed byndash Fluid (aspiration)
ndash Inhaled irritants
13
DOS CME Course 2011
Gas exchange
bull Movement of oxygen into the blood
bull Exchanged with carbon dioxide from the capillaries to the alveoli
Merckmanual 2006
14
DOS CME Course 2011
The brains of the outfitbull Medulla oblongata and pons control respiration
bull The smooth muscle of the airways is controlled by the autonomic nervous system
ndashParasympathetic
ndashrelaxed
ndashbronchoconstriction
ndashSympathetic
ndashfight or flight
ndashbronchodilation
ndashIncreased respiratory rate
15
DOS CME Course 2011
Assessment Inspection
bull Use your powers of observation
bull Respiratory raterhythm and quality of breathing
ndashRetracting use of accessory muscles
bull Chest diameter
ndashbarrel pigeon and funnel chest kyphosis scoliosis
bull Symmetry of chest movement
ndashanterior and posterior
bull Sound of breathing without a stethoscope
ndashCan you hear wheezing or moisture as they walk in
16
DOS CME Course 2011
Assessment Inspection
bull Color of skin nails lips
ndashCyanosis ashen
ndashClubbed fingernails
17
DOS CME Course 2011
Let the patient be your guide
bull Good history
bull Pain
bull Are you sometimes uncomfortably aware of your breathing
bull How many pillows do you usendash Recliner chair
bull How far can you walk before you need to rest
bull Do you ever pass up activities because of lack of energy
18
DOS CME Course 2011
Landmarks
19
DOS CME Course 2011
Assessment Palpation
bull Thoracic Expansion
ndashThumbs at 10th rib
ndashUnequal indicating pneumonia pleural effusion bronchial obstruction on one side
bull Crepitus
ndashFree air indicating pneumothorax
20
DOS CME Course 2011
Assessment Palpationbull Tactile fremitus
ndash Palpable vibration of sound waves
ndash Place palms or sides of hands on landmarks while the patient repeats a phrase
ndash Ninety nine toy boat
bull Increased over areas of consolidation
bull Decreased over areas which are fluid filledndash Pneumonia
ndash Pleural effusion
21
DOS CME Course 2011
Assessment percussion
Percussion Technique
Place the middle finger over the intercostal spaceTap it briskly with the middle finger of your dominant hand
22
DOS CME Course 2011
Assessmentbull Percussion
bull Resonantndash Over areas of normal lung inflation
bull Flatndash Soft high short
bull Dullndash loud low long
bull Tympanicndash Loud high
bull Hyperresonantndash Loud low long
23
DOS CME Course 2011
Crackles (Rales)
bull Adventitious
bull Noise produced by fluid-filled alveoli opening
bull Typically occur during inspirationndashmay be described as early middle late
ndashdiscontinuous sound
bull Sounds like velcro pulling pulled or when you rub your hair together
bull May be present in elderly bedridden or can be a normal finding in some people
24
DOS CME Course 2011
Crackles
bull Air bubbling through fluid or secretionsndash typically coarse low-pitched sounds longer in duration
ndash may clear with coughing or suctioning
bull Sudden opening of airwaysndash produced by rapid equalization of pressure between patent and
collapsed airways
ndash softer high-pitched sounds short duration
bull Associated withndash Atelectasis
ndash Lobar Pneumonia
ndash Pulmonary Edema
ndash Interstitial Fibrosis
25
DOS CME Course 2011
Wheezes
bull Continuous musical sounds
bull May be produced on inspiration or exhalation
bull More often heard on exhalationndash classified as high or low pitched
bull Associated with obstruction of airways
bull Pitch of the wheeze depends on severity of airway obstruction
bull Sudden cessation of wheezing may be an ominous sign
bull Associated withndash Asthmandash Chronic Bronchitisndash Cystic Fibrosis
26
DOS CME Course 2011
Rhonchi
bull Low pitched continuous coarse sounds
bull Sounds like snoring
bull May be heard on inspiration or exhalation
bull Frequently associated with smokers
bull Caused by mucus moving in large airways
bull Upon auscultation appear and disappear in a disorganized pattern
bull Associated with ndash Pneumonia
ndash Bronchitis or bronchiectasis
ndash Atelectasis
27
DOS CME Course 2011
Bronchial
bull Location - heard over trachea amp bronchus
bull Intensity - loud harsh and high pitched
28
DOS CME Course 2011
Lungs
bull Right lung
ndashUpper
ndashMiddle
ndashLower
bull Left
ndashUpper
ndashLower
ndashCardiac notch
9
DOS CME Course 2011
Breathe in then out
(Modified from McCance KL Huether SE editors Pathophysiology the biologic basis for disease in adults and children ed 5 St Louis 2006 Mosby)
Active
Passive
10
DOS CME Course 2011
Alveoli
11
DOS CME Course 2011
Alveoli
12
DOS CME Course 2011
Surfactant
bull Produced by type-II pneumocytes within the alveoli
bull Composed of cholesterol and phospholipids
bull Decreases surface tension to facilitate oxygen transport across the alveolar membrane
bull Removal is associated with respiratory failure
bull May be removed byndash Fluid (aspiration)
ndash Inhaled irritants
13
DOS CME Course 2011
Gas exchange
bull Movement of oxygen into the blood
bull Exchanged with carbon dioxide from the capillaries to the alveoli
Merckmanual 2006
14
DOS CME Course 2011
The brains of the outfitbull Medulla oblongata and pons control respiration
bull The smooth muscle of the airways is controlled by the autonomic nervous system
ndashParasympathetic
ndashrelaxed
ndashbronchoconstriction
ndashSympathetic
ndashfight or flight
ndashbronchodilation
ndashIncreased respiratory rate
15
DOS CME Course 2011
Assessment Inspection
bull Use your powers of observation
bull Respiratory raterhythm and quality of breathing
ndashRetracting use of accessory muscles
bull Chest diameter
ndashbarrel pigeon and funnel chest kyphosis scoliosis
bull Symmetry of chest movement
ndashanterior and posterior
bull Sound of breathing without a stethoscope
ndashCan you hear wheezing or moisture as they walk in
16
DOS CME Course 2011
Assessment Inspection
bull Color of skin nails lips
ndashCyanosis ashen
ndashClubbed fingernails
17
DOS CME Course 2011
Let the patient be your guide
bull Good history
bull Pain
bull Are you sometimes uncomfortably aware of your breathing
bull How many pillows do you usendash Recliner chair
bull How far can you walk before you need to rest
bull Do you ever pass up activities because of lack of energy
18
DOS CME Course 2011
Landmarks
19
DOS CME Course 2011
Assessment Palpation
bull Thoracic Expansion
ndashThumbs at 10th rib
ndashUnequal indicating pneumonia pleural effusion bronchial obstruction on one side
bull Crepitus
ndashFree air indicating pneumothorax
20
DOS CME Course 2011
Assessment Palpationbull Tactile fremitus
ndash Palpable vibration of sound waves
ndash Place palms or sides of hands on landmarks while the patient repeats a phrase
ndash Ninety nine toy boat
bull Increased over areas of consolidation
bull Decreased over areas which are fluid filledndash Pneumonia
ndash Pleural effusion
21
DOS CME Course 2011
Assessment percussion
Percussion Technique
Place the middle finger over the intercostal spaceTap it briskly with the middle finger of your dominant hand
22
DOS CME Course 2011
Assessmentbull Percussion
bull Resonantndash Over areas of normal lung inflation
bull Flatndash Soft high short
bull Dullndash loud low long
bull Tympanicndash Loud high
bull Hyperresonantndash Loud low long
23
DOS CME Course 2011
Crackles (Rales)
bull Adventitious
bull Noise produced by fluid-filled alveoli opening
bull Typically occur during inspirationndashmay be described as early middle late
ndashdiscontinuous sound
bull Sounds like velcro pulling pulled or when you rub your hair together
bull May be present in elderly bedridden or can be a normal finding in some people
24
DOS CME Course 2011
Crackles
bull Air bubbling through fluid or secretionsndash typically coarse low-pitched sounds longer in duration
ndash may clear with coughing or suctioning
bull Sudden opening of airwaysndash produced by rapid equalization of pressure between patent and
collapsed airways
ndash softer high-pitched sounds short duration
bull Associated withndash Atelectasis
ndash Lobar Pneumonia
ndash Pulmonary Edema
ndash Interstitial Fibrosis
25
DOS CME Course 2011
Wheezes
bull Continuous musical sounds
bull May be produced on inspiration or exhalation
bull More often heard on exhalationndash classified as high or low pitched
bull Associated with obstruction of airways
bull Pitch of the wheeze depends on severity of airway obstruction
bull Sudden cessation of wheezing may be an ominous sign
bull Associated withndash Asthmandash Chronic Bronchitisndash Cystic Fibrosis
26
DOS CME Course 2011
Rhonchi
bull Low pitched continuous coarse sounds
bull Sounds like snoring
bull May be heard on inspiration or exhalation
bull Frequently associated with smokers
bull Caused by mucus moving in large airways
bull Upon auscultation appear and disappear in a disorganized pattern
bull Associated with ndash Pneumonia
ndash Bronchitis or bronchiectasis
ndash Atelectasis
27
DOS CME Course 2011
Bronchial
bull Location - heard over trachea amp bronchus
bull Intensity - loud harsh and high pitched
28
DOS CME Course 2011
Alveoli
11
DOS CME Course 2011
Alveoli
12
DOS CME Course 2011
Surfactant
bull Produced by type-II pneumocytes within the alveoli
bull Composed of cholesterol and phospholipids
bull Decreases surface tension to facilitate oxygen transport across the alveolar membrane
bull Removal is associated with respiratory failure
bull May be removed byndash Fluid (aspiration)
ndash Inhaled irritants
13
DOS CME Course 2011
Gas exchange
bull Movement of oxygen into the blood
bull Exchanged with carbon dioxide from the capillaries to the alveoli
Merckmanual 2006
14
DOS CME Course 2011
The brains of the outfitbull Medulla oblongata and pons control respiration
bull The smooth muscle of the airways is controlled by the autonomic nervous system
ndashParasympathetic
ndashrelaxed
ndashbronchoconstriction
ndashSympathetic
ndashfight or flight
ndashbronchodilation
ndashIncreased respiratory rate
15
DOS CME Course 2011
Assessment Inspection
bull Use your powers of observation
bull Respiratory raterhythm and quality of breathing
ndashRetracting use of accessory muscles
bull Chest diameter
ndashbarrel pigeon and funnel chest kyphosis scoliosis
bull Symmetry of chest movement
ndashanterior and posterior
bull Sound of breathing without a stethoscope
ndashCan you hear wheezing or moisture as they walk in
16
DOS CME Course 2011
Assessment Inspection
bull Color of skin nails lips
ndashCyanosis ashen
ndashClubbed fingernails
17
DOS CME Course 2011
Let the patient be your guide
bull Good history
bull Pain
bull Are you sometimes uncomfortably aware of your breathing
bull How many pillows do you usendash Recliner chair
bull How far can you walk before you need to rest
bull Do you ever pass up activities because of lack of energy
18
DOS CME Course 2011
Landmarks
19
DOS CME Course 2011
Assessment Palpation
bull Thoracic Expansion
ndashThumbs at 10th rib
ndashUnequal indicating pneumonia pleural effusion bronchial obstruction on one side
bull Crepitus
ndashFree air indicating pneumothorax
20
DOS CME Course 2011
Assessment Palpationbull Tactile fremitus
ndash Palpable vibration of sound waves
ndash Place palms or sides of hands on landmarks while the patient repeats a phrase
ndash Ninety nine toy boat
bull Increased over areas of consolidation
bull Decreased over areas which are fluid filledndash Pneumonia
ndash Pleural effusion
21
DOS CME Course 2011
Assessment percussion
Percussion Technique
Place the middle finger over the intercostal spaceTap it briskly with the middle finger of your dominant hand
22
DOS CME Course 2011
Assessmentbull Percussion
bull Resonantndash Over areas of normal lung inflation
bull Flatndash Soft high short
bull Dullndash loud low long
bull Tympanicndash Loud high
bull Hyperresonantndash Loud low long
23
DOS CME Course 2011
Crackles (Rales)
bull Adventitious
bull Noise produced by fluid-filled alveoli opening
bull Typically occur during inspirationndashmay be described as early middle late
ndashdiscontinuous sound
bull Sounds like velcro pulling pulled or when you rub your hair together
bull May be present in elderly bedridden or can be a normal finding in some people
24
DOS CME Course 2011
Crackles
bull Air bubbling through fluid or secretionsndash typically coarse low-pitched sounds longer in duration
ndash may clear with coughing or suctioning
bull Sudden opening of airwaysndash produced by rapid equalization of pressure between patent and
collapsed airways
ndash softer high-pitched sounds short duration
bull Associated withndash Atelectasis
ndash Lobar Pneumonia
ndash Pulmonary Edema
ndash Interstitial Fibrosis
25
DOS CME Course 2011
Wheezes
bull Continuous musical sounds
bull May be produced on inspiration or exhalation
bull More often heard on exhalationndash classified as high or low pitched
bull Associated with obstruction of airways
bull Pitch of the wheeze depends on severity of airway obstruction
bull Sudden cessation of wheezing may be an ominous sign
bull Associated withndash Asthmandash Chronic Bronchitisndash Cystic Fibrosis
26
DOS CME Course 2011
Rhonchi
bull Low pitched continuous coarse sounds
bull Sounds like snoring
bull May be heard on inspiration or exhalation
bull Frequently associated with smokers
bull Caused by mucus moving in large airways
bull Upon auscultation appear and disappear in a disorganized pattern
bull Associated with ndash Pneumonia
ndash Bronchitis or bronchiectasis
ndash Atelectasis
27
DOS CME Course 2011
Bronchial
bull Location - heard over trachea amp bronchus
bull Intensity - loud harsh and high pitched
28
DOS CME Course 2011
Surfactant
bull Produced by type-II pneumocytes within the alveoli
bull Composed of cholesterol and phospholipids
bull Decreases surface tension to facilitate oxygen transport across the alveolar membrane
bull Removal is associated with respiratory failure
bull May be removed byndash Fluid (aspiration)
ndash Inhaled irritants
13
DOS CME Course 2011
Gas exchange
bull Movement of oxygen into the blood
bull Exchanged with carbon dioxide from the capillaries to the alveoli
Merckmanual 2006
14
DOS CME Course 2011
The brains of the outfitbull Medulla oblongata and pons control respiration
bull The smooth muscle of the airways is controlled by the autonomic nervous system
ndashParasympathetic
ndashrelaxed
ndashbronchoconstriction
ndashSympathetic
ndashfight or flight
ndashbronchodilation
ndashIncreased respiratory rate
15
DOS CME Course 2011
Assessment Inspection
bull Use your powers of observation
bull Respiratory raterhythm and quality of breathing
ndashRetracting use of accessory muscles
bull Chest diameter
ndashbarrel pigeon and funnel chest kyphosis scoliosis
bull Symmetry of chest movement
ndashanterior and posterior
bull Sound of breathing without a stethoscope
ndashCan you hear wheezing or moisture as they walk in
16
DOS CME Course 2011
Assessment Inspection
bull Color of skin nails lips
ndashCyanosis ashen
ndashClubbed fingernails
17
DOS CME Course 2011
Let the patient be your guide
bull Good history
bull Pain
bull Are you sometimes uncomfortably aware of your breathing
bull How many pillows do you usendash Recliner chair
bull How far can you walk before you need to rest
bull Do you ever pass up activities because of lack of energy
18
DOS CME Course 2011
Landmarks
19
DOS CME Course 2011
Assessment Palpation
bull Thoracic Expansion
ndashThumbs at 10th rib
ndashUnequal indicating pneumonia pleural effusion bronchial obstruction on one side
bull Crepitus
ndashFree air indicating pneumothorax
20
DOS CME Course 2011
Assessment Palpationbull Tactile fremitus
ndash Palpable vibration of sound waves
ndash Place palms or sides of hands on landmarks while the patient repeats a phrase
ndash Ninety nine toy boat
bull Increased over areas of consolidation
bull Decreased over areas which are fluid filledndash Pneumonia
ndash Pleural effusion
21
DOS CME Course 2011
Assessment percussion
Percussion Technique
Place the middle finger over the intercostal spaceTap it briskly with the middle finger of your dominant hand
22
DOS CME Course 2011
Assessmentbull Percussion
bull Resonantndash Over areas of normal lung inflation
bull Flatndash Soft high short
bull Dullndash loud low long
bull Tympanicndash Loud high
bull Hyperresonantndash Loud low long
23
DOS CME Course 2011
Crackles (Rales)
bull Adventitious
bull Noise produced by fluid-filled alveoli opening
bull Typically occur during inspirationndashmay be described as early middle late
ndashdiscontinuous sound
bull Sounds like velcro pulling pulled or when you rub your hair together
bull May be present in elderly bedridden or can be a normal finding in some people
24
DOS CME Course 2011
Crackles
bull Air bubbling through fluid or secretionsndash typically coarse low-pitched sounds longer in duration
ndash may clear with coughing or suctioning
bull Sudden opening of airwaysndash produced by rapid equalization of pressure between patent and
collapsed airways
ndash softer high-pitched sounds short duration
bull Associated withndash Atelectasis
ndash Lobar Pneumonia
ndash Pulmonary Edema
ndash Interstitial Fibrosis
25
DOS CME Course 2011
Wheezes
bull Continuous musical sounds
bull May be produced on inspiration or exhalation
bull More often heard on exhalationndash classified as high or low pitched
bull Associated with obstruction of airways
bull Pitch of the wheeze depends on severity of airway obstruction
bull Sudden cessation of wheezing may be an ominous sign
bull Associated withndash Asthmandash Chronic Bronchitisndash Cystic Fibrosis
26
DOS CME Course 2011
Rhonchi
bull Low pitched continuous coarse sounds
bull Sounds like snoring
bull May be heard on inspiration or exhalation
bull Frequently associated with smokers
bull Caused by mucus moving in large airways
bull Upon auscultation appear and disappear in a disorganized pattern
bull Associated with ndash Pneumonia
ndash Bronchitis or bronchiectasis
ndash Atelectasis
27
DOS CME Course 2011
Bronchial
bull Location - heard over trachea amp bronchus
bull Intensity - loud harsh and high pitched
28
DOS CME Course 2011
The brains of the outfitbull Medulla oblongata and pons control respiration
bull The smooth muscle of the airways is controlled by the autonomic nervous system
ndashParasympathetic
ndashrelaxed
ndashbronchoconstriction
ndashSympathetic
ndashfight or flight
ndashbronchodilation
ndashIncreased respiratory rate
15
DOS CME Course 2011
Assessment Inspection
bull Use your powers of observation
bull Respiratory raterhythm and quality of breathing
ndashRetracting use of accessory muscles
bull Chest diameter
ndashbarrel pigeon and funnel chest kyphosis scoliosis
bull Symmetry of chest movement
ndashanterior and posterior
bull Sound of breathing without a stethoscope
ndashCan you hear wheezing or moisture as they walk in
16
DOS CME Course 2011
Assessment Inspection
bull Color of skin nails lips
ndashCyanosis ashen
ndashClubbed fingernails
17
DOS CME Course 2011
Let the patient be your guide
bull Good history
bull Pain
bull Are you sometimes uncomfortably aware of your breathing
bull How many pillows do you usendash Recliner chair
bull How far can you walk before you need to rest
bull Do you ever pass up activities because of lack of energy
18
DOS CME Course 2011
Landmarks
19
DOS CME Course 2011
Assessment Palpation
bull Thoracic Expansion
ndashThumbs at 10th rib
ndashUnequal indicating pneumonia pleural effusion bronchial obstruction on one side
bull Crepitus
ndashFree air indicating pneumothorax
20
DOS CME Course 2011
Assessment Palpationbull Tactile fremitus
ndash Palpable vibration of sound waves
ndash Place palms or sides of hands on landmarks while the patient repeats a phrase
ndash Ninety nine toy boat
bull Increased over areas of consolidation
bull Decreased over areas which are fluid filledndash Pneumonia
ndash Pleural effusion
21
DOS CME Course 2011
Assessment percussion
Percussion Technique
Place the middle finger over the intercostal spaceTap it briskly with the middle finger of your dominant hand
22
DOS CME Course 2011
Assessmentbull Percussion
bull Resonantndash Over areas of normal lung inflation
bull Flatndash Soft high short
bull Dullndash loud low long
bull Tympanicndash Loud high
bull Hyperresonantndash Loud low long
23
DOS CME Course 2011
Crackles (Rales)
bull Adventitious
bull Noise produced by fluid-filled alveoli opening
bull Typically occur during inspirationndashmay be described as early middle late
ndashdiscontinuous sound
bull Sounds like velcro pulling pulled or when you rub your hair together
bull May be present in elderly bedridden or can be a normal finding in some people
24
DOS CME Course 2011
Crackles
bull Air bubbling through fluid or secretionsndash typically coarse low-pitched sounds longer in duration
ndash may clear with coughing or suctioning
bull Sudden opening of airwaysndash produced by rapid equalization of pressure between patent and
collapsed airways
ndash softer high-pitched sounds short duration
bull Associated withndash Atelectasis
ndash Lobar Pneumonia
ndash Pulmonary Edema
ndash Interstitial Fibrosis
25
DOS CME Course 2011
Wheezes
bull Continuous musical sounds
bull May be produced on inspiration or exhalation
bull More often heard on exhalationndash classified as high or low pitched
bull Associated with obstruction of airways
bull Pitch of the wheeze depends on severity of airway obstruction
bull Sudden cessation of wheezing may be an ominous sign
bull Associated withndash Asthmandash Chronic Bronchitisndash Cystic Fibrosis
26
DOS CME Course 2011
Rhonchi
bull Low pitched continuous coarse sounds
bull Sounds like snoring
bull May be heard on inspiration or exhalation
bull Frequently associated with smokers
bull Caused by mucus moving in large airways
bull Upon auscultation appear and disappear in a disorganized pattern
bull Associated with ndash Pneumonia
ndash Bronchitis or bronchiectasis
ndash Atelectasis
27
DOS CME Course 2011
Bronchial
bull Location - heard over trachea amp bronchus
bull Intensity - loud harsh and high pitched
28
DOS CME Course 2011
Assessment Inspection
bull Color of skin nails lips
ndashCyanosis ashen
ndashClubbed fingernails
17
DOS CME Course 2011
Let the patient be your guide
bull Good history
bull Pain
bull Are you sometimes uncomfortably aware of your breathing
bull How many pillows do you usendash Recliner chair
bull How far can you walk before you need to rest
bull Do you ever pass up activities because of lack of energy
18
DOS CME Course 2011
Landmarks
19
DOS CME Course 2011
Assessment Palpation
bull Thoracic Expansion
ndashThumbs at 10th rib
ndashUnequal indicating pneumonia pleural effusion bronchial obstruction on one side
bull Crepitus
ndashFree air indicating pneumothorax
20
DOS CME Course 2011
Assessment Palpationbull Tactile fremitus
ndash Palpable vibration of sound waves
ndash Place palms or sides of hands on landmarks while the patient repeats a phrase
ndash Ninety nine toy boat
bull Increased over areas of consolidation
bull Decreased over areas which are fluid filledndash Pneumonia
ndash Pleural effusion
21
DOS CME Course 2011
Assessment percussion
Percussion Technique
Place the middle finger over the intercostal spaceTap it briskly with the middle finger of your dominant hand
22
DOS CME Course 2011
Assessmentbull Percussion
bull Resonantndash Over areas of normal lung inflation
bull Flatndash Soft high short
bull Dullndash loud low long
bull Tympanicndash Loud high
bull Hyperresonantndash Loud low long
23
DOS CME Course 2011
Crackles (Rales)
bull Adventitious
bull Noise produced by fluid-filled alveoli opening
bull Typically occur during inspirationndashmay be described as early middle late
ndashdiscontinuous sound
bull Sounds like velcro pulling pulled or when you rub your hair together
bull May be present in elderly bedridden or can be a normal finding in some people
24
DOS CME Course 2011
Crackles
bull Air bubbling through fluid or secretionsndash typically coarse low-pitched sounds longer in duration
ndash may clear with coughing or suctioning
bull Sudden opening of airwaysndash produced by rapid equalization of pressure between patent and
collapsed airways
ndash softer high-pitched sounds short duration
bull Associated withndash Atelectasis
ndash Lobar Pneumonia
ndash Pulmonary Edema
ndash Interstitial Fibrosis
25
DOS CME Course 2011
Wheezes
bull Continuous musical sounds
bull May be produced on inspiration or exhalation
bull More often heard on exhalationndash classified as high or low pitched
bull Associated with obstruction of airways
bull Pitch of the wheeze depends on severity of airway obstruction
bull Sudden cessation of wheezing may be an ominous sign
bull Associated withndash Asthmandash Chronic Bronchitisndash Cystic Fibrosis
26
DOS CME Course 2011
Rhonchi
bull Low pitched continuous coarse sounds
bull Sounds like snoring
bull May be heard on inspiration or exhalation
bull Frequently associated with smokers
bull Caused by mucus moving in large airways
bull Upon auscultation appear and disappear in a disorganized pattern
bull Associated with ndash Pneumonia
ndash Bronchitis or bronchiectasis
ndash Atelectasis
27
DOS CME Course 2011
Bronchial
bull Location - heard over trachea amp bronchus
bull Intensity - loud harsh and high pitched
28
DOS CME Course 2011
Landmarks
19
DOS CME Course 2011
Assessment Palpation
bull Thoracic Expansion
ndashThumbs at 10th rib
ndashUnequal indicating pneumonia pleural effusion bronchial obstruction on one side
bull Crepitus
ndashFree air indicating pneumothorax
20
DOS CME Course 2011
Assessment Palpationbull Tactile fremitus
ndash Palpable vibration of sound waves
ndash Place palms or sides of hands on landmarks while the patient repeats a phrase
ndash Ninety nine toy boat
bull Increased over areas of consolidation
bull Decreased over areas which are fluid filledndash Pneumonia
ndash Pleural effusion
21
DOS CME Course 2011
Assessment percussion
Percussion Technique
Place the middle finger over the intercostal spaceTap it briskly with the middle finger of your dominant hand
22
DOS CME Course 2011
Assessmentbull Percussion
bull Resonantndash Over areas of normal lung inflation
bull Flatndash Soft high short
bull Dullndash loud low long
bull Tympanicndash Loud high
bull Hyperresonantndash Loud low long
23
DOS CME Course 2011
Crackles (Rales)
bull Adventitious
bull Noise produced by fluid-filled alveoli opening
bull Typically occur during inspirationndashmay be described as early middle late
ndashdiscontinuous sound
bull Sounds like velcro pulling pulled or when you rub your hair together
bull May be present in elderly bedridden or can be a normal finding in some people
24
DOS CME Course 2011
Crackles
bull Air bubbling through fluid or secretionsndash typically coarse low-pitched sounds longer in duration
ndash may clear with coughing or suctioning
bull Sudden opening of airwaysndash produced by rapid equalization of pressure between patent and
collapsed airways
ndash softer high-pitched sounds short duration
bull Associated withndash Atelectasis
ndash Lobar Pneumonia
ndash Pulmonary Edema
ndash Interstitial Fibrosis
25
DOS CME Course 2011
Wheezes
bull Continuous musical sounds
bull May be produced on inspiration or exhalation
bull More often heard on exhalationndash classified as high or low pitched
bull Associated with obstruction of airways
bull Pitch of the wheeze depends on severity of airway obstruction
bull Sudden cessation of wheezing may be an ominous sign
bull Associated withndash Asthmandash Chronic Bronchitisndash Cystic Fibrosis
26
DOS CME Course 2011
Rhonchi
bull Low pitched continuous coarse sounds
bull Sounds like snoring
bull May be heard on inspiration or exhalation
bull Frequently associated with smokers
bull Caused by mucus moving in large airways
bull Upon auscultation appear and disappear in a disorganized pattern
bull Associated with ndash Pneumonia
ndash Bronchitis or bronchiectasis
ndash Atelectasis
27
DOS CME Course 2011
Bronchial
bull Location - heard over trachea amp bronchus
bull Intensity - loud harsh and high pitched
28
DOS CME Course 2011
Assessment Palpationbull Tactile fremitus
ndash Palpable vibration of sound waves
ndash Place palms or sides of hands on landmarks while the patient repeats a phrase
ndash Ninety nine toy boat
bull Increased over areas of consolidation
bull Decreased over areas which are fluid filledndash Pneumonia
ndash Pleural effusion
21
DOS CME Course 2011
Assessment percussion
Percussion Technique
Place the middle finger over the intercostal spaceTap it briskly with the middle finger of your dominant hand
22
DOS CME Course 2011
Assessmentbull Percussion
bull Resonantndash Over areas of normal lung inflation
bull Flatndash Soft high short
bull Dullndash loud low long
bull Tympanicndash Loud high
bull Hyperresonantndash Loud low long
23
DOS CME Course 2011
Crackles (Rales)
bull Adventitious
bull Noise produced by fluid-filled alveoli opening
bull Typically occur during inspirationndashmay be described as early middle late
ndashdiscontinuous sound
bull Sounds like velcro pulling pulled or when you rub your hair together
bull May be present in elderly bedridden or can be a normal finding in some people
24
DOS CME Course 2011
Crackles
bull Air bubbling through fluid or secretionsndash typically coarse low-pitched sounds longer in duration
ndash may clear with coughing or suctioning
bull Sudden opening of airwaysndash produced by rapid equalization of pressure between patent and
collapsed airways
ndash softer high-pitched sounds short duration
bull Associated withndash Atelectasis
ndash Lobar Pneumonia
ndash Pulmonary Edema
ndash Interstitial Fibrosis
25
DOS CME Course 2011
Wheezes
bull Continuous musical sounds
bull May be produced on inspiration or exhalation
bull More often heard on exhalationndash classified as high or low pitched
bull Associated with obstruction of airways
bull Pitch of the wheeze depends on severity of airway obstruction
bull Sudden cessation of wheezing may be an ominous sign
bull Associated withndash Asthmandash Chronic Bronchitisndash Cystic Fibrosis
26
DOS CME Course 2011
Rhonchi
bull Low pitched continuous coarse sounds
bull Sounds like snoring
bull May be heard on inspiration or exhalation
bull Frequently associated with smokers
bull Caused by mucus moving in large airways
bull Upon auscultation appear and disappear in a disorganized pattern
bull Associated with ndash Pneumonia
ndash Bronchitis or bronchiectasis
ndash Atelectasis
27
DOS CME Course 2011
Bronchial
bull Location - heard over trachea amp bronchus
bull Intensity - loud harsh and high pitched
28
DOS CME Course 2011
Assessmentbull Percussion
bull Resonantndash Over areas of normal lung inflation
bull Flatndash Soft high short
bull Dullndash loud low long
bull Tympanicndash Loud high
bull Hyperresonantndash Loud low long
23
DOS CME Course 2011
Crackles (Rales)
bull Adventitious
bull Noise produced by fluid-filled alveoli opening
bull Typically occur during inspirationndashmay be described as early middle late
ndashdiscontinuous sound
bull Sounds like velcro pulling pulled or when you rub your hair together
bull May be present in elderly bedridden or can be a normal finding in some people
24
DOS CME Course 2011
Crackles
bull Air bubbling through fluid or secretionsndash typically coarse low-pitched sounds longer in duration
ndash may clear with coughing or suctioning
bull Sudden opening of airwaysndash produced by rapid equalization of pressure between patent and
collapsed airways
ndash softer high-pitched sounds short duration
bull Associated withndash Atelectasis
ndash Lobar Pneumonia
ndash Pulmonary Edema
ndash Interstitial Fibrosis
25
DOS CME Course 2011
Wheezes
bull Continuous musical sounds
bull May be produced on inspiration or exhalation
bull More often heard on exhalationndash classified as high or low pitched
bull Associated with obstruction of airways
bull Pitch of the wheeze depends on severity of airway obstruction
bull Sudden cessation of wheezing may be an ominous sign
bull Associated withndash Asthmandash Chronic Bronchitisndash Cystic Fibrosis
26
DOS CME Course 2011
Rhonchi
bull Low pitched continuous coarse sounds
bull Sounds like snoring
bull May be heard on inspiration or exhalation
bull Frequently associated with smokers
bull Caused by mucus moving in large airways
bull Upon auscultation appear and disappear in a disorganized pattern
bull Associated with ndash Pneumonia
ndash Bronchitis or bronchiectasis
ndash Atelectasis
27
DOS CME Course 2011
Bronchial
bull Location - heard over trachea amp bronchus
bull Intensity - loud harsh and high pitched
28
DOS CME Course 2011
Crackles
bull Air bubbling through fluid or secretionsndash typically coarse low-pitched sounds longer in duration
ndash may clear with coughing or suctioning
bull Sudden opening of airwaysndash produced by rapid equalization of pressure between patent and
collapsed airways
ndash softer high-pitched sounds short duration
bull Associated withndash Atelectasis
ndash Lobar Pneumonia
ndash Pulmonary Edema
ndash Interstitial Fibrosis
25
DOS CME Course 2011
Wheezes
bull Continuous musical sounds
bull May be produced on inspiration or exhalation
bull More often heard on exhalationndash classified as high or low pitched
bull Associated with obstruction of airways
bull Pitch of the wheeze depends on severity of airway obstruction
bull Sudden cessation of wheezing may be an ominous sign
bull Associated withndash Asthmandash Chronic Bronchitisndash Cystic Fibrosis
26
DOS CME Course 2011
Rhonchi
bull Low pitched continuous coarse sounds
bull Sounds like snoring
bull May be heard on inspiration or exhalation
bull Frequently associated with smokers
bull Caused by mucus moving in large airways
bull Upon auscultation appear and disappear in a disorganized pattern
bull Associated with ndash Pneumonia
ndash Bronchitis or bronchiectasis
ndash Atelectasis
27
DOS CME Course 2011
Bronchial
bull Location - heard over trachea amp bronchus
bull Intensity - loud harsh and high pitched
28
DOS CME Course 2011
Rhonchi
bull Low pitched continuous coarse sounds
bull Sounds like snoring
bull May be heard on inspiration or exhalation
bull Frequently associated with smokers
bull Caused by mucus moving in large airways
bull Upon auscultation appear and disappear in a disorganized pattern
bull Associated with ndash Pneumonia
ndash Bronchitis or bronchiectasis
ndash Atelectasis
27
DOS CME Course 2011
Bronchial
bull Location - heard over trachea amp bronchus
bull Intensity - loud harsh and high pitched
28
DOS CME Course 2011
Bronchovesicular
bull Location - heard just distal to central airways
bull Intensity - softer and lower pitched than bronchial breath sounds
29
DOS CME Course 2011
Vesicular
bull Location - heard in all lung fields distal to the central airways
bull Intensity - soft sounding primarily an inspiratory sound
30
DOS CME Course 2011
Crackles bull Abnormal sound due to pneumonia fibrosis or congestive
heart failure
ndashProduced by the alveoli as they inflate
bull Discontinuous
bull Non-musical and brief
bull Like dots in time
31
DOS CME Course 2011
Wheezes
bull Abnormal sound associated with narrowed airways as a result of edema inflammation or secretions
bull High-pitched and continuous
bull Like dashes in time
32
DOS CME Course 2011
Rhonchi
bull Abnormal lung sounds associated with secretions in the large airways
bull Continuous snoring sound
bull May be in inspiration or exhalation
33
DOS CME Course 2011DOS CME Course 201134
Asthma Diagnosis and management
Every Life Deserves World Class Care
34
DOS CME Course 2011
Asthma by the numbers
bull Who gets asthma
bull In the United States (2007)ndash13 are children ndash89 are femalendash65 are male
bull Medical carecosts (2006)ndash106 million asthma-related visits to doctorsrsquo officesndashAnnual cost of $106 billion dollars annuallyndash444000 hospital discharges related to asthmandashAverage length of stay of 32 days
35
DOS CME Course 2011
Asthma by the numbers
bull 300 million people suffer from asthma
bull In 2005 255000 asthma-related fatalities
ndashMuch lower than other chronic illnesses
bull Most common chronic disease among children
bull Crosses economic levels
ndashMost deaths seen at lower and low-middle incomes
bull Underdiagnosed and undertreated
36
DOS CME Course 2011
Asthma
bull Chronic disease characterized by inflammation of the airways ndash Episodes of breathlessness- ldquoattacksrdquo
ndash Exacerbation of inflammation and mucous plugs
ndash Vary in frequency duration and severity
bull Onset at any time of life
37
DOS CME Course 2011
Asthmabull Aggravating factors may include
ndash exercisendash viral infectionndash animal exposure ndash house dust mites ndash mold ndash smoke ndash pollen ndash changes in weatherndash menses ndash exposure to airborne chemicals or dustsndash exposure to cockroach secretions ndash Sulfites in food shrimp dried fruit processed potatoes beer
and wineDOS wheezing protocol
38
DOS CME Course 2011
Asthma
bull History and physical ndash Do you sometimes struggle to breathe
ndash Do you ever feel like you canrsquot get enough air
ndash What were you doing when this happened
ndash How many times have you felt this way in the last weekthe lastmonth
ndash Does your breathing wake you up at night
bull Environmental factorsndash What do you do for a living
ndashAre you exposed to temperature extremes
ndashInhale chemicals or particles such as dirt or dust
bull Do you smoke
39
DOS CME Course 2011
Diagnosis
bull Good medical history
bull Cough chest discomfort especially at night
bull Wheezing
bull Difficulty breathing
bull Co-morbid hay fever eczema or family history of asthma
bull Colds tend to ldquogo to the chestrdquo
bull Responds to bronchodilators
40
DOS CME Course 2011
Remember to askhellip
bull Previous asthma attacks or exacerbations
bull Past and present management strategies and responses
bull Family history of asthma allergy sinusitis rhinitis or nasal polyps
bull Impact of disease on family finances schoolwork activity sleep and childrenrsquos growth and development
bull Patient and family knowledge base understanding of treatments and sociocultural beliefs
bull Number of sick days per month
DOS wheezing protocol
41
DOS CME Course 2011
Physical assessment
bull Pulse and respiratory rate and O2 Sat (PaO2)
bull Assess for dehydration delayed capillary refill poor skin turgor dry mucous membranes
bull Use of accessory respiratory muscles retractions nasal flaring sweating and cyanosis
bull Hyperexpansion of thorax ( hunched shoulders chest deformity)
bull Manifestations of skin allergies
DOS wheezing protocol
42
DOS CME Course 2011
Physical assessment
bull Nasal discharge allergic dark circles under eyes
bull Lungs
ndashInspection percussion palpation and auscultation may all be within normal limits between attacks
ndashIn some cases wheezes persist or lung sounds will be diminished
43
DOS CME Course 2011
Pulmonary Function tests (PFTrsquoS)
bull A group of tests which measure the lungsrsquo ability to take in and release air and how well they move oxygen into circulation
bull May include total lung volume measurement spirometry arterial blood gases
bull Spirometry is the recommended test for suspected asthma
Gildea TR Retrieved (January 2011)
44
DOS CME Course 2011
PFTrsquos
bull Prepare the patient
ndashDo not smoke before the test
ndashThere will be clip on your nose
ndashDemonstrate how to achieve a tight seal on the mouthpiece
ndashNecessary for accurate results
ndashThe test requires some deep breathing which may produce fatigue
Gildea TR Retrieved (January 2011)
45
DOS CME Course 2011
How it worksbull Spirometry
ndashWhile seated the patient inhales and exhales into a tube
ndashA machine measures the volume of air exhaled ndashThe volumes are compared to the patientrsquos baseline (if
known)ndashResults less than 80 of baseline are considered
abnormal
bull Measurements ndashForced vital capacity (FVC) is the maximum amount
the patient can exhale after filling the lungs completely ndashForced expiratory volume in one second (FEV1)
Gildea TR Retrieved (January 2011)
46
Spirometry results
bull Forced Vital Capacity (FVC) is the maximum volume of gas that can be forcefully and rapidly exhaled after a maximal inhalation
bull Forced Expiratory Volume after 1 second (FEV1) is the volume of gas exhaled after one second from the beginning of the FVC maneuver
bull Forced Expiratory Flow from 25 to 75 (FEF 25-75) is the average rate of flow during the middle half of an FVC maneuver that includes the flow from medium-sized and small airways also known as mid flow rates
bull Total Lung Capacity (TLC) is the volume of gas in the lungs at the end of a maximal inhalation
DOS CME Course 201147
Spirometry results
bull Functional Residual Capacity (FRC) is the volume of gas in the lungs after exhalation of a normal breath
bull Residual Volume (RV) is the volume of gas in the lungs after complete exhalation
bull Diffusing Capacity DLCO measures the transfer of a gas usually Carbon Monoxide (CO 03) across the membrane that separates the air sacs and the blood stream
DOS CME Course 201148
DOS CME Course 2011
Asthma
bull FEV1ndash Reflects about 75 to 85 of total lung capacity ndash Decreased in patients with asthma and COPD
bull Administer an inhaled bronchodilator and repeat the test
bull A decrease in FEV1 is diagnostic for asthma ndash gt or = 12 and gt or = 200 ml
bull Peak expiratory flow (PEF) ndash Use patientrsquos own meter and compare with their baselinendash Administer bronchodilator
ndashImprovement of gt or = 20 is diagnostic
(Gildea TR Retrieved January 2011)
49
DOS CME Course 2011
Asthmabull Exercise-induced
ndash Perform spirometry following an 8-minute running protocol
bull Airway responsivenessndash Evaluate with inhaled mannitol or methacholine and histamine
ndash For the patient with normal spirometry but asthma symptoms persist
bull Elderly patients ndash May underreport symptoms
ndash Co-morbidities such as heart failure or COPD
ndash Expect fatigue and shortness of breath as normal aging
bull Occupational ndash Evaluate for correlation of symptoms with exposure to
occupational environment
50
DOS CME Course 2011
Asthma
bull Pharmacologic management
bull Stepwise approach
bull Reduce impairmentndash Prevent chronic symptoms
ndash Require 2 days or lessweek of short-acting beta agonists
ndash Maintain normal activities
ndash Maintain normal lung function
ndash Meet patient and family expectations of care
bull Reduce riskndash Prevent emergency hospitalizations
ndash Avoid adverse drug reactions
NHLBI 2007
51
DOS CME Course 2011
Pharmacology bull Beta-2 adrenergic agonists
ndashBronchodilators-smooth muscle relaxants
ndashSympathomimetic
ndashShort acting ndashalbuterolterbutalinelevalbuterol
ndashUse of short acting before exercise to improve tolerance
ndashLong acting (LABA)ndashSalmeterol formoterol
bull Side effects include
ndash tachycardia tremor hypokalemia hyperglycemia HA dizziness
52
DOS CME Course 2011
Pharmacology
bull Methylxanthines (theophylline)ndash Smooth muscle relaxants
ndashPO PR IV
bull Side effects ndash nausea irritability tachycardia dysrrhythmia seizures brain
damage death
bull Theophylline causes concern because the therapeutic and toxic ranges overlapndash Monitor after initiation with any dose increases or signs of toxicity
(Micromedex 2010)
53
DOS CME Course 2011
Pharmacology
bull Inhaled glucocorticosteroid (ICS)
ndashDecrease swelling due to inflammation
ndashBeclomethasone budesonide fluticasone triamcinolone
ndashSide effects oral candidiasis dry mouth hoarseness hypersensitivity
ndashOnset of effects 10-20 minutes
ndashRecommend using a spacer
54
DOS CME Course 2011
Pharmacologybull Leukotriene modifiers
ndash Disrupt the function or synthesis of inflammatory mediators related to asthma
ndashMontelukast zafirlukast zileuton
bull Long-term control
bull Side effects elevation of liver enzymes HA dizziness GI distress
bull Mast cell stabilizersndash Cromolyn sodium nedocromil
ndash Inhibit release of inflammatory mediators
ndash Side effects bronchospasm pharyngeal irritation
55
DOS CME Course 2011
Pharmacology
bull Anticholinergics chemically related to atropine
ndashIpratropium bromide (Atrovent)
ndashInhaled form as rescue therapy
bull Side effects
ndashurinary obstruction HA restlessness palpitations bronchospasm
56
DOS CME Course 2011
The big guns
bull Systemic corticosteroidsndash Methylprednisolone hydrocortisone dexamethasone
ndash IV or PO
ndash Treatment of acute exacerbations
bull Side effects ndash adrenal suppression weight gain fluid retention hyperglycemia
ndash Long term
ndash osteoporosis immune suppression gastric ulcers
57
DOS CME Course 2011
Right here and now
bull Nursing Intervention
bull Quick Relief
bull Short acting bronchodilator ndash Up to 3 treatments at 20 minute intervals
bull Or single nebulizer treatment
bull Course of systemic corticosteroids may be needed
DOS Wheezing protocol
58
DOS CME Course 2011
Nebulizer Treatment
bull Albuterol Solution
ndashlt5 years old 063-25 mg in 3 cc of saline q 4-6 hours as needed
ndashgt5 years old -adult 125-5 mg in 3 cc of saline q 4-8 hours as needed
bull Levalbuterol (R-albuterol solution Xopinex)
ndashlt 5 years old 031 mg-125 mg in 3 cc NS q 4-6 hrs as needed
ndash5-11 yrs old 031-063 mg q 8 hours prn symptoms
ndashgt12 yrs old063mg-125 mg q 8 hours prn symptoms
DOS Wheezing protocol
59
DOS CME Course 2011
Treatment at home
bull Nebulizers convert liquid or powder medications to aerosolized formndash Effective to deliver larger doses than metered dose inhalers
Patient safety alert Some medications in powder formcome as a capsule which is broken open The patient should not take this medication orally
60
DOS CME Course 2011
How often
do the following
happen
MILD INTERMITTENT(check appropriate box)
MILD PERSISTENT
MODERATE PERSISTENT
SEVERE PERSISTENT
Daytime wheezingshortness of breath
0-2 times per week
Greater than 2 times per week
Daily Continually
Night-time wheezing shortness of breath
0-2 times per month
Greater than 2 times per month
Greater than 1 time per week
Frequent
How often are your physical activities limited by asthma
0-2 times per week
0-2 times per week
Greater than 2 times per week
Frequent
Daily use of albuterol or ldquorescue drugsrdquo
Less than 1 time per week or less than 3 times per month
2 time per week or more
Daily Use Frequent
DOS Wheezing protocol61
DOS CME Course 2011
Plan of carebull Step 1mdashmild intermittent
ndash no daily medication
ndash should have prn short acting rescue Beta 2 inhaler on hand
bull Step 2mdashmild persistentndash low dose inhaled corticosteroids
bull Step 3mdashmoderate persistentndash low to med inhaled corticosteroids and long acting beta 2 agonists
bull Step 4mdashsevere persistentndash high dose inhaled corticosteroids and long acting inhaled beta 2
agonists
DOS Wheezing protocol
62
DOS CME Course 2011
Ongoing carebull Plan Follow-up
ndash Evaluate 2-6 weeks after treatment initiationndash Evaluate every 1-6 months when stablendash Evaluate every 3 months interval after stepping down therapyndash Annual inactivated influenza vaccine
bull ConsultationReferralndash Life threatening or severe persistent asthmandash Goals of asthma therapy not fulfilled in 3-6 monthsndash Signs and symptoms are not typicalndash Sinusitis gastroesophageal reflux or chronic pulmonary disease
complicate the asthma
DOS Wheezing protocol
63
DOS CME Course 2011
Consults
bull Continuous oral corticosteroids or 2 bursts of oral steroids in 1 year
bull Patient under 3 years with step 3 or 4 asthma
bull If omalizumab (Xolair) is considered for treatment as there is an increase in rate of anaphylaxis with this medication
bull Exacerbation requiring hospitalization
DOS Wheezing protocol
64
DOS CME Course 2011
Patient educationbull Basic understanding of asthma and how the disease
works
bull Medications ndash Names and doses of all medications
ndash Short acting vs long acting
bull Equipment ndash Metered dose inhalers (MDI)
ndash Nebulizers
bull Emergency response
bull Activity level
bull Illness management
65
DOS CME Course 2011
Patient education
bull Know your triggers and have a strategy for avoidance
bull If mold or mites are known triggers humidifiers and evaporator coolers are not recommended in the home
bull Know the early signs of an exacerbation and what to do
bull Develop an action plan based on peak flow readings
bull What to do in case of an attack at school or work
66
DOS CME Course 2011
Patient educationbull Metered dose inhalers
ndash Remove cap and invert the device several times
ndash Exhale
ndash Place the mouthpiece between your lips with a good seal
ndash Inhale while depressing the top of the MDI
ndash Hold your breath for 10 seconds
ndash Exhale
ndash Repeat as needed
67
DOS CME Course 2011
Patient educationbull Spacers are used with MDIrsquos
used to deliver inhaled steroidsndash Ease coordination of breathing
and medication delivery
ndash Decrease the amount of medication contacting the oral mucosa
ndash Fewer side effects
bull Attach the spacer to the mouthpiece of the MDI ndash Use the MDI as described
before
ndash Some models have a whistle to indicate you are inhaling too rapidly
68
DOS CME Course 201169
DOS CME Course 2011
Characteristic Controlled
(All of the following)
Partly controlled
(Any measure noted)
Uncontrolled
Daytime symptoms
None (twice or less a week)
More than twice a week
Three or more features of partly controlled asthma
Limitation of activities
None Any
Nocturnal symptomsawakening
None Any
Need for rescue treatment
None (twice or less a week)
More than twice a week
Lung function (FEV1 or PEF)
Normal lt80 predicted or personal best
70
DOS CME Course 2011
Asthma
bull Self monitoring is essential to effective management and control
bull The following are validated tools to assess asthma control
ndashAsthmacontrolcom
ndashFree web-based
ndashQoltechcouk
ndashFree in hard copy or electronic versions
ndashRequires permission
ndashAtaqinstrumentcom
ndashFree web-based
71
DOS CME Course 2011DOS CME Course 201172
Every Life Deserves World Class Care
COPD
72
DOS CME Course 2011
Chronic obstructive pulmonary disease
bull By the numbers
bull 210 million suffer worldwide
bull 3 million fatalities
bull By 2030 COPD is expected to be the third leading cause of death worldwide
bull Most important risk factors ndash Smoking
ndash Indoor pollution
ndash Outdoor pollution
ndash Occupational irritants
WHO Retrieved January 2011
73
DOS CME Course 2011
COPD
bull Causes ndash Cigarette smoking is the number one cause worldwide
ndash Environmental irritants
ndash Genetic alpha-one antitrypsin deficiency
bull Birth defects ndash Low birth weight
ndash Respiratory infections
ndash Any factor which impairs lung development during gestation
bull Other ndash HIV
ndash Connective tissue disorders
ndash Vasculitis
74
DOS CME Course 2011
COPD
bull Sometimes referred to as umbrella term for a family of diseases which cause limited airflow
ndashChronic bronchitis
ndashEmphysema
bull Inflammation of the airways
bull Increased mucous productionndash Especially in bronchitis
bull Decreased ciliary function
bull Loss of elastic recoil ndash Especially in emphysema
75
DOS CME Course 2011
COPD
bull How inflammation ruins a lung
bull Cell mediated ndash Neutrophils
ndash Macrophages
ndash Lymphocytes
bull Release cytokines which attract more cells
bull Oxidants released by cells and found in cigarette smoke
bull Proteases
bull Cause remodeling and long term structural changes
76
DOS CME Course 2011
COPDbull Alveoli lose elasticity and become distended
ndashSaggy sacs
ndashCarbon dioxide retention
ndashChronic respiratory acidosis
bull Walls of the alveoli are degraded
ndashLoss of surface area necessary for gas exchange
77
DOS CME Course 2011
What the patient looks like
bull Productive Cough
ndashEspecially in chronic bronchitis
bull Progressive dyspnea
ndashUncomfortable awareness of breathing
bull Wheezing and chest tightness
bull Increase in AP chest diameter
ndashldquoBarrel chestrdquo especially in emphysema
ndashIncreased inspiratory effort loosens costochondral cartilage
78
DOS CME Course 2011
Alpha one antitrypsin deficiency
bull Enzyme normally produced which protects the lungs
bull Deactivates neutrophil elastase
ndashReleased during inflammation
bull Estimated over 100000 in US have AATD
bull Time to diagnosis gt8 years
bull Related to increased mortality (Krowka 2010)
ndashIncreased incidence of emphysema
79
DOS CME Course 2011
Chronic bronchitis
bull Presence of cough and sputum production over three months for two consecutive years
ndashNote the months need not be consecutive
bull The patient may feel as though they are constantly sick
bull Multiple courses of antibiotics with no improvement
bull No relationship to acute bronchitis caused by bacteria or virus
80
DOS CME Course 2011
COPD
bull Break out the testing ndash CXR
ndash ECG
ndash Sputum culture
ndash CBC and electrolytes
bull ABGrsquos ndash Respiratory failure indicated by
ndash PaO2lt 60 and SaO2 lt 90
ndash with or without PaCO2 gt 50
ndash On room air
ndash Severe acidosis pHlt 736 in addition to the above is an indication for mechanical ventilation
(GOLD 2009 p 22)
81
DOS CME Course 2011
Chronic bronchitis
bull Airway of a child afflicted with chronic bronchitis compared to normal
82
DOS CME Course 2011
Chronic bronchitisbull Related to mucociliary dysfunction
ndashIncreased mucous production and thickening
ndashLoss of cilia
ndashLoss of ciliary function
ndashMobility required to sweep out particles
83
DOS CME Course 2011
Emphysemabull Permanent enlargement of the airspaces terminal to the
distal bronchioles ndashLoss of surface area for gas exchangendashDestruction of supporting structure of alveoli
ndashAirway narrowing
bull Three distinct patterns ndashCentracinar begins centrally and spreads to terminal
bronchioles and is most closely associated with cigarette smoking
ndashPanacinar destroys alveoli uniformly predominant in lower half of lungs most closely associated with AATD
ndashParaseptal destroys the distal airway structures alveolar ducts and sacs
Demirjian BG 2010
84
DOS CME Course 2011
Bullaebull Outpouchingsballooning of lung tissue due to trapped air
ndashAir is released from damaged alveoli
ndashAsymptomatic
ndashRupture can cause pneumothorax
85
DOS CME Course 2011
Diagnosis
bull History of smoking or exposure to inhaled irritants
ndashRemember to consider work and living environment
ndashCooking indoors with fossil fuels
ndashAge over 40
bull Signs and symptoms
ndashChronic cough with sputum production
ndashDyspnea which persists daily worsens with exercise and progresses over time
bull Spirometry is strongly recommended
86
DOS CME Course 2011
Diagnosis
bull Chest x-ray
ndashRule out pneumonia cardiomyopathy
ndashNot diagnostic for COPD but may reveal other causes for symptoms
bull Arterial blood gases
ndashRecommended for patients with FEVlt 50
ndashPaO2lt 60 mmHg suggests respiratory failure
bull Sputum culture
ndashRule out infectious process
87
DOS CME Course 2011
Disease stages
bull Stage Indash FEVFVC lt 70
ndash FEV gt 80
ndash Few symptoms if any patient may be unaware
bull Stage II moderate ndash FEVFVC lt 70
ndash FEV lt 80
ndash Along with shortness of breath
88
DOS CME Course 2011
Disease stages
bull Stage IV very severe ndash FEVFVC lt 70
ndash FEV lt 30
ndash At this stage exacerbations are life-threatening
ndash Quality of life is impaired further
bull Stage III severe ndash FEVFVC lt 70
ndash FEV lt 50
ndash Worsening symptoms increasing frequency of exacerbations
89
DOS CME Course 2011
COPD vs Asthma
bull COPD
ndashOnset later in life
ndashProgressive worsening symptoms
ndashSmoking history
ndashDyspnea with exercise
ndashLargely irreversible airflow limitation
bull Asthma
ndashOnset of symptoms usually earlier in life
ndashWorsening at night
ndashLargely reversible airflow limitation
ndashSymptoms vary from day to day
90
DOS CME Course 2011
COPD Treatmentbull Now that we have diagnosis what do I do about it
bull Assess and monitor diseasendash Assess for risk factors ie smoking family history
ndash Co-morbidities such as heart failure
ndash Pattern of symptoms
ndash Impact on quality of life
bull Reduce risk factors ndash Identify environmentaloccupational factors which can be modified
ndash Smoking cessation is essential
ndash Manage exacerbations
91
DOS CME Course 2011
COPDbull Manage stable COPD
ndash Determine disease severity based on frequency and severity of symptoms
ndash Educate the patient about risk factors and disease management regimen
ndash Collaborate with the patient to develop a personalized regimen
ndashFits their lifestyle
ndashAccounts for cultural preferences family involvement
ndashAvailability of testing and medications
92
DOS CME Course 2011
Pharmacologybull Goals
ndash Improve exercise tolerance
ndash Control symptoms
ndash Reduce frequency and severity of exacerbations
ndash Improve health status
bull Bronchodilators ndash Include long-acting therapy with short-acting for better control
bull Combine medications from different classes rather than increasing dosage of just onendash Minimizes side effects
93
DOS CME Course 2011
Pharmacologybull Glucocorticosteroids
ndashCan reduce the number of exacerbations
ndashIncreased risk of pneumonia
ndashNo noted reduction in mortality
bull Vaccines
ndashInfluenza vaccines decrease serious illness and death by 50
ndashRecommended annually
ndashPneumococcal vaccines recommended for all COPD sufferers even under age 65
GOLD 2009
94
DOS CME Course 2011
Antibiotics
bull Antibiotics are not a treatment for COPD nor do they manage symptoms of an exacerbation
bull Should be given only if the following are metndash Presence of three cardinal symptoms increased dyspnea
increased sputum volume increased sputum purulence
ndash Increased sputum purulence plus one other cardinal symptom
ndash Mechanically ventilated
bull May be difficult for patients to understand why antibiotics will not ldquofixrdquo what is wrong
bull Good opportunity for learning needs assessment
GOLD 2009
95
DOS CME Course 2011
COPD
bull Pulmonary rehabilitation
bull Encourage the patient to continue activities as tolerated ndash Move as much as you can before you canrsquot move
bull Uses low impact exercise to maintain physical function
bull Exercise can be done while seatedndash Monitor pulse oximetry respiratory rate and effort before during
and after activity
bull Set goals which are realistic for both of you
96
DOS CME Course 2011
COPD
bull Pulmonary rehab includes education nutrition and exercise
bull Can be a good source of social support for someone who has seen function decline
ndashTalk with others in the same situation
ndashFind out how they cope
ndashSocialize
bull Regular influenza and pneumonia vaccines
97
DOS CME Course 2011
COPD
bull Oxygen therapy
bull Recommended for stage IV disease ndash PaO2 lt or = 55 mmHg
ndash SaO2 lt or = 88
bull Increases survival improves hemodynamicsbenefits mental state
bull Surgical options reviewed on a case-by-case basisndash Bullectomy
ndash Lung volume reduction ndashNo evidence to support this as a widespread therapy
98
DOS CME Course 2011
COPD
bull Managing exacerbations
bull An event in the natural course of the disease characterized by a change in baseline dyspnea cough or sputum beyond day to day variance is acute in onset and may warrant a change in medication
bull Air pollution and tracheobronchial infections are the most common causes
bull 30 of exacerbations no cause identified
(GOLD 2009 p 22)
99
DOS CME Course 2011
COPD
bull Hospitalization is recommended for patients exhibiting the following
ndash Failure of exacerbation to respond to medical treatment
ndash Development of new symptoms ie peripheral edema cyanosis
ndash Significant co-morbidities
ndash History of frequent exacerbations
ndash Newly occurring arrhythmias
ndash Advanced age
ndash Insufficient home support
ndash Unclear diagnosis
(GOLD 2009 p 23)
100
DOS CME Course 2011
COPD
bull Mechanical ventilation is not recognized as an effective management strategy for stable COPD
bull May be required as supportive therapy during an exacerbation
bull Associated with mortality
bull Carries risks of its ownndash Ventilator acquired pneumonia
ndash Ventilator induced lung injury
ndash Failure to wean
(GOLD 2009)
101
DOS CME Course 2011DOS CME Course 2011102
Every Life Deserves World Class Care
Smoking
102
DOS CME Course 2011
Smoking bull By the numbers
bull More than 400 000 Americans die from smoking-related illnesses each yearndash Thatrsquos one of every 5 deaths
bull In a study of 2963 health care encounters smoking was discussed 633 times
bull Nicotine released into the body within 10 seconds of inhalation
bull If a person smokes one pack per day and takes ten puffs of each cigarette that equates to 200 ldquohitsrdquo of nicotine daily
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
103
DOS CME Course 2011
Nicotine
bull Nicotinic receptors occur naturally
bull N1 receptors in the adrenal medulla
bull Neuromuscular junction of autonomic ganglia
bull N2 receptors in skeletal muscle
bull Number of receptor sites increases with regular stimulation
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
104
DOS CME Course 2011
Nicotinebull Addictive
bull Vasoconstrictor
bull Releases adrenaline from the adrenal cortex
ndashFeeling of increased energy
bull Releases dopamine to produce feelings of well-beingndash Actually improves memory and cognition
bull Sensitivity actually declines overnight
bull Release of insulinndash Slightly hyperglycemic
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
105
DOS CME Course 2011
Genetic componentbull About 10 of smokers lack the gene for nicotine
dependence
ndashldquosocial or occasionalrdquo smokers
ndashThey really can quit anytime they want to
ndashNo withdrawal symptoms
ndashStill poses a health risk
bull The other 90 will demonstrate physical and psychological symptoms of withdrawal
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
106
DOS CME Course 2011
Smoking
bull Identify tobacco users ndash Ask every patient every visit
ndash Have you used tobacco in the last 12 months
ndash Clinic-wide program
bull Advise every tobacco user to quitndash Personalize the message
ndash Be clear
ndash Be firm
If at first you donrsquot succeed try tryagain Bring it up at every encounter
107
DOS CME Course 2011
Smoking cessationbull Some more good reasons to quit
ndashSmoking costs over $2000 a year in current US dollars
ndashThere is no accepted safe level of cigarette smoke
ndashSecondhand smoke carries the same hazards
ndashIncreased risk of SIDS and asthma exacerbations in children
httpwwwlungusaorgstop-smokingabout-smokingfacts-figuresgeneral-smoking-factshtml
108
DOS CME Course 2011
Smoking cessation
bull Nicotine is a powerful drug addiction
bull Treat as a chronic illness
bull All healthcare providers encouraged to participate
bull Assess willingness to quit
bull Promote motivation
109
DOS CME Course 2011
Smoking cessation
bull Prochaskarsquos change theory
bull Precontemplation
ndashNot even thinking about quitting
ndashProvide education on the risks and costs of smoking
bull Contemplation
ndashAwareness that a problem exists
ndashContinue to find motivations to stop
NorcrossJC Krebs PM Prochaska JO(2011)
110
DOS CME Course 2011
Change is good
bull Determination
ndashExpressing willingness to act
ndashSelf-efficacy
bull Action ndash Currently not smoking
ndash May relapse
bull It is not unusual for a patient to ldquoquitrdquo three or four times
bull Continue to encourage and motivate himher to stop
NorcrossJC Krebs PM Prochaska JO(2011)
111
DOS CME Course 2011
Smoking cessationbull Assist the patient
ndashCollaborate with the patient to develop a plan to quit
ndashAchievable clearly defined goals
ndashIdentify and engage social supports
ndashFamily support groups
ndashPharmacologic (more on this later)
bull Arrange follow-up
ndashAt each successive visit review progress on quitting strategy
ndashLets the patient know heshe is not alone in this effort
ndashAccountability
112
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
Asthma by the numbers
bull Who gets asthma
bull In the United States (2007)ndash13 are children ndash89 are femalendash65 are male
bull Medical carecosts (2006)ndash106 million asthma-related visits to doctorsrsquo officesndashAnnual cost of $106 billion dollars annuallyndash444000 hospital discharges related to asthmandashAverage length of stay of 32 days
35
DOS CME Course 2011
Asthma by the numbers
bull 300 million people suffer from asthma
bull In 2005 255000 asthma-related fatalities
ndashMuch lower than other chronic illnesses
bull Most common chronic disease among children
bull Crosses economic levels
ndashMost deaths seen at lower and low-middle incomes
bull Underdiagnosed and undertreated
36
DOS CME Course 2011
Asthma
bull Chronic disease characterized by inflammation of the airways ndash Episodes of breathlessness- ldquoattacksrdquo
ndash Exacerbation of inflammation and mucous plugs
ndash Vary in frequency duration and severity
bull Onset at any time of life
37
DOS CME Course 2011
Asthmabull Aggravating factors may include
ndash exercisendash viral infectionndash animal exposure ndash house dust mites ndash mold ndash smoke ndash pollen ndash changes in weatherndash menses ndash exposure to airborne chemicals or dustsndash exposure to cockroach secretions ndash Sulfites in food shrimp dried fruit processed potatoes beer
and wineDOS wheezing protocol
38
DOS CME Course 2011
Asthma
bull History and physical ndash Do you sometimes struggle to breathe
ndash Do you ever feel like you canrsquot get enough air
ndash What were you doing when this happened
ndash How many times have you felt this way in the last weekthe lastmonth
ndash Does your breathing wake you up at night
bull Environmental factorsndash What do you do for a living
ndashAre you exposed to temperature extremes
ndashInhale chemicals or particles such as dirt or dust
bull Do you smoke
39
DOS CME Course 2011
Diagnosis
bull Good medical history
bull Cough chest discomfort especially at night
bull Wheezing
bull Difficulty breathing
bull Co-morbid hay fever eczema or family history of asthma
bull Colds tend to ldquogo to the chestrdquo
bull Responds to bronchodilators
40
DOS CME Course 2011
Remember to askhellip
bull Previous asthma attacks or exacerbations
bull Past and present management strategies and responses
bull Family history of asthma allergy sinusitis rhinitis or nasal polyps
bull Impact of disease on family finances schoolwork activity sleep and childrenrsquos growth and development
bull Patient and family knowledge base understanding of treatments and sociocultural beliefs
bull Number of sick days per month
DOS wheezing protocol
41
DOS CME Course 2011
Physical assessment
bull Pulse and respiratory rate and O2 Sat (PaO2)
bull Assess for dehydration delayed capillary refill poor skin turgor dry mucous membranes
bull Use of accessory respiratory muscles retractions nasal flaring sweating and cyanosis
bull Hyperexpansion of thorax ( hunched shoulders chest deformity)
bull Manifestations of skin allergies
DOS wheezing protocol
42
DOS CME Course 2011
Physical assessment
bull Nasal discharge allergic dark circles under eyes
bull Lungs
ndashInspection percussion palpation and auscultation may all be within normal limits between attacks
ndashIn some cases wheezes persist or lung sounds will be diminished
43
DOS CME Course 2011
Pulmonary Function tests (PFTrsquoS)
bull A group of tests which measure the lungsrsquo ability to take in and release air and how well they move oxygen into circulation
bull May include total lung volume measurement spirometry arterial blood gases
bull Spirometry is the recommended test for suspected asthma
Gildea TR Retrieved (January 2011)
44
DOS CME Course 2011
PFTrsquos
bull Prepare the patient
ndashDo not smoke before the test
ndashThere will be clip on your nose
ndashDemonstrate how to achieve a tight seal on the mouthpiece
ndashNecessary for accurate results
ndashThe test requires some deep breathing which may produce fatigue
Gildea TR Retrieved (January 2011)
45
DOS CME Course 2011
How it worksbull Spirometry
ndashWhile seated the patient inhales and exhales into a tube
ndashA machine measures the volume of air exhaled ndashThe volumes are compared to the patientrsquos baseline (if
known)ndashResults less than 80 of baseline are considered
abnormal
bull Measurements ndashForced vital capacity (FVC) is the maximum amount
the patient can exhale after filling the lungs completely ndashForced expiratory volume in one second (FEV1)
Gildea TR Retrieved (January 2011)
46
Spirometry results
bull Forced Vital Capacity (FVC) is the maximum volume of gas that can be forcefully and rapidly exhaled after a maximal inhalation
bull Forced Expiratory Volume after 1 second (FEV1) is the volume of gas exhaled after one second from the beginning of the FVC maneuver
bull Forced Expiratory Flow from 25 to 75 (FEF 25-75) is the average rate of flow during the middle half of an FVC maneuver that includes the flow from medium-sized and small airways also known as mid flow rates
bull Total Lung Capacity (TLC) is the volume of gas in the lungs at the end of a maximal inhalation
DOS CME Course 201147
Spirometry results
bull Functional Residual Capacity (FRC) is the volume of gas in the lungs after exhalation of a normal breath
bull Residual Volume (RV) is the volume of gas in the lungs after complete exhalation
bull Diffusing Capacity DLCO measures the transfer of a gas usually Carbon Monoxide (CO 03) across the membrane that separates the air sacs and the blood stream
DOS CME Course 201148
DOS CME Course 2011
Asthma
bull FEV1ndash Reflects about 75 to 85 of total lung capacity ndash Decreased in patients with asthma and COPD
bull Administer an inhaled bronchodilator and repeat the test
bull A decrease in FEV1 is diagnostic for asthma ndash gt or = 12 and gt or = 200 ml
bull Peak expiratory flow (PEF) ndash Use patientrsquos own meter and compare with their baselinendash Administer bronchodilator
ndashImprovement of gt or = 20 is diagnostic
(Gildea TR Retrieved January 2011)
49
DOS CME Course 2011
Asthmabull Exercise-induced
ndash Perform spirometry following an 8-minute running protocol
bull Airway responsivenessndash Evaluate with inhaled mannitol or methacholine and histamine
ndash For the patient with normal spirometry but asthma symptoms persist
bull Elderly patients ndash May underreport symptoms
ndash Co-morbidities such as heart failure or COPD
ndash Expect fatigue and shortness of breath as normal aging
bull Occupational ndash Evaluate for correlation of symptoms with exposure to
occupational environment
50
DOS CME Course 2011
Asthma
bull Pharmacologic management
bull Stepwise approach
bull Reduce impairmentndash Prevent chronic symptoms
ndash Require 2 days or lessweek of short-acting beta agonists
ndash Maintain normal activities
ndash Maintain normal lung function
ndash Meet patient and family expectations of care
bull Reduce riskndash Prevent emergency hospitalizations
ndash Avoid adverse drug reactions
NHLBI 2007
51
DOS CME Course 2011
Pharmacology bull Beta-2 adrenergic agonists
ndashBronchodilators-smooth muscle relaxants
ndashSympathomimetic
ndashShort acting ndashalbuterolterbutalinelevalbuterol
ndashUse of short acting before exercise to improve tolerance
ndashLong acting (LABA)ndashSalmeterol formoterol
bull Side effects include
ndash tachycardia tremor hypokalemia hyperglycemia HA dizziness
52
DOS CME Course 2011
Pharmacology
bull Methylxanthines (theophylline)ndash Smooth muscle relaxants
ndashPO PR IV
bull Side effects ndash nausea irritability tachycardia dysrrhythmia seizures brain
damage death
bull Theophylline causes concern because the therapeutic and toxic ranges overlapndash Monitor after initiation with any dose increases or signs of toxicity
(Micromedex 2010)
53
DOS CME Course 2011
Pharmacology
bull Inhaled glucocorticosteroid (ICS)
ndashDecrease swelling due to inflammation
ndashBeclomethasone budesonide fluticasone triamcinolone
ndashSide effects oral candidiasis dry mouth hoarseness hypersensitivity
ndashOnset of effects 10-20 minutes
ndashRecommend using a spacer
54
DOS CME Course 2011
Pharmacologybull Leukotriene modifiers
ndash Disrupt the function or synthesis of inflammatory mediators related to asthma
ndashMontelukast zafirlukast zileuton
bull Long-term control
bull Side effects elevation of liver enzymes HA dizziness GI distress
bull Mast cell stabilizersndash Cromolyn sodium nedocromil
ndash Inhibit release of inflammatory mediators
ndash Side effects bronchospasm pharyngeal irritation
55
DOS CME Course 2011
Pharmacology
bull Anticholinergics chemically related to atropine
ndashIpratropium bromide (Atrovent)
ndashInhaled form as rescue therapy
bull Side effects
ndashurinary obstruction HA restlessness palpitations bronchospasm
56
DOS CME Course 2011
The big guns
bull Systemic corticosteroidsndash Methylprednisolone hydrocortisone dexamethasone
ndash IV or PO
ndash Treatment of acute exacerbations
bull Side effects ndash adrenal suppression weight gain fluid retention hyperglycemia
ndash Long term
ndash osteoporosis immune suppression gastric ulcers
57
DOS CME Course 2011
Right here and now
bull Nursing Intervention
bull Quick Relief
bull Short acting bronchodilator ndash Up to 3 treatments at 20 minute intervals
bull Or single nebulizer treatment
bull Course of systemic corticosteroids may be needed
DOS Wheezing protocol
58
DOS CME Course 2011
Nebulizer Treatment
bull Albuterol Solution
ndashlt5 years old 063-25 mg in 3 cc of saline q 4-6 hours as needed
ndashgt5 years old -adult 125-5 mg in 3 cc of saline q 4-8 hours as needed
bull Levalbuterol (R-albuterol solution Xopinex)
ndashlt 5 years old 031 mg-125 mg in 3 cc NS q 4-6 hrs as needed
ndash5-11 yrs old 031-063 mg q 8 hours prn symptoms
ndashgt12 yrs old063mg-125 mg q 8 hours prn symptoms
DOS Wheezing protocol
59
DOS CME Course 2011
Treatment at home
bull Nebulizers convert liquid or powder medications to aerosolized formndash Effective to deliver larger doses than metered dose inhalers
Patient safety alert Some medications in powder formcome as a capsule which is broken open The patient should not take this medication orally
60
DOS CME Course 2011
How often
do the following
happen
MILD INTERMITTENT(check appropriate box)
MILD PERSISTENT
MODERATE PERSISTENT
SEVERE PERSISTENT
Daytime wheezingshortness of breath
0-2 times per week
Greater than 2 times per week
Daily Continually
Night-time wheezing shortness of breath
0-2 times per month
Greater than 2 times per month
Greater than 1 time per week
Frequent
How often are your physical activities limited by asthma
0-2 times per week
0-2 times per week
Greater than 2 times per week
Frequent
Daily use of albuterol or ldquorescue drugsrdquo
Less than 1 time per week or less than 3 times per month
2 time per week or more
Daily Use Frequent
DOS Wheezing protocol61
DOS CME Course 2011
Plan of carebull Step 1mdashmild intermittent
ndash no daily medication
ndash should have prn short acting rescue Beta 2 inhaler on hand
bull Step 2mdashmild persistentndash low dose inhaled corticosteroids
bull Step 3mdashmoderate persistentndash low to med inhaled corticosteroids and long acting beta 2 agonists
bull Step 4mdashsevere persistentndash high dose inhaled corticosteroids and long acting inhaled beta 2
agonists
DOS Wheezing protocol
62
DOS CME Course 2011
Ongoing carebull Plan Follow-up
ndash Evaluate 2-6 weeks after treatment initiationndash Evaluate every 1-6 months when stablendash Evaluate every 3 months interval after stepping down therapyndash Annual inactivated influenza vaccine
bull ConsultationReferralndash Life threatening or severe persistent asthmandash Goals of asthma therapy not fulfilled in 3-6 monthsndash Signs and symptoms are not typicalndash Sinusitis gastroesophageal reflux or chronic pulmonary disease
complicate the asthma
DOS Wheezing protocol
63
DOS CME Course 2011
Consults
bull Continuous oral corticosteroids or 2 bursts of oral steroids in 1 year
bull Patient under 3 years with step 3 or 4 asthma
bull If omalizumab (Xolair) is considered for treatment as there is an increase in rate of anaphylaxis with this medication
bull Exacerbation requiring hospitalization
DOS Wheezing protocol
64
DOS CME Course 2011
Patient educationbull Basic understanding of asthma and how the disease
works
bull Medications ndash Names and doses of all medications
ndash Short acting vs long acting
bull Equipment ndash Metered dose inhalers (MDI)
ndash Nebulizers
bull Emergency response
bull Activity level
bull Illness management
65
DOS CME Course 2011
Patient education
bull Know your triggers and have a strategy for avoidance
bull If mold or mites are known triggers humidifiers and evaporator coolers are not recommended in the home
bull Know the early signs of an exacerbation and what to do
bull Develop an action plan based on peak flow readings
bull What to do in case of an attack at school or work
66
DOS CME Course 2011
Patient educationbull Metered dose inhalers
ndash Remove cap and invert the device several times
ndash Exhale
ndash Place the mouthpiece between your lips with a good seal
ndash Inhale while depressing the top of the MDI
ndash Hold your breath for 10 seconds
ndash Exhale
ndash Repeat as needed
67
DOS CME Course 2011
Patient educationbull Spacers are used with MDIrsquos
used to deliver inhaled steroidsndash Ease coordination of breathing
and medication delivery
ndash Decrease the amount of medication contacting the oral mucosa
ndash Fewer side effects
bull Attach the spacer to the mouthpiece of the MDI ndash Use the MDI as described
before
ndash Some models have a whistle to indicate you are inhaling too rapidly
68
DOS CME Course 201169
DOS CME Course 2011
Characteristic Controlled
(All of the following)
Partly controlled
(Any measure noted)
Uncontrolled
Daytime symptoms
None (twice or less a week)
More than twice a week
Three or more features of partly controlled asthma
Limitation of activities
None Any
Nocturnal symptomsawakening
None Any
Need for rescue treatment
None (twice or less a week)
More than twice a week
Lung function (FEV1 or PEF)
Normal lt80 predicted or personal best
70
DOS CME Course 2011
Asthma
bull Self monitoring is essential to effective management and control
bull The following are validated tools to assess asthma control
ndashAsthmacontrolcom
ndashFree web-based
ndashQoltechcouk
ndashFree in hard copy or electronic versions
ndashRequires permission
ndashAtaqinstrumentcom
ndashFree web-based
71
DOS CME Course 2011DOS CME Course 201172
Every Life Deserves World Class Care
COPD
72
DOS CME Course 2011
Chronic obstructive pulmonary disease
bull By the numbers
bull 210 million suffer worldwide
bull 3 million fatalities
bull By 2030 COPD is expected to be the third leading cause of death worldwide
bull Most important risk factors ndash Smoking
ndash Indoor pollution
ndash Outdoor pollution
ndash Occupational irritants
WHO Retrieved January 2011
73
DOS CME Course 2011
COPD
bull Causes ndash Cigarette smoking is the number one cause worldwide
ndash Environmental irritants
ndash Genetic alpha-one antitrypsin deficiency
bull Birth defects ndash Low birth weight
ndash Respiratory infections
ndash Any factor which impairs lung development during gestation
bull Other ndash HIV
ndash Connective tissue disorders
ndash Vasculitis
74
DOS CME Course 2011
COPD
bull Sometimes referred to as umbrella term for a family of diseases which cause limited airflow
ndashChronic bronchitis
ndashEmphysema
bull Inflammation of the airways
bull Increased mucous productionndash Especially in bronchitis
bull Decreased ciliary function
bull Loss of elastic recoil ndash Especially in emphysema
75
DOS CME Course 2011
COPD
bull How inflammation ruins a lung
bull Cell mediated ndash Neutrophils
ndash Macrophages
ndash Lymphocytes
bull Release cytokines which attract more cells
bull Oxidants released by cells and found in cigarette smoke
bull Proteases
bull Cause remodeling and long term structural changes
76
DOS CME Course 2011
COPDbull Alveoli lose elasticity and become distended
ndashSaggy sacs
ndashCarbon dioxide retention
ndashChronic respiratory acidosis
bull Walls of the alveoli are degraded
ndashLoss of surface area necessary for gas exchange
77
DOS CME Course 2011
What the patient looks like
bull Productive Cough
ndashEspecially in chronic bronchitis
bull Progressive dyspnea
ndashUncomfortable awareness of breathing
bull Wheezing and chest tightness
bull Increase in AP chest diameter
ndashldquoBarrel chestrdquo especially in emphysema
ndashIncreased inspiratory effort loosens costochondral cartilage
78
DOS CME Course 2011
Alpha one antitrypsin deficiency
bull Enzyme normally produced which protects the lungs
bull Deactivates neutrophil elastase
ndashReleased during inflammation
bull Estimated over 100000 in US have AATD
bull Time to diagnosis gt8 years
bull Related to increased mortality (Krowka 2010)
ndashIncreased incidence of emphysema
79
DOS CME Course 2011
Chronic bronchitis
bull Presence of cough and sputum production over three months for two consecutive years
ndashNote the months need not be consecutive
bull The patient may feel as though they are constantly sick
bull Multiple courses of antibiotics with no improvement
bull No relationship to acute bronchitis caused by bacteria or virus
80
DOS CME Course 2011
COPD
bull Break out the testing ndash CXR
ndash ECG
ndash Sputum culture
ndash CBC and electrolytes
bull ABGrsquos ndash Respiratory failure indicated by
ndash PaO2lt 60 and SaO2 lt 90
ndash with or without PaCO2 gt 50
ndash On room air
ndash Severe acidosis pHlt 736 in addition to the above is an indication for mechanical ventilation
(GOLD 2009 p 22)
81
DOS CME Course 2011
Chronic bronchitis
bull Airway of a child afflicted with chronic bronchitis compared to normal
82
DOS CME Course 2011
Chronic bronchitisbull Related to mucociliary dysfunction
ndashIncreased mucous production and thickening
ndashLoss of cilia
ndashLoss of ciliary function
ndashMobility required to sweep out particles
83
DOS CME Course 2011
Emphysemabull Permanent enlargement of the airspaces terminal to the
distal bronchioles ndashLoss of surface area for gas exchangendashDestruction of supporting structure of alveoli
ndashAirway narrowing
bull Three distinct patterns ndashCentracinar begins centrally and spreads to terminal
bronchioles and is most closely associated with cigarette smoking
ndashPanacinar destroys alveoli uniformly predominant in lower half of lungs most closely associated with AATD
ndashParaseptal destroys the distal airway structures alveolar ducts and sacs
Demirjian BG 2010
84
DOS CME Course 2011
Bullaebull Outpouchingsballooning of lung tissue due to trapped air
ndashAir is released from damaged alveoli
ndashAsymptomatic
ndashRupture can cause pneumothorax
85
DOS CME Course 2011
Diagnosis
bull History of smoking or exposure to inhaled irritants
ndashRemember to consider work and living environment
ndashCooking indoors with fossil fuels
ndashAge over 40
bull Signs and symptoms
ndashChronic cough with sputum production
ndashDyspnea which persists daily worsens with exercise and progresses over time
bull Spirometry is strongly recommended
86
DOS CME Course 2011
Diagnosis
bull Chest x-ray
ndashRule out pneumonia cardiomyopathy
ndashNot diagnostic for COPD but may reveal other causes for symptoms
bull Arterial blood gases
ndashRecommended for patients with FEVlt 50
ndashPaO2lt 60 mmHg suggests respiratory failure
bull Sputum culture
ndashRule out infectious process
87
DOS CME Course 2011
Disease stages
bull Stage Indash FEVFVC lt 70
ndash FEV gt 80
ndash Few symptoms if any patient may be unaware
bull Stage II moderate ndash FEVFVC lt 70
ndash FEV lt 80
ndash Along with shortness of breath
88
DOS CME Course 2011
Disease stages
bull Stage IV very severe ndash FEVFVC lt 70
ndash FEV lt 30
ndash At this stage exacerbations are life-threatening
ndash Quality of life is impaired further
bull Stage III severe ndash FEVFVC lt 70
ndash FEV lt 50
ndash Worsening symptoms increasing frequency of exacerbations
89
DOS CME Course 2011
COPD vs Asthma
bull COPD
ndashOnset later in life
ndashProgressive worsening symptoms
ndashSmoking history
ndashDyspnea with exercise
ndashLargely irreversible airflow limitation
bull Asthma
ndashOnset of symptoms usually earlier in life
ndashWorsening at night
ndashLargely reversible airflow limitation
ndashSymptoms vary from day to day
90
DOS CME Course 2011
COPD Treatmentbull Now that we have diagnosis what do I do about it
bull Assess and monitor diseasendash Assess for risk factors ie smoking family history
ndash Co-morbidities such as heart failure
ndash Pattern of symptoms
ndash Impact on quality of life
bull Reduce risk factors ndash Identify environmentaloccupational factors which can be modified
ndash Smoking cessation is essential
ndash Manage exacerbations
91
DOS CME Course 2011
COPDbull Manage stable COPD
ndash Determine disease severity based on frequency and severity of symptoms
ndash Educate the patient about risk factors and disease management regimen
ndash Collaborate with the patient to develop a personalized regimen
ndashFits their lifestyle
ndashAccounts for cultural preferences family involvement
ndashAvailability of testing and medications
92
DOS CME Course 2011
Pharmacologybull Goals
ndash Improve exercise tolerance
ndash Control symptoms
ndash Reduce frequency and severity of exacerbations
ndash Improve health status
bull Bronchodilators ndash Include long-acting therapy with short-acting for better control
bull Combine medications from different classes rather than increasing dosage of just onendash Minimizes side effects
93
DOS CME Course 2011
Pharmacologybull Glucocorticosteroids
ndashCan reduce the number of exacerbations
ndashIncreased risk of pneumonia
ndashNo noted reduction in mortality
bull Vaccines
ndashInfluenza vaccines decrease serious illness and death by 50
ndashRecommended annually
ndashPneumococcal vaccines recommended for all COPD sufferers even under age 65
GOLD 2009
94
DOS CME Course 2011
Antibiotics
bull Antibiotics are not a treatment for COPD nor do they manage symptoms of an exacerbation
bull Should be given only if the following are metndash Presence of three cardinal symptoms increased dyspnea
increased sputum volume increased sputum purulence
ndash Increased sputum purulence plus one other cardinal symptom
ndash Mechanically ventilated
bull May be difficult for patients to understand why antibiotics will not ldquofixrdquo what is wrong
bull Good opportunity for learning needs assessment
GOLD 2009
95
DOS CME Course 2011
COPD
bull Pulmonary rehabilitation
bull Encourage the patient to continue activities as tolerated ndash Move as much as you can before you canrsquot move
bull Uses low impact exercise to maintain physical function
bull Exercise can be done while seatedndash Monitor pulse oximetry respiratory rate and effort before during
and after activity
bull Set goals which are realistic for both of you
96
DOS CME Course 2011
COPD
bull Pulmonary rehab includes education nutrition and exercise
bull Can be a good source of social support for someone who has seen function decline
ndashTalk with others in the same situation
ndashFind out how they cope
ndashSocialize
bull Regular influenza and pneumonia vaccines
97
DOS CME Course 2011
COPD
bull Oxygen therapy
bull Recommended for stage IV disease ndash PaO2 lt or = 55 mmHg
ndash SaO2 lt or = 88
bull Increases survival improves hemodynamicsbenefits mental state
bull Surgical options reviewed on a case-by-case basisndash Bullectomy
ndash Lung volume reduction ndashNo evidence to support this as a widespread therapy
98
DOS CME Course 2011
COPD
bull Managing exacerbations
bull An event in the natural course of the disease characterized by a change in baseline dyspnea cough or sputum beyond day to day variance is acute in onset and may warrant a change in medication
bull Air pollution and tracheobronchial infections are the most common causes
bull 30 of exacerbations no cause identified
(GOLD 2009 p 22)
99
DOS CME Course 2011
COPD
bull Hospitalization is recommended for patients exhibiting the following
ndash Failure of exacerbation to respond to medical treatment
ndash Development of new symptoms ie peripheral edema cyanosis
ndash Significant co-morbidities
ndash History of frequent exacerbations
ndash Newly occurring arrhythmias
ndash Advanced age
ndash Insufficient home support
ndash Unclear diagnosis
(GOLD 2009 p 23)
100
DOS CME Course 2011
COPD
bull Mechanical ventilation is not recognized as an effective management strategy for stable COPD
bull May be required as supportive therapy during an exacerbation
bull Associated with mortality
bull Carries risks of its ownndash Ventilator acquired pneumonia
ndash Ventilator induced lung injury
ndash Failure to wean
(GOLD 2009)
101
DOS CME Course 2011DOS CME Course 2011102
Every Life Deserves World Class Care
Smoking
102
DOS CME Course 2011
Smoking bull By the numbers
bull More than 400 000 Americans die from smoking-related illnesses each yearndash Thatrsquos one of every 5 deaths
bull In a study of 2963 health care encounters smoking was discussed 633 times
bull Nicotine released into the body within 10 seconds of inhalation
bull If a person smokes one pack per day and takes ten puffs of each cigarette that equates to 200 ldquohitsrdquo of nicotine daily
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
103
DOS CME Course 2011
Nicotine
bull Nicotinic receptors occur naturally
bull N1 receptors in the adrenal medulla
bull Neuromuscular junction of autonomic ganglia
bull N2 receptors in skeletal muscle
bull Number of receptor sites increases with regular stimulation
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
104
DOS CME Course 2011
Nicotinebull Addictive
bull Vasoconstrictor
bull Releases adrenaline from the adrenal cortex
ndashFeeling of increased energy
bull Releases dopamine to produce feelings of well-beingndash Actually improves memory and cognition
bull Sensitivity actually declines overnight
bull Release of insulinndash Slightly hyperglycemic
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
105
DOS CME Course 2011
Genetic componentbull About 10 of smokers lack the gene for nicotine
dependence
ndashldquosocial or occasionalrdquo smokers
ndashThey really can quit anytime they want to
ndashNo withdrawal symptoms
ndashStill poses a health risk
bull The other 90 will demonstrate physical and psychological symptoms of withdrawal
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
106
DOS CME Course 2011
Smoking
bull Identify tobacco users ndash Ask every patient every visit
ndash Have you used tobacco in the last 12 months
ndash Clinic-wide program
bull Advise every tobacco user to quitndash Personalize the message
ndash Be clear
ndash Be firm
If at first you donrsquot succeed try tryagain Bring it up at every encounter
107
DOS CME Course 2011
Smoking cessationbull Some more good reasons to quit
ndashSmoking costs over $2000 a year in current US dollars
ndashThere is no accepted safe level of cigarette smoke
ndashSecondhand smoke carries the same hazards
ndashIncreased risk of SIDS and asthma exacerbations in children
httpwwwlungusaorgstop-smokingabout-smokingfacts-figuresgeneral-smoking-factshtml
108
DOS CME Course 2011
Smoking cessation
bull Nicotine is a powerful drug addiction
bull Treat as a chronic illness
bull All healthcare providers encouraged to participate
bull Assess willingness to quit
bull Promote motivation
109
DOS CME Course 2011
Smoking cessation
bull Prochaskarsquos change theory
bull Precontemplation
ndashNot even thinking about quitting
ndashProvide education on the risks and costs of smoking
bull Contemplation
ndashAwareness that a problem exists
ndashContinue to find motivations to stop
NorcrossJC Krebs PM Prochaska JO(2011)
110
DOS CME Course 2011
Change is good
bull Determination
ndashExpressing willingness to act
ndashSelf-efficacy
bull Action ndash Currently not smoking
ndash May relapse
bull It is not unusual for a patient to ldquoquitrdquo three or four times
bull Continue to encourage and motivate himher to stop
NorcrossJC Krebs PM Prochaska JO(2011)
111
DOS CME Course 2011
Smoking cessationbull Assist the patient
ndashCollaborate with the patient to develop a plan to quit
ndashAchievable clearly defined goals
ndashIdentify and engage social supports
ndashFamily support groups
ndashPharmacologic (more on this later)
bull Arrange follow-up
ndashAt each successive visit review progress on quitting strategy
ndashLets the patient know heshe is not alone in this effort
ndashAccountability
112
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
Asthma
bull Chronic disease characterized by inflammation of the airways ndash Episodes of breathlessness- ldquoattacksrdquo
ndash Exacerbation of inflammation and mucous plugs
ndash Vary in frequency duration and severity
bull Onset at any time of life
37
DOS CME Course 2011
Asthmabull Aggravating factors may include
ndash exercisendash viral infectionndash animal exposure ndash house dust mites ndash mold ndash smoke ndash pollen ndash changes in weatherndash menses ndash exposure to airborne chemicals or dustsndash exposure to cockroach secretions ndash Sulfites in food shrimp dried fruit processed potatoes beer
and wineDOS wheezing protocol
38
DOS CME Course 2011
Asthma
bull History and physical ndash Do you sometimes struggle to breathe
ndash Do you ever feel like you canrsquot get enough air
ndash What were you doing when this happened
ndash How many times have you felt this way in the last weekthe lastmonth
ndash Does your breathing wake you up at night
bull Environmental factorsndash What do you do for a living
ndashAre you exposed to temperature extremes
ndashInhale chemicals or particles such as dirt or dust
bull Do you smoke
39
DOS CME Course 2011
Diagnosis
bull Good medical history
bull Cough chest discomfort especially at night
bull Wheezing
bull Difficulty breathing
bull Co-morbid hay fever eczema or family history of asthma
bull Colds tend to ldquogo to the chestrdquo
bull Responds to bronchodilators
40
DOS CME Course 2011
Remember to askhellip
bull Previous asthma attacks or exacerbations
bull Past and present management strategies and responses
bull Family history of asthma allergy sinusitis rhinitis or nasal polyps
bull Impact of disease on family finances schoolwork activity sleep and childrenrsquos growth and development
bull Patient and family knowledge base understanding of treatments and sociocultural beliefs
bull Number of sick days per month
DOS wheezing protocol
41
DOS CME Course 2011
Physical assessment
bull Pulse and respiratory rate and O2 Sat (PaO2)
bull Assess for dehydration delayed capillary refill poor skin turgor dry mucous membranes
bull Use of accessory respiratory muscles retractions nasal flaring sweating and cyanosis
bull Hyperexpansion of thorax ( hunched shoulders chest deformity)
bull Manifestations of skin allergies
DOS wheezing protocol
42
DOS CME Course 2011
Physical assessment
bull Nasal discharge allergic dark circles under eyes
bull Lungs
ndashInspection percussion palpation and auscultation may all be within normal limits between attacks
ndashIn some cases wheezes persist or lung sounds will be diminished
43
DOS CME Course 2011
Pulmonary Function tests (PFTrsquoS)
bull A group of tests which measure the lungsrsquo ability to take in and release air and how well they move oxygen into circulation
bull May include total lung volume measurement spirometry arterial blood gases
bull Spirometry is the recommended test for suspected asthma
Gildea TR Retrieved (January 2011)
44
DOS CME Course 2011
PFTrsquos
bull Prepare the patient
ndashDo not smoke before the test
ndashThere will be clip on your nose
ndashDemonstrate how to achieve a tight seal on the mouthpiece
ndashNecessary for accurate results
ndashThe test requires some deep breathing which may produce fatigue
Gildea TR Retrieved (January 2011)
45
DOS CME Course 2011
How it worksbull Spirometry
ndashWhile seated the patient inhales and exhales into a tube
ndashA machine measures the volume of air exhaled ndashThe volumes are compared to the patientrsquos baseline (if
known)ndashResults less than 80 of baseline are considered
abnormal
bull Measurements ndashForced vital capacity (FVC) is the maximum amount
the patient can exhale after filling the lungs completely ndashForced expiratory volume in one second (FEV1)
Gildea TR Retrieved (January 2011)
46
Spirometry results
bull Forced Vital Capacity (FVC) is the maximum volume of gas that can be forcefully and rapidly exhaled after a maximal inhalation
bull Forced Expiratory Volume after 1 second (FEV1) is the volume of gas exhaled after one second from the beginning of the FVC maneuver
bull Forced Expiratory Flow from 25 to 75 (FEF 25-75) is the average rate of flow during the middle half of an FVC maneuver that includes the flow from medium-sized and small airways also known as mid flow rates
bull Total Lung Capacity (TLC) is the volume of gas in the lungs at the end of a maximal inhalation
DOS CME Course 201147
Spirometry results
bull Functional Residual Capacity (FRC) is the volume of gas in the lungs after exhalation of a normal breath
bull Residual Volume (RV) is the volume of gas in the lungs after complete exhalation
bull Diffusing Capacity DLCO measures the transfer of a gas usually Carbon Monoxide (CO 03) across the membrane that separates the air sacs and the blood stream
DOS CME Course 201148
DOS CME Course 2011
Asthma
bull FEV1ndash Reflects about 75 to 85 of total lung capacity ndash Decreased in patients with asthma and COPD
bull Administer an inhaled bronchodilator and repeat the test
bull A decrease in FEV1 is diagnostic for asthma ndash gt or = 12 and gt or = 200 ml
bull Peak expiratory flow (PEF) ndash Use patientrsquos own meter and compare with their baselinendash Administer bronchodilator
ndashImprovement of gt or = 20 is diagnostic
(Gildea TR Retrieved January 2011)
49
DOS CME Course 2011
Asthmabull Exercise-induced
ndash Perform spirometry following an 8-minute running protocol
bull Airway responsivenessndash Evaluate with inhaled mannitol or methacholine and histamine
ndash For the patient with normal spirometry but asthma symptoms persist
bull Elderly patients ndash May underreport symptoms
ndash Co-morbidities such as heart failure or COPD
ndash Expect fatigue and shortness of breath as normal aging
bull Occupational ndash Evaluate for correlation of symptoms with exposure to
occupational environment
50
DOS CME Course 2011
Asthma
bull Pharmacologic management
bull Stepwise approach
bull Reduce impairmentndash Prevent chronic symptoms
ndash Require 2 days or lessweek of short-acting beta agonists
ndash Maintain normal activities
ndash Maintain normal lung function
ndash Meet patient and family expectations of care
bull Reduce riskndash Prevent emergency hospitalizations
ndash Avoid adverse drug reactions
NHLBI 2007
51
DOS CME Course 2011
Pharmacology bull Beta-2 adrenergic agonists
ndashBronchodilators-smooth muscle relaxants
ndashSympathomimetic
ndashShort acting ndashalbuterolterbutalinelevalbuterol
ndashUse of short acting before exercise to improve tolerance
ndashLong acting (LABA)ndashSalmeterol formoterol
bull Side effects include
ndash tachycardia tremor hypokalemia hyperglycemia HA dizziness
52
DOS CME Course 2011
Pharmacology
bull Methylxanthines (theophylline)ndash Smooth muscle relaxants
ndashPO PR IV
bull Side effects ndash nausea irritability tachycardia dysrrhythmia seizures brain
damage death
bull Theophylline causes concern because the therapeutic and toxic ranges overlapndash Monitor after initiation with any dose increases or signs of toxicity
(Micromedex 2010)
53
DOS CME Course 2011
Pharmacology
bull Inhaled glucocorticosteroid (ICS)
ndashDecrease swelling due to inflammation
ndashBeclomethasone budesonide fluticasone triamcinolone
ndashSide effects oral candidiasis dry mouth hoarseness hypersensitivity
ndashOnset of effects 10-20 minutes
ndashRecommend using a spacer
54
DOS CME Course 2011
Pharmacologybull Leukotriene modifiers
ndash Disrupt the function or synthesis of inflammatory mediators related to asthma
ndashMontelukast zafirlukast zileuton
bull Long-term control
bull Side effects elevation of liver enzymes HA dizziness GI distress
bull Mast cell stabilizersndash Cromolyn sodium nedocromil
ndash Inhibit release of inflammatory mediators
ndash Side effects bronchospasm pharyngeal irritation
55
DOS CME Course 2011
Pharmacology
bull Anticholinergics chemically related to atropine
ndashIpratropium bromide (Atrovent)
ndashInhaled form as rescue therapy
bull Side effects
ndashurinary obstruction HA restlessness palpitations bronchospasm
56
DOS CME Course 2011
The big guns
bull Systemic corticosteroidsndash Methylprednisolone hydrocortisone dexamethasone
ndash IV or PO
ndash Treatment of acute exacerbations
bull Side effects ndash adrenal suppression weight gain fluid retention hyperglycemia
ndash Long term
ndash osteoporosis immune suppression gastric ulcers
57
DOS CME Course 2011
Right here and now
bull Nursing Intervention
bull Quick Relief
bull Short acting bronchodilator ndash Up to 3 treatments at 20 minute intervals
bull Or single nebulizer treatment
bull Course of systemic corticosteroids may be needed
DOS Wheezing protocol
58
DOS CME Course 2011
Nebulizer Treatment
bull Albuterol Solution
ndashlt5 years old 063-25 mg in 3 cc of saline q 4-6 hours as needed
ndashgt5 years old -adult 125-5 mg in 3 cc of saline q 4-8 hours as needed
bull Levalbuterol (R-albuterol solution Xopinex)
ndashlt 5 years old 031 mg-125 mg in 3 cc NS q 4-6 hrs as needed
ndash5-11 yrs old 031-063 mg q 8 hours prn symptoms
ndashgt12 yrs old063mg-125 mg q 8 hours prn symptoms
DOS Wheezing protocol
59
DOS CME Course 2011
Treatment at home
bull Nebulizers convert liquid or powder medications to aerosolized formndash Effective to deliver larger doses than metered dose inhalers
Patient safety alert Some medications in powder formcome as a capsule which is broken open The patient should not take this medication orally
60
DOS CME Course 2011
How often
do the following
happen
MILD INTERMITTENT(check appropriate box)
MILD PERSISTENT
MODERATE PERSISTENT
SEVERE PERSISTENT
Daytime wheezingshortness of breath
0-2 times per week
Greater than 2 times per week
Daily Continually
Night-time wheezing shortness of breath
0-2 times per month
Greater than 2 times per month
Greater than 1 time per week
Frequent
How often are your physical activities limited by asthma
0-2 times per week
0-2 times per week
Greater than 2 times per week
Frequent
Daily use of albuterol or ldquorescue drugsrdquo
Less than 1 time per week or less than 3 times per month
2 time per week or more
Daily Use Frequent
DOS Wheezing protocol61
DOS CME Course 2011
Plan of carebull Step 1mdashmild intermittent
ndash no daily medication
ndash should have prn short acting rescue Beta 2 inhaler on hand
bull Step 2mdashmild persistentndash low dose inhaled corticosteroids
bull Step 3mdashmoderate persistentndash low to med inhaled corticosteroids and long acting beta 2 agonists
bull Step 4mdashsevere persistentndash high dose inhaled corticosteroids and long acting inhaled beta 2
agonists
DOS Wheezing protocol
62
DOS CME Course 2011
Ongoing carebull Plan Follow-up
ndash Evaluate 2-6 weeks after treatment initiationndash Evaluate every 1-6 months when stablendash Evaluate every 3 months interval after stepping down therapyndash Annual inactivated influenza vaccine
bull ConsultationReferralndash Life threatening or severe persistent asthmandash Goals of asthma therapy not fulfilled in 3-6 monthsndash Signs and symptoms are not typicalndash Sinusitis gastroesophageal reflux or chronic pulmonary disease
complicate the asthma
DOS Wheezing protocol
63
DOS CME Course 2011
Consults
bull Continuous oral corticosteroids or 2 bursts of oral steroids in 1 year
bull Patient under 3 years with step 3 or 4 asthma
bull If omalizumab (Xolair) is considered for treatment as there is an increase in rate of anaphylaxis with this medication
bull Exacerbation requiring hospitalization
DOS Wheezing protocol
64
DOS CME Course 2011
Patient educationbull Basic understanding of asthma and how the disease
works
bull Medications ndash Names and doses of all medications
ndash Short acting vs long acting
bull Equipment ndash Metered dose inhalers (MDI)
ndash Nebulizers
bull Emergency response
bull Activity level
bull Illness management
65
DOS CME Course 2011
Patient education
bull Know your triggers and have a strategy for avoidance
bull If mold or mites are known triggers humidifiers and evaporator coolers are not recommended in the home
bull Know the early signs of an exacerbation and what to do
bull Develop an action plan based on peak flow readings
bull What to do in case of an attack at school or work
66
DOS CME Course 2011
Patient educationbull Metered dose inhalers
ndash Remove cap and invert the device several times
ndash Exhale
ndash Place the mouthpiece between your lips with a good seal
ndash Inhale while depressing the top of the MDI
ndash Hold your breath for 10 seconds
ndash Exhale
ndash Repeat as needed
67
DOS CME Course 2011
Patient educationbull Spacers are used with MDIrsquos
used to deliver inhaled steroidsndash Ease coordination of breathing
and medication delivery
ndash Decrease the amount of medication contacting the oral mucosa
ndash Fewer side effects
bull Attach the spacer to the mouthpiece of the MDI ndash Use the MDI as described
before
ndash Some models have a whistle to indicate you are inhaling too rapidly
68
DOS CME Course 201169
DOS CME Course 2011
Characteristic Controlled
(All of the following)
Partly controlled
(Any measure noted)
Uncontrolled
Daytime symptoms
None (twice or less a week)
More than twice a week
Three or more features of partly controlled asthma
Limitation of activities
None Any
Nocturnal symptomsawakening
None Any
Need for rescue treatment
None (twice or less a week)
More than twice a week
Lung function (FEV1 or PEF)
Normal lt80 predicted or personal best
70
DOS CME Course 2011
Asthma
bull Self monitoring is essential to effective management and control
bull The following are validated tools to assess asthma control
ndashAsthmacontrolcom
ndashFree web-based
ndashQoltechcouk
ndashFree in hard copy or electronic versions
ndashRequires permission
ndashAtaqinstrumentcom
ndashFree web-based
71
DOS CME Course 2011DOS CME Course 201172
Every Life Deserves World Class Care
COPD
72
DOS CME Course 2011
Chronic obstructive pulmonary disease
bull By the numbers
bull 210 million suffer worldwide
bull 3 million fatalities
bull By 2030 COPD is expected to be the third leading cause of death worldwide
bull Most important risk factors ndash Smoking
ndash Indoor pollution
ndash Outdoor pollution
ndash Occupational irritants
WHO Retrieved January 2011
73
DOS CME Course 2011
COPD
bull Causes ndash Cigarette smoking is the number one cause worldwide
ndash Environmental irritants
ndash Genetic alpha-one antitrypsin deficiency
bull Birth defects ndash Low birth weight
ndash Respiratory infections
ndash Any factor which impairs lung development during gestation
bull Other ndash HIV
ndash Connective tissue disorders
ndash Vasculitis
74
DOS CME Course 2011
COPD
bull Sometimes referred to as umbrella term for a family of diseases which cause limited airflow
ndashChronic bronchitis
ndashEmphysema
bull Inflammation of the airways
bull Increased mucous productionndash Especially in bronchitis
bull Decreased ciliary function
bull Loss of elastic recoil ndash Especially in emphysema
75
DOS CME Course 2011
COPD
bull How inflammation ruins a lung
bull Cell mediated ndash Neutrophils
ndash Macrophages
ndash Lymphocytes
bull Release cytokines which attract more cells
bull Oxidants released by cells and found in cigarette smoke
bull Proteases
bull Cause remodeling and long term structural changes
76
DOS CME Course 2011
COPDbull Alveoli lose elasticity and become distended
ndashSaggy sacs
ndashCarbon dioxide retention
ndashChronic respiratory acidosis
bull Walls of the alveoli are degraded
ndashLoss of surface area necessary for gas exchange
77
DOS CME Course 2011
What the patient looks like
bull Productive Cough
ndashEspecially in chronic bronchitis
bull Progressive dyspnea
ndashUncomfortable awareness of breathing
bull Wheezing and chest tightness
bull Increase in AP chest diameter
ndashldquoBarrel chestrdquo especially in emphysema
ndashIncreased inspiratory effort loosens costochondral cartilage
78
DOS CME Course 2011
Alpha one antitrypsin deficiency
bull Enzyme normally produced which protects the lungs
bull Deactivates neutrophil elastase
ndashReleased during inflammation
bull Estimated over 100000 in US have AATD
bull Time to diagnosis gt8 years
bull Related to increased mortality (Krowka 2010)
ndashIncreased incidence of emphysema
79
DOS CME Course 2011
Chronic bronchitis
bull Presence of cough and sputum production over three months for two consecutive years
ndashNote the months need not be consecutive
bull The patient may feel as though they are constantly sick
bull Multiple courses of antibiotics with no improvement
bull No relationship to acute bronchitis caused by bacteria or virus
80
DOS CME Course 2011
COPD
bull Break out the testing ndash CXR
ndash ECG
ndash Sputum culture
ndash CBC and electrolytes
bull ABGrsquos ndash Respiratory failure indicated by
ndash PaO2lt 60 and SaO2 lt 90
ndash with or without PaCO2 gt 50
ndash On room air
ndash Severe acidosis pHlt 736 in addition to the above is an indication for mechanical ventilation
(GOLD 2009 p 22)
81
DOS CME Course 2011
Chronic bronchitis
bull Airway of a child afflicted with chronic bronchitis compared to normal
82
DOS CME Course 2011
Chronic bronchitisbull Related to mucociliary dysfunction
ndashIncreased mucous production and thickening
ndashLoss of cilia
ndashLoss of ciliary function
ndashMobility required to sweep out particles
83
DOS CME Course 2011
Emphysemabull Permanent enlargement of the airspaces terminal to the
distal bronchioles ndashLoss of surface area for gas exchangendashDestruction of supporting structure of alveoli
ndashAirway narrowing
bull Three distinct patterns ndashCentracinar begins centrally and spreads to terminal
bronchioles and is most closely associated with cigarette smoking
ndashPanacinar destroys alveoli uniformly predominant in lower half of lungs most closely associated with AATD
ndashParaseptal destroys the distal airway structures alveolar ducts and sacs
Demirjian BG 2010
84
DOS CME Course 2011
Bullaebull Outpouchingsballooning of lung tissue due to trapped air
ndashAir is released from damaged alveoli
ndashAsymptomatic
ndashRupture can cause pneumothorax
85
DOS CME Course 2011
Diagnosis
bull History of smoking or exposure to inhaled irritants
ndashRemember to consider work and living environment
ndashCooking indoors with fossil fuels
ndashAge over 40
bull Signs and symptoms
ndashChronic cough with sputum production
ndashDyspnea which persists daily worsens with exercise and progresses over time
bull Spirometry is strongly recommended
86
DOS CME Course 2011
Diagnosis
bull Chest x-ray
ndashRule out pneumonia cardiomyopathy
ndashNot diagnostic for COPD but may reveal other causes for symptoms
bull Arterial blood gases
ndashRecommended for patients with FEVlt 50
ndashPaO2lt 60 mmHg suggests respiratory failure
bull Sputum culture
ndashRule out infectious process
87
DOS CME Course 2011
Disease stages
bull Stage Indash FEVFVC lt 70
ndash FEV gt 80
ndash Few symptoms if any patient may be unaware
bull Stage II moderate ndash FEVFVC lt 70
ndash FEV lt 80
ndash Along with shortness of breath
88
DOS CME Course 2011
Disease stages
bull Stage IV very severe ndash FEVFVC lt 70
ndash FEV lt 30
ndash At this stage exacerbations are life-threatening
ndash Quality of life is impaired further
bull Stage III severe ndash FEVFVC lt 70
ndash FEV lt 50
ndash Worsening symptoms increasing frequency of exacerbations
89
DOS CME Course 2011
COPD vs Asthma
bull COPD
ndashOnset later in life
ndashProgressive worsening symptoms
ndashSmoking history
ndashDyspnea with exercise
ndashLargely irreversible airflow limitation
bull Asthma
ndashOnset of symptoms usually earlier in life
ndashWorsening at night
ndashLargely reversible airflow limitation
ndashSymptoms vary from day to day
90
DOS CME Course 2011
COPD Treatmentbull Now that we have diagnosis what do I do about it
bull Assess and monitor diseasendash Assess for risk factors ie smoking family history
ndash Co-morbidities such as heart failure
ndash Pattern of symptoms
ndash Impact on quality of life
bull Reduce risk factors ndash Identify environmentaloccupational factors which can be modified
ndash Smoking cessation is essential
ndash Manage exacerbations
91
DOS CME Course 2011
COPDbull Manage stable COPD
ndash Determine disease severity based on frequency and severity of symptoms
ndash Educate the patient about risk factors and disease management regimen
ndash Collaborate with the patient to develop a personalized regimen
ndashFits their lifestyle
ndashAccounts for cultural preferences family involvement
ndashAvailability of testing and medications
92
DOS CME Course 2011
Pharmacologybull Goals
ndash Improve exercise tolerance
ndash Control symptoms
ndash Reduce frequency and severity of exacerbations
ndash Improve health status
bull Bronchodilators ndash Include long-acting therapy with short-acting for better control
bull Combine medications from different classes rather than increasing dosage of just onendash Minimizes side effects
93
DOS CME Course 2011
Pharmacologybull Glucocorticosteroids
ndashCan reduce the number of exacerbations
ndashIncreased risk of pneumonia
ndashNo noted reduction in mortality
bull Vaccines
ndashInfluenza vaccines decrease serious illness and death by 50
ndashRecommended annually
ndashPneumococcal vaccines recommended for all COPD sufferers even under age 65
GOLD 2009
94
DOS CME Course 2011
Antibiotics
bull Antibiotics are not a treatment for COPD nor do they manage symptoms of an exacerbation
bull Should be given only if the following are metndash Presence of three cardinal symptoms increased dyspnea
increased sputum volume increased sputum purulence
ndash Increased sputum purulence plus one other cardinal symptom
ndash Mechanically ventilated
bull May be difficult for patients to understand why antibiotics will not ldquofixrdquo what is wrong
bull Good opportunity for learning needs assessment
GOLD 2009
95
DOS CME Course 2011
COPD
bull Pulmonary rehabilitation
bull Encourage the patient to continue activities as tolerated ndash Move as much as you can before you canrsquot move
bull Uses low impact exercise to maintain physical function
bull Exercise can be done while seatedndash Monitor pulse oximetry respiratory rate and effort before during
and after activity
bull Set goals which are realistic for both of you
96
DOS CME Course 2011
COPD
bull Pulmonary rehab includes education nutrition and exercise
bull Can be a good source of social support for someone who has seen function decline
ndashTalk with others in the same situation
ndashFind out how they cope
ndashSocialize
bull Regular influenza and pneumonia vaccines
97
DOS CME Course 2011
COPD
bull Oxygen therapy
bull Recommended for stage IV disease ndash PaO2 lt or = 55 mmHg
ndash SaO2 lt or = 88
bull Increases survival improves hemodynamicsbenefits mental state
bull Surgical options reviewed on a case-by-case basisndash Bullectomy
ndash Lung volume reduction ndashNo evidence to support this as a widespread therapy
98
DOS CME Course 2011
COPD
bull Managing exacerbations
bull An event in the natural course of the disease characterized by a change in baseline dyspnea cough or sputum beyond day to day variance is acute in onset and may warrant a change in medication
bull Air pollution and tracheobronchial infections are the most common causes
bull 30 of exacerbations no cause identified
(GOLD 2009 p 22)
99
DOS CME Course 2011
COPD
bull Hospitalization is recommended for patients exhibiting the following
ndash Failure of exacerbation to respond to medical treatment
ndash Development of new symptoms ie peripheral edema cyanosis
ndash Significant co-morbidities
ndash History of frequent exacerbations
ndash Newly occurring arrhythmias
ndash Advanced age
ndash Insufficient home support
ndash Unclear diagnosis
(GOLD 2009 p 23)
100
DOS CME Course 2011
COPD
bull Mechanical ventilation is not recognized as an effective management strategy for stable COPD
bull May be required as supportive therapy during an exacerbation
bull Associated with mortality
bull Carries risks of its ownndash Ventilator acquired pneumonia
ndash Ventilator induced lung injury
ndash Failure to wean
(GOLD 2009)
101
DOS CME Course 2011DOS CME Course 2011102
Every Life Deserves World Class Care
Smoking
102
DOS CME Course 2011
Smoking bull By the numbers
bull More than 400 000 Americans die from smoking-related illnesses each yearndash Thatrsquos one of every 5 deaths
bull In a study of 2963 health care encounters smoking was discussed 633 times
bull Nicotine released into the body within 10 seconds of inhalation
bull If a person smokes one pack per day and takes ten puffs of each cigarette that equates to 200 ldquohitsrdquo of nicotine daily
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
103
DOS CME Course 2011
Nicotine
bull Nicotinic receptors occur naturally
bull N1 receptors in the adrenal medulla
bull Neuromuscular junction of autonomic ganglia
bull N2 receptors in skeletal muscle
bull Number of receptor sites increases with regular stimulation
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
104
DOS CME Course 2011
Nicotinebull Addictive
bull Vasoconstrictor
bull Releases adrenaline from the adrenal cortex
ndashFeeling of increased energy
bull Releases dopamine to produce feelings of well-beingndash Actually improves memory and cognition
bull Sensitivity actually declines overnight
bull Release of insulinndash Slightly hyperglycemic
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
105
DOS CME Course 2011
Genetic componentbull About 10 of smokers lack the gene for nicotine
dependence
ndashldquosocial or occasionalrdquo smokers
ndashThey really can quit anytime they want to
ndashNo withdrawal symptoms
ndashStill poses a health risk
bull The other 90 will demonstrate physical and psychological symptoms of withdrawal
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
106
DOS CME Course 2011
Smoking
bull Identify tobacco users ndash Ask every patient every visit
ndash Have you used tobacco in the last 12 months
ndash Clinic-wide program
bull Advise every tobacco user to quitndash Personalize the message
ndash Be clear
ndash Be firm
If at first you donrsquot succeed try tryagain Bring it up at every encounter
107
DOS CME Course 2011
Smoking cessationbull Some more good reasons to quit
ndashSmoking costs over $2000 a year in current US dollars
ndashThere is no accepted safe level of cigarette smoke
ndashSecondhand smoke carries the same hazards
ndashIncreased risk of SIDS and asthma exacerbations in children
httpwwwlungusaorgstop-smokingabout-smokingfacts-figuresgeneral-smoking-factshtml
108
DOS CME Course 2011
Smoking cessation
bull Nicotine is a powerful drug addiction
bull Treat as a chronic illness
bull All healthcare providers encouraged to participate
bull Assess willingness to quit
bull Promote motivation
109
DOS CME Course 2011
Smoking cessation
bull Prochaskarsquos change theory
bull Precontemplation
ndashNot even thinking about quitting
ndashProvide education on the risks and costs of smoking
bull Contemplation
ndashAwareness that a problem exists
ndashContinue to find motivations to stop
NorcrossJC Krebs PM Prochaska JO(2011)
110
DOS CME Course 2011
Change is good
bull Determination
ndashExpressing willingness to act
ndashSelf-efficacy
bull Action ndash Currently not smoking
ndash May relapse
bull It is not unusual for a patient to ldquoquitrdquo three or four times
bull Continue to encourage and motivate himher to stop
NorcrossJC Krebs PM Prochaska JO(2011)
111
DOS CME Course 2011
Smoking cessationbull Assist the patient
ndashCollaborate with the patient to develop a plan to quit
ndashAchievable clearly defined goals
ndashIdentify and engage social supports
ndashFamily support groups
ndashPharmacologic (more on this later)
bull Arrange follow-up
ndashAt each successive visit review progress on quitting strategy
ndashLets the patient know heshe is not alone in this effort
ndashAccountability
112
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
Asthma
bull History and physical ndash Do you sometimes struggle to breathe
ndash Do you ever feel like you canrsquot get enough air
ndash What were you doing when this happened
ndash How many times have you felt this way in the last weekthe lastmonth
ndash Does your breathing wake you up at night
bull Environmental factorsndash What do you do for a living
ndashAre you exposed to temperature extremes
ndashInhale chemicals or particles such as dirt or dust
bull Do you smoke
39
DOS CME Course 2011
Diagnosis
bull Good medical history
bull Cough chest discomfort especially at night
bull Wheezing
bull Difficulty breathing
bull Co-morbid hay fever eczema or family history of asthma
bull Colds tend to ldquogo to the chestrdquo
bull Responds to bronchodilators
40
DOS CME Course 2011
Remember to askhellip
bull Previous asthma attacks or exacerbations
bull Past and present management strategies and responses
bull Family history of asthma allergy sinusitis rhinitis or nasal polyps
bull Impact of disease on family finances schoolwork activity sleep and childrenrsquos growth and development
bull Patient and family knowledge base understanding of treatments and sociocultural beliefs
bull Number of sick days per month
DOS wheezing protocol
41
DOS CME Course 2011
Physical assessment
bull Pulse and respiratory rate and O2 Sat (PaO2)
bull Assess for dehydration delayed capillary refill poor skin turgor dry mucous membranes
bull Use of accessory respiratory muscles retractions nasal flaring sweating and cyanosis
bull Hyperexpansion of thorax ( hunched shoulders chest deformity)
bull Manifestations of skin allergies
DOS wheezing protocol
42
DOS CME Course 2011
Physical assessment
bull Nasal discharge allergic dark circles under eyes
bull Lungs
ndashInspection percussion palpation and auscultation may all be within normal limits between attacks
ndashIn some cases wheezes persist or lung sounds will be diminished
43
DOS CME Course 2011
Pulmonary Function tests (PFTrsquoS)
bull A group of tests which measure the lungsrsquo ability to take in and release air and how well they move oxygen into circulation
bull May include total lung volume measurement spirometry arterial blood gases
bull Spirometry is the recommended test for suspected asthma
Gildea TR Retrieved (January 2011)
44
DOS CME Course 2011
PFTrsquos
bull Prepare the patient
ndashDo not smoke before the test
ndashThere will be clip on your nose
ndashDemonstrate how to achieve a tight seal on the mouthpiece
ndashNecessary for accurate results
ndashThe test requires some deep breathing which may produce fatigue
Gildea TR Retrieved (January 2011)
45
DOS CME Course 2011
How it worksbull Spirometry
ndashWhile seated the patient inhales and exhales into a tube
ndashA machine measures the volume of air exhaled ndashThe volumes are compared to the patientrsquos baseline (if
known)ndashResults less than 80 of baseline are considered
abnormal
bull Measurements ndashForced vital capacity (FVC) is the maximum amount
the patient can exhale after filling the lungs completely ndashForced expiratory volume in one second (FEV1)
Gildea TR Retrieved (January 2011)
46
Spirometry results
bull Forced Vital Capacity (FVC) is the maximum volume of gas that can be forcefully and rapidly exhaled after a maximal inhalation
bull Forced Expiratory Volume after 1 second (FEV1) is the volume of gas exhaled after one second from the beginning of the FVC maneuver
bull Forced Expiratory Flow from 25 to 75 (FEF 25-75) is the average rate of flow during the middle half of an FVC maneuver that includes the flow from medium-sized and small airways also known as mid flow rates
bull Total Lung Capacity (TLC) is the volume of gas in the lungs at the end of a maximal inhalation
DOS CME Course 201147
Spirometry results
bull Functional Residual Capacity (FRC) is the volume of gas in the lungs after exhalation of a normal breath
bull Residual Volume (RV) is the volume of gas in the lungs after complete exhalation
bull Diffusing Capacity DLCO measures the transfer of a gas usually Carbon Monoxide (CO 03) across the membrane that separates the air sacs and the blood stream
DOS CME Course 201148
DOS CME Course 2011
Asthma
bull FEV1ndash Reflects about 75 to 85 of total lung capacity ndash Decreased in patients with asthma and COPD
bull Administer an inhaled bronchodilator and repeat the test
bull A decrease in FEV1 is diagnostic for asthma ndash gt or = 12 and gt or = 200 ml
bull Peak expiratory flow (PEF) ndash Use patientrsquos own meter and compare with their baselinendash Administer bronchodilator
ndashImprovement of gt or = 20 is diagnostic
(Gildea TR Retrieved January 2011)
49
DOS CME Course 2011
Asthmabull Exercise-induced
ndash Perform spirometry following an 8-minute running protocol
bull Airway responsivenessndash Evaluate with inhaled mannitol or methacholine and histamine
ndash For the patient with normal spirometry but asthma symptoms persist
bull Elderly patients ndash May underreport symptoms
ndash Co-morbidities such as heart failure or COPD
ndash Expect fatigue and shortness of breath as normal aging
bull Occupational ndash Evaluate for correlation of symptoms with exposure to
occupational environment
50
DOS CME Course 2011
Asthma
bull Pharmacologic management
bull Stepwise approach
bull Reduce impairmentndash Prevent chronic symptoms
ndash Require 2 days or lessweek of short-acting beta agonists
ndash Maintain normal activities
ndash Maintain normal lung function
ndash Meet patient and family expectations of care
bull Reduce riskndash Prevent emergency hospitalizations
ndash Avoid adverse drug reactions
NHLBI 2007
51
DOS CME Course 2011
Pharmacology bull Beta-2 adrenergic agonists
ndashBronchodilators-smooth muscle relaxants
ndashSympathomimetic
ndashShort acting ndashalbuterolterbutalinelevalbuterol
ndashUse of short acting before exercise to improve tolerance
ndashLong acting (LABA)ndashSalmeterol formoterol
bull Side effects include
ndash tachycardia tremor hypokalemia hyperglycemia HA dizziness
52
DOS CME Course 2011
Pharmacology
bull Methylxanthines (theophylline)ndash Smooth muscle relaxants
ndashPO PR IV
bull Side effects ndash nausea irritability tachycardia dysrrhythmia seizures brain
damage death
bull Theophylline causes concern because the therapeutic and toxic ranges overlapndash Monitor after initiation with any dose increases or signs of toxicity
(Micromedex 2010)
53
DOS CME Course 2011
Pharmacology
bull Inhaled glucocorticosteroid (ICS)
ndashDecrease swelling due to inflammation
ndashBeclomethasone budesonide fluticasone triamcinolone
ndashSide effects oral candidiasis dry mouth hoarseness hypersensitivity
ndashOnset of effects 10-20 minutes
ndashRecommend using a spacer
54
DOS CME Course 2011
Pharmacologybull Leukotriene modifiers
ndash Disrupt the function or synthesis of inflammatory mediators related to asthma
ndashMontelukast zafirlukast zileuton
bull Long-term control
bull Side effects elevation of liver enzymes HA dizziness GI distress
bull Mast cell stabilizersndash Cromolyn sodium nedocromil
ndash Inhibit release of inflammatory mediators
ndash Side effects bronchospasm pharyngeal irritation
55
DOS CME Course 2011
Pharmacology
bull Anticholinergics chemically related to atropine
ndashIpratropium bromide (Atrovent)
ndashInhaled form as rescue therapy
bull Side effects
ndashurinary obstruction HA restlessness palpitations bronchospasm
56
DOS CME Course 2011
The big guns
bull Systemic corticosteroidsndash Methylprednisolone hydrocortisone dexamethasone
ndash IV or PO
ndash Treatment of acute exacerbations
bull Side effects ndash adrenal suppression weight gain fluid retention hyperglycemia
ndash Long term
ndash osteoporosis immune suppression gastric ulcers
57
DOS CME Course 2011
Right here and now
bull Nursing Intervention
bull Quick Relief
bull Short acting bronchodilator ndash Up to 3 treatments at 20 minute intervals
bull Or single nebulizer treatment
bull Course of systemic corticosteroids may be needed
DOS Wheezing protocol
58
DOS CME Course 2011
Nebulizer Treatment
bull Albuterol Solution
ndashlt5 years old 063-25 mg in 3 cc of saline q 4-6 hours as needed
ndashgt5 years old -adult 125-5 mg in 3 cc of saline q 4-8 hours as needed
bull Levalbuterol (R-albuterol solution Xopinex)
ndashlt 5 years old 031 mg-125 mg in 3 cc NS q 4-6 hrs as needed
ndash5-11 yrs old 031-063 mg q 8 hours prn symptoms
ndashgt12 yrs old063mg-125 mg q 8 hours prn symptoms
DOS Wheezing protocol
59
DOS CME Course 2011
Treatment at home
bull Nebulizers convert liquid or powder medications to aerosolized formndash Effective to deliver larger doses than metered dose inhalers
Patient safety alert Some medications in powder formcome as a capsule which is broken open The patient should not take this medication orally
60
DOS CME Course 2011
How often
do the following
happen
MILD INTERMITTENT(check appropriate box)
MILD PERSISTENT
MODERATE PERSISTENT
SEVERE PERSISTENT
Daytime wheezingshortness of breath
0-2 times per week
Greater than 2 times per week
Daily Continually
Night-time wheezing shortness of breath
0-2 times per month
Greater than 2 times per month
Greater than 1 time per week
Frequent
How often are your physical activities limited by asthma
0-2 times per week
0-2 times per week
Greater than 2 times per week
Frequent
Daily use of albuterol or ldquorescue drugsrdquo
Less than 1 time per week or less than 3 times per month
2 time per week or more
Daily Use Frequent
DOS Wheezing protocol61
DOS CME Course 2011
Plan of carebull Step 1mdashmild intermittent
ndash no daily medication
ndash should have prn short acting rescue Beta 2 inhaler on hand
bull Step 2mdashmild persistentndash low dose inhaled corticosteroids
bull Step 3mdashmoderate persistentndash low to med inhaled corticosteroids and long acting beta 2 agonists
bull Step 4mdashsevere persistentndash high dose inhaled corticosteroids and long acting inhaled beta 2
agonists
DOS Wheezing protocol
62
DOS CME Course 2011
Ongoing carebull Plan Follow-up
ndash Evaluate 2-6 weeks after treatment initiationndash Evaluate every 1-6 months when stablendash Evaluate every 3 months interval after stepping down therapyndash Annual inactivated influenza vaccine
bull ConsultationReferralndash Life threatening or severe persistent asthmandash Goals of asthma therapy not fulfilled in 3-6 monthsndash Signs and symptoms are not typicalndash Sinusitis gastroesophageal reflux or chronic pulmonary disease
complicate the asthma
DOS Wheezing protocol
63
DOS CME Course 2011
Consults
bull Continuous oral corticosteroids or 2 bursts of oral steroids in 1 year
bull Patient under 3 years with step 3 or 4 asthma
bull If omalizumab (Xolair) is considered for treatment as there is an increase in rate of anaphylaxis with this medication
bull Exacerbation requiring hospitalization
DOS Wheezing protocol
64
DOS CME Course 2011
Patient educationbull Basic understanding of asthma and how the disease
works
bull Medications ndash Names and doses of all medications
ndash Short acting vs long acting
bull Equipment ndash Metered dose inhalers (MDI)
ndash Nebulizers
bull Emergency response
bull Activity level
bull Illness management
65
DOS CME Course 2011
Patient education
bull Know your triggers and have a strategy for avoidance
bull If mold or mites are known triggers humidifiers and evaporator coolers are not recommended in the home
bull Know the early signs of an exacerbation and what to do
bull Develop an action plan based on peak flow readings
bull What to do in case of an attack at school or work
66
DOS CME Course 2011
Patient educationbull Metered dose inhalers
ndash Remove cap and invert the device several times
ndash Exhale
ndash Place the mouthpiece between your lips with a good seal
ndash Inhale while depressing the top of the MDI
ndash Hold your breath for 10 seconds
ndash Exhale
ndash Repeat as needed
67
DOS CME Course 2011
Patient educationbull Spacers are used with MDIrsquos
used to deliver inhaled steroidsndash Ease coordination of breathing
and medication delivery
ndash Decrease the amount of medication contacting the oral mucosa
ndash Fewer side effects
bull Attach the spacer to the mouthpiece of the MDI ndash Use the MDI as described
before
ndash Some models have a whistle to indicate you are inhaling too rapidly
68
DOS CME Course 201169
DOS CME Course 2011
Characteristic Controlled
(All of the following)
Partly controlled
(Any measure noted)
Uncontrolled
Daytime symptoms
None (twice or less a week)
More than twice a week
Three or more features of partly controlled asthma
Limitation of activities
None Any
Nocturnal symptomsawakening
None Any
Need for rescue treatment
None (twice or less a week)
More than twice a week
Lung function (FEV1 or PEF)
Normal lt80 predicted or personal best
70
DOS CME Course 2011
Asthma
bull Self monitoring is essential to effective management and control
bull The following are validated tools to assess asthma control
ndashAsthmacontrolcom
ndashFree web-based
ndashQoltechcouk
ndashFree in hard copy or electronic versions
ndashRequires permission
ndashAtaqinstrumentcom
ndashFree web-based
71
DOS CME Course 2011DOS CME Course 201172
Every Life Deserves World Class Care
COPD
72
DOS CME Course 2011
Chronic obstructive pulmonary disease
bull By the numbers
bull 210 million suffer worldwide
bull 3 million fatalities
bull By 2030 COPD is expected to be the third leading cause of death worldwide
bull Most important risk factors ndash Smoking
ndash Indoor pollution
ndash Outdoor pollution
ndash Occupational irritants
WHO Retrieved January 2011
73
DOS CME Course 2011
COPD
bull Causes ndash Cigarette smoking is the number one cause worldwide
ndash Environmental irritants
ndash Genetic alpha-one antitrypsin deficiency
bull Birth defects ndash Low birth weight
ndash Respiratory infections
ndash Any factor which impairs lung development during gestation
bull Other ndash HIV
ndash Connective tissue disorders
ndash Vasculitis
74
DOS CME Course 2011
COPD
bull Sometimes referred to as umbrella term for a family of diseases which cause limited airflow
ndashChronic bronchitis
ndashEmphysema
bull Inflammation of the airways
bull Increased mucous productionndash Especially in bronchitis
bull Decreased ciliary function
bull Loss of elastic recoil ndash Especially in emphysema
75
DOS CME Course 2011
COPD
bull How inflammation ruins a lung
bull Cell mediated ndash Neutrophils
ndash Macrophages
ndash Lymphocytes
bull Release cytokines which attract more cells
bull Oxidants released by cells and found in cigarette smoke
bull Proteases
bull Cause remodeling and long term structural changes
76
DOS CME Course 2011
COPDbull Alveoli lose elasticity and become distended
ndashSaggy sacs
ndashCarbon dioxide retention
ndashChronic respiratory acidosis
bull Walls of the alveoli are degraded
ndashLoss of surface area necessary for gas exchange
77
DOS CME Course 2011
What the patient looks like
bull Productive Cough
ndashEspecially in chronic bronchitis
bull Progressive dyspnea
ndashUncomfortable awareness of breathing
bull Wheezing and chest tightness
bull Increase in AP chest diameter
ndashldquoBarrel chestrdquo especially in emphysema
ndashIncreased inspiratory effort loosens costochondral cartilage
78
DOS CME Course 2011
Alpha one antitrypsin deficiency
bull Enzyme normally produced which protects the lungs
bull Deactivates neutrophil elastase
ndashReleased during inflammation
bull Estimated over 100000 in US have AATD
bull Time to diagnosis gt8 years
bull Related to increased mortality (Krowka 2010)
ndashIncreased incidence of emphysema
79
DOS CME Course 2011
Chronic bronchitis
bull Presence of cough and sputum production over three months for two consecutive years
ndashNote the months need not be consecutive
bull The patient may feel as though they are constantly sick
bull Multiple courses of antibiotics with no improvement
bull No relationship to acute bronchitis caused by bacteria or virus
80
DOS CME Course 2011
COPD
bull Break out the testing ndash CXR
ndash ECG
ndash Sputum culture
ndash CBC and electrolytes
bull ABGrsquos ndash Respiratory failure indicated by
ndash PaO2lt 60 and SaO2 lt 90
ndash with or without PaCO2 gt 50
ndash On room air
ndash Severe acidosis pHlt 736 in addition to the above is an indication for mechanical ventilation
(GOLD 2009 p 22)
81
DOS CME Course 2011
Chronic bronchitis
bull Airway of a child afflicted with chronic bronchitis compared to normal
82
DOS CME Course 2011
Chronic bronchitisbull Related to mucociliary dysfunction
ndashIncreased mucous production and thickening
ndashLoss of cilia
ndashLoss of ciliary function
ndashMobility required to sweep out particles
83
DOS CME Course 2011
Emphysemabull Permanent enlargement of the airspaces terminal to the
distal bronchioles ndashLoss of surface area for gas exchangendashDestruction of supporting structure of alveoli
ndashAirway narrowing
bull Three distinct patterns ndashCentracinar begins centrally and spreads to terminal
bronchioles and is most closely associated with cigarette smoking
ndashPanacinar destroys alveoli uniformly predominant in lower half of lungs most closely associated with AATD
ndashParaseptal destroys the distal airway structures alveolar ducts and sacs
Demirjian BG 2010
84
DOS CME Course 2011
Bullaebull Outpouchingsballooning of lung tissue due to trapped air
ndashAir is released from damaged alveoli
ndashAsymptomatic
ndashRupture can cause pneumothorax
85
DOS CME Course 2011
Diagnosis
bull History of smoking or exposure to inhaled irritants
ndashRemember to consider work and living environment
ndashCooking indoors with fossil fuels
ndashAge over 40
bull Signs and symptoms
ndashChronic cough with sputum production
ndashDyspnea which persists daily worsens with exercise and progresses over time
bull Spirometry is strongly recommended
86
DOS CME Course 2011
Diagnosis
bull Chest x-ray
ndashRule out pneumonia cardiomyopathy
ndashNot diagnostic for COPD but may reveal other causes for symptoms
bull Arterial blood gases
ndashRecommended for patients with FEVlt 50
ndashPaO2lt 60 mmHg suggests respiratory failure
bull Sputum culture
ndashRule out infectious process
87
DOS CME Course 2011
Disease stages
bull Stage Indash FEVFVC lt 70
ndash FEV gt 80
ndash Few symptoms if any patient may be unaware
bull Stage II moderate ndash FEVFVC lt 70
ndash FEV lt 80
ndash Along with shortness of breath
88
DOS CME Course 2011
Disease stages
bull Stage IV very severe ndash FEVFVC lt 70
ndash FEV lt 30
ndash At this stage exacerbations are life-threatening
ndash Quality of life is impaired further
bull Stage III severe ndash FEVFVC lt 70
ndash FEV lt 50
ndash Worsening symptoms increasing frequency of exacerbations
89
DOS CME Course 2011
COPD vs Asthma
bull COPD
ndashOnset later in life
ndashProgressive worsening symptoms
ndashSmoking history
ndashDyspnea with exercise
ndashLargely irreversible airflow limitation
bull Asthma
ndashOnset of symptoms usually earlier in life
ndashWorsening at night
ndashLargely reversible airflow limitation
ndashSymptoms vary from day to day
90
DOS CME Course 2011
COPD Treatmentbull Now that we have diagnosis what do I do about it
bull Assess and monitor diseasendash Assess for risk factors ie smoking family history
ndash Co-morbidities such as heart failure
ndash Pattern of symptoms
ndash Impact on quality of life
bull Reduce risk factors ndash Identify environmentaloccupational factors which can be modified
ndash Smoking cessation is essential
ndash Manage exacerbations
91
DOS CME Course 2011
COPDbull Manage stable COPD
ndash Determine disease severity based on frequency and severity of symptoms
ndash Educate the patient about risk factors and disease management regimen
ndash Collaborate with the patient to develop a personalized regimen
ndashFits their lifestyle
ndashAccounts for cultural preferences family involvement
ndashAvailability of testing and medications
92
DOS CME Course 2011
Pharmacologybull Goals
ndash Improve exercise tolerance
ndash Control symptoms
ndash Reduce frequency and severity of exacerbations
ndash Improve health status
bull Bronchodilators ndash Include long-acting therapy with short-acting for better control
bull Combine medications from different classes rather than increasing dosage of just onendash Minimizes side effects
93
DOS CME Course 2011
Pharmacologybull Glucocorticosteroids
ndashCan reduce the number of exacerbations
ndashIncreased risk of pneumonia
ndashNo noted reduction in mortality
bull Vaccines
ndashInfluenza vaccines decrease serious illness and death by 50
ndashRecommended annually
ndashPneumococcal vaccines recommended for all COPD sufferers even under age 65
GOLD 2009
94
DOS CME Course 2011
Antibiotics
bull Antibiotics are not a treatment for COPD nor do they manage symptoms of an exacerbation
bull Should be given only if the following are metndash Presence of three cardinal symptoms increased dyspnea
increased sputum volume increased sputum purulence
ndash Increased sputum purulence plus one other cardinal symptom
ndash Mechanically ventilated
bull May be difficult for patients to understand why antibiotics will not ldquofixrdquo what is wrong
bull Good opportunity for learning needs assessment
GOLD 2009
95
DOS CME Course 2011
COPD
bull Pulmonary rehabilitation
bull Encourage the patient to continue activities as tolerated ndash Move as much as you can before you canrsquot move
bull Uses low impact exercise to maintain physical function
bull Exercise can be done while seatedndash Monitor pulse oximetry respiratory rate and effort before during
and after activity
bull Set goals which are realistic for both of you
96
DOS CME Course 2011
COPD
bull Pulmonary rehab includes education nutrition and exercise
bull Can be a good source of social support for someone who has seen function decline
ndashTalk with others in the same situation
ndashFind out how they cope
ndashSocialize
bull Regular influenza and pneumonia vaccines
97
DOS CME Course 2011
COPD
bull Oxygen therapy
bull Recommended for stage IV disease ndash PaO2 lt or = 55 mmHg
ndash SaO2 lt or = 88
bull Increases survival improves hemodynamicsbenefits mental state
bull Surgical options reviewed on a case-by-case basisndash Bullectomy
ndash Lung volume reduction ndashNo evidence to support this as a widespread therapy
98
DOS CME Course 2011
COPD
bull Managing exacerbations
bull An event in the natural course of the disease characterized by a change in baseline dyspnea cough or sputum beyond day to day variance is acute in onset and may warrant a change in medication
bull Air pollution and tracheobronchial infections are the most common causes
bull 30 of exacerbations no cause identified
(GOLD 2009 p 22)
99
DOS CME Course 2011
COPD
bull Hospitalization is recommended for patients exhibiting the following
ndash Failure of exacerbation to respond to medical treatment
ndash Development of new symptoms ie peripheral edema cyanosis
ndash Significant co-morbidities
ndash History of frequent exacerbations
ndash Newly occurring arrhythmias
ndash Advanced age
ndash Insufficient home support
ndash Unclear diagnosis
(GOLD 2009 p 23)
100
DOS CME Course 2011
COPD
bull Mechanical ventilation is not recognized as an effective management strategy for stable COPD
bull May be required as supportive therapy during an exacerbation
bull Associated with mortality
bull Carries risks of its ownndash Ventilator acquired pneumonia
ndash Ventilator induced lung injury
ndash Failure to wean
(GOLD 2009)
101
DOS CME Course 2011DOS CME Course 2011102
Every Life Deserves World Class Care
Smoking
102
DOS CME Course 2011
Smoking bull By the numbers
bull More than 400 000 Americans die from smoking-related illnesses each yearndash Thatrsquos one of every 5 deaths
bull In a study of 2963 health care encounters smoking was discussed 633 times
bull Nicotine released into the body within 10 seconds of inhalation
bull If a person smokes one pack per day and takes ten puffs of each cigarette that equates to 200 ldquohitsrdquo of nicotine daily
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
103
DOS CME Course 2011
Nicotine
bull Nicotinic receptors occur naturally
bull N1 receptors in the adrenal medulla
bull Neuromuscular junction of autonomic ganglia
bull N2 receptors in skeletal muscle
bull Number of receptor sites increases with regular stimulation
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
104
DOS CME Course 2011
Nicotinebull Addictive
bull Vasoconstrictor
bull Releases adrenaline from the adrenal cortex
ndashFeeling of increased energy
bull Releases dopamine to produce feelings of well-beingndash Actually improves memory and cognition
bull Sensitivity actually declines overnight
bull Release of insulinndash Slightly hyperglycemic
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
105
DOS CME Course 2011
Genetic componentbull About 10 of smokers lack the gene for nicotine
dependence
ndashldquosocial or occasionalrdquo smokers
ndashThey really can quit anytime they want to
ndashNo withdrawal symptoms
ndashStill poses a health risk
bull The other 90 will demonstrate physical and psychological symptoms of withdrawal
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
106
DOS CME Course 2011
Smoking
bull Identify tobacco users ndash Ask every patient every visit
ndash Have you used tobacco in the last 12 months
ndash Clinic-wide program
bull Advise every tobacco user to quitndash Personalize the message
ndash Be clear
ndash Be firm
If at first you donrsquot succeed try tryagain Bring it up at every encounter
107
DOS CME Course 2011
Smoking cessationbull Some more good reasons to quit
ndashSmoking costs over $2000 a year in current US dollars
ndashThere is no accepted safe level of cigarette smoke
ndashSecondhand smoke carries the same hazards
ndashIncreased risk of SIDS and asthma exacerbations in children
httpwwwlungusaorgstop-smokingabout-smokingfacts-figuresgeneral-smoking-factshtml
108
DOS CME Course 2011
Smoking cessation
bull Nicotine is a powerful drug addiction
bull Treat as a chronic illness
bull All healthcare providers encouraged to participate
bull Assess willingness to quit
bull Promote motivation
109
DOS CME Course 2011
Smoking cessation
bull Prochaskarsquos change theory
bull Precontemplation
ndashNot even thinking about quitting
ndashProvide education on the risks and costs of smoking
bull Contemplation
ndashAwareness that a problem exists
ndashContinue to find motivations to stop
NorcrossJC Krebs PM Prochaska JO(2011)
110
DOS CME Course 2011
Change is good
bull Determination
ndashExpressing willingness to act
ndashSelf-efficacy
bull Action ndash Currently not smoking
ndash May relapse
bull It is not unusual for a patient to ldquoquitrdquo three or four times
bull Continue to encourage and motivate himher to stop
NorcrossJC Krebs PM Prochaska JO(2011)
111
DOS CME Course 2011
Smoking cessationbull Assist the patient
ndashCollaborate with the patient to develop a plan to quit
ndashAchievable clearly defined goals
ndashIdentify and engage social supports
ndashFamily support groups
ndashPharmacologic (more on this later)
bull Arrange follow-up
ndashAt each successive visit review progress on quitting strategy
ndashLets the patient know heshe is not alone in this effort
ndashAccountability
112
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
Remember to askhellip
bull Previous asthma attacks or exacerbations
bull Past and present management strategies and responses
bull Family history of asthma allergy sinusitis rhinitis or nasal polyps
bull Impact of disease on family finances schoolwork activity sleep and childrenrsquos growth and development
bull Patient and family knowledge base understanding of treatments and sociocultural beliefs
bull Number of sick days per month
DOS wheezing protocol
41
DOS CME Course 2011
Physical assessment
bull Pulse and respiratory rate and O2 Sat (PaO2)
bull Assess for dehydration delayed capillary refill poor skin turgor dry mucous membranes
bull Use of accessory respiratory muscles retractions nasal flaring sweating and cyanosis
bull Hyperexpansion of thorax ( hunched shoulders chest deformity)
bull Manifestations of skin allergies
DOS wheezing protocol
42
DOS CME Course 2011
Physical assessment
bull Nasal discharge allergic dark circles under eyes
bull Lungs
ndashInspection percussion palpation and auscultation may all be within normal limits between attacks
ndashIn some cases wheezes persist or lung sounds will be diminished
43
DOS CME Course 2011
Pulmonary Function tests (PFTrsquoS)
bull A group of tests which measure the lungsrsquo ability to take in and release air and how well they move oxygen into circulation
bull May include total lung volume measurement spirometry arterial blood gases
bull Spirometry is the recommended test for suspected asthma
Gildea TR Retrieved (January 2011)
44
DOS CME Course 2011
PFTrsquos
bull Prepare the patient
ndashDo not smoke before the test
ndashThere will be clip on your nose
ndashDemonstrate how to achieve a tight seal on the mouthpiece
ndashNecessary for accurate results
ndashThe test requires some deep breathing which may produce fatigue
Gildea TR Retrieved (January 2011)
45
DOS CME Course 2011
How it worksbull Spirometry
ndashWhile seated the patient inhales and exhales into a tube
ndashA machine measures the volume of air exhaled ndashThe volumes are compared to the patientrsquos baseline (if
known)ndashResults less than 80 of baseline are considered
abnormal
bull Measurements ndashForced vital capacity (FVC) is the maximum amount
the patient can exhale after filling the lungs completely ndashForced expiratory volume in one second (FEV1)
Gildea TR Retrieved (January 2011)
46
Spirometry results
bull Forced Vital Capacity (FVC) is the maximum volume of gas that can be forcefully and rapidly exhaled after a maximal inhalation
bull Forced Expiratory Volume after 1 second (FEV1) is the volume of gas exhaled after one second from the beginning of the FVC maneuver
bull Forced Expiratory Flow from 25 to 75 (FEF 25-75) is the average rate of flow during the middle half of an FVC maneuver that includes the flow from medium-sized and small airways also known as mid flow rates
bull Total Lung Capacity (TLC) is the volume of gas in the lungs at the end of a maximal inhalation
DOS CME Course 201147
Spirometry results
bull Functional Residual Capacity (FRC) is the volume of gas in the lungs after exhalation of a normal breath
bull Residual Volume (RV) is the volume of gas in the lungs after complete exhalation
bull Diffusing Capacity DLCO measures the transfer of a gas usually Carbon Monoxide (CO 03) across the membrane that separates the air sacs and the blood stream
DOS CME Course 201148
DOS CME Course 2011
Asthma
bull FEV1ndash Reflects about 75 to 85 of total lung capacity ndash Decreased in patients with asthma and COPD
bull Administer an inhaled bronchodilator and repeat the test
bull A decrease in FEV1 is diagnostic for asthma ndash gt or = 12 and gt or = 200 ml
bull Peak expiratory flow (PEF) ndash Use patientrsquos own meter and compare with their baselinendash Administer bronchodilator
ndashImprovement of gt or = 20 is diagnostic
(Gildea TR Retrieved January 2011)
49
DOS CME Course 2011
Asthmabull Exercise-induced
ndash Perform spirometry following an 8-minute running protocol
bull Airway responsivenessndash Evaluate with inhaled mannitol or methacholine and histamine
ndash For the patient with normal spirometry but asthma symptoms persist
bull Elderly patients ndash May underreport symptoms
ndash Co-morbidities such as heart failure or COPD
ndash Expect fatigue and shortness of breath as normal aging
bull Occupational ndash Evaluate for correlation of symptoms with exposure to
occupational environment
50
DOS CME Course 2011
Asthma
bull Pharmacologic management
bull Stepwise approach
bull Reduce impairmentndash Prevent chronic symptoms
ndash Require 2 days or lessweek of short-acting beta agonists
ndash Maintain normal activities
ndash Maintain normal lung function
ndash Meet patient and family expectations of care
bull Reduce riskndash Prevent emergency hospitalizations
ndash Avoid adverse drug reactions
NHLBI 2007
51
DOS CME Course 2011
Pharmacology bull Beta-2 adrenergic agonists
ndashBronchodilators-smooth muscle relaxants
ndashSympathomimetic
ndashShort acting ndashalbuterolterbutalinelevalbuterol
ndashUse of short acting before exercise to improve tolerance
ndashLong acting (LABA)ndashSalmeterol formoterol
bull Side effects include
ndash tachycardia tremor hypokalemia hyperglycemia HA dizziness
52
DOS CME Course 2011
Pharmacology
bull Methylxanthines (theophylline)ndash Smooth muscle relaxants
ndashPO PR IV
bull Side effects ndash nausea irritability tachycardia dysrrhythmia seizures brain
damage death
bull Theophylline causes concern because the therapeutic and toxic ranges overlapndash Monitor after initiation with any dose increases or signs of toxicity
(Micromedex 2010)
53
DOS CME Course 2011
Pharmacology
bull Inhaled glucocorticosteroid (ICS)
ndashDecrease swelling due to inflammation
ndashBeclomethasone budesonide fluticasone triamcinolone
ndashSide effects oral candidiasis dry mouth hoarseness hypersensitivity
ndashOnset of effects 10-20 minutes
ndashRecommend using a spacer
54
DOS CME Course 2011
Pharmacologybull Leukotriene modifiers
ndash Disrupt the function or synthesis of inflammatory mediators related to asthma
ndashMontelukast zafirlukast zileuton
bull Long-term control
bull Side effects elevation of liver enzymes HA dizziness GI distress
bull Mast cell stabilizersndash Cromolyn sodium nedocromil
ndash Inhibit release of inflammatory mediators
ndash Side effects bronchospasm pharyngeal irritation
55
DOS CME Course 2011
Pharmacology
bull Anticholinergics chemically related to atropine
ndashIpratropium bromide (Atrovent)
ndashInhaled form as rescue therapy
bull Side effects
ndashurinary obstruction HA restlessness palpitations bronchospasm
56
DOS CME Course 2011
The big guns
bull Systemic corticosteroidsndash Methylprednisolone hydrocortisone dexamethasone
ndash IV or PO
ndash Treatment of acute exacerbations
bull Side effects ndash adrenal suppression weight gain fluid retention hyperglycemia
ndash Long term
ndash osteoporosis immune suppression gastric ulcers
57
DOS CME Course 2011
Right here and now
bull Nursing Intervention
bull Quick Relief
bull Short acting bronchodilator ndash Up to 3 treatments at 20 minute intervals
bull Or single nebulizer treatment
bull Course of systemic corticosteroids may be needed
DOS Wheezing protocol
58
DOS CME Course 2011
Nebulizer Treatment
bull Albuterol Solution
ndashlt5 years old 063-25 mg in 3 cc of saline q 4-6 hours as needed
ndashgt5 years old -adult 125-5 mg in 3 cc of saline q 4-8 hours as needed
bull Levalbuterol (R-albuterol solution Xopinex)
ndashlt 5 years old 031 mg-125 mg in 3 cc NS q 4-6 hrs as needed
ndash5-11 yrs old 031-063 mg q 8 hours prn symptoms
ndashgt12 yrs old063mg-125 mg q 8 hours prn symptoms
DOS Wheezing protocol
59
DOS CME Course 2011
Treatment at home
bull Nebulizers convert liquid or powder medications to aerosolized formndash Effective to deliver larger doses than metered dose inhalers
Patient safety alert Some medications in powder formcome as a capsule which is broken open The patient should not take this medication orally
60
DOS CME Course 2011
How often
do the following
happen
MILD INTERMITTENT(check appropriate box)
MILD PERSISTENT
MODERATE PERSISTENT
SEVERE PERSISTENT
Daytime wheezingshortness of breath
0-2 times per week
Greater than 2 times per week
Daily Continually
Night-time wheezing shortness of breath
0-2 times per month
Greater than 2 times per month
Greater than 1 time per week
Frequent
How often are your physical activities limited by asthma
0-2 times per week
0-2 times per week
Greater than 2 times per week
Frequent
Daily use of albuterol or ldquorescue drugsrdquo
Less than 1 time per week or less than 3 times per month
2 time per week or more
Daily Use Frequent
DOS Wheezing protocol61
DOS CME Course 2011
Plan of carebull Step 1mdashmild intermittent
ndash no daily medication
ndash should have prn short acting rescue Beta 2 inhaler on hand
bull Step 2mdashmild persistentndash low dose inhaled corticosteroids
bull Step 3mdashmoderate persistentndash low to med inhaled corticosteroids and long acting beta 2 agonists
bull Step 4mdashsevere persistentndash high dose inhaled corticosteroids and long acting inhaled beta 2
agonists
DOS Wheezing protocol
62
DOS CME Course 2011
Ongoing carebull Plan Follow-up
ndash Evaluate 2-6 weeks after treatment initiationndash Evaluate every 1-6 months when stablendash Evaluate every 3 months interval after stepping down therapyndash Annual inactivated influenza vaccine
bull ConsultationReferralndash Life threatening or severe persistent asthmandash Goals of asthma therapy not fulfilled in 3-6 monthsndash Signs and symptoms are not typicalndash Sinusitis gastroesophageal reflux or chronic pulmonary disease
complicate the asthma
DOS Wheezing protocol
63
DOS CME Course 2011
Consults
bull Continuous oral corticosteroids or 2 bursts of oral steroids in 1 year
bull Patient under 3 years with step 3 or 4 asthma
bull If omalizumab (Xolair) is considered for treatment as there is an increase in rate of anaphylaxis with this medication
bull Exacerbation requiring hospitalization
DOS Wheezing protocol
64
DOS CME Course 2011
Patient educationbull Basic understanding of asthma and how the disease
works
bull Medications ndash Names and doses of all medications
ndash Short acting vs long acting
bull Equipment ndash Metered dose inhalers (MDI)
ndash Nebulizers
bull Emergency response
bull Activity level
bull Illness management
65
DOS CME Course 2011
Patient education
bull Know your triggers and have a strategy for avoidance
bull If mold or mites are known triggers humidifiers and evaporator coolers are not recommended in the home
bull Know the early signs of an exacerbation and what to do
bull Develop an action plan based on peak flow readings
bull What to do in case of an attack at school or work
66
DOS CME Course 2011
Patient educationbull Metered dose inhalers
ndash Remove cap and invert the device several times
ndash Exhale
ndash Place the mouthpiece between your lips with a good seal
ndash Inhale while depressing the top of the MDI
ndash Hold your breath for 10 seconds
ndash Exhale
ndash Repeat as needed
67
DOS CME Course 2011
Patient educationbull Spacers are used with MDIrsquos
used to deliver inhaled steroidsndash Ease coordination of breathing
and medication delivery
ndash Decrease the amount of medication contacting the oral mucosa
ndash Fewer side effects
bull Attach the spacer to the mouthpiece of the MDI ndash Use the MDI as described
before
ndash Some models have a whistle to indicate you are inhaling too rapidly
68
DOS CME Course 201169
DOS CME Course 2011
Characteristic Controlled
(All of the following)
Partly controlled
(Any measure noted)
Uncontrolled
Daytime symptoms
None (twice or less a week)
More than twice a week
Three or more features of partly controlled asthma
Limitation of activities
None Any
Nocturnal symptomsawakening
None Any
Need for rescue treatment
None (twice or less a week)
More than twice a week
Lung function (FEV1 or PEF)
Normal lt80 predicted or personal best
70
DOS CME Course 2011
Asthma
bull Self monitoring is essential to effective management and control
bull The following are validated tools to assess asthma control
ndashAsthmacontrolcom
ndashFree web-based
ndashQoltechcouk
ndashFree in hard copy or electronic versions
ndashRequires permission
ndashAtaqinstrumentcom
ndashFree web-based
71
DOS CME Course 2011DOS CME Course 201172
Every Life Deserves World Class Care
COPD
72
DOS CME Course 2011
Chronic obstructive pulmonary disease
bull By the numbers
bull 210 million suffer worldwide
bull 3 million fatalities
bull By 2030 COPD is expected to be the third leading cause of death worldwide
bull Most important risk factors ndash Smoking
ndash Indoor pollution
ndash Outdoor pollution
ndash Occupational irritants
WHO Retrieved January 2011
73
DOS CME Course 2011
COPD
bull Causes ndash Cigarette smoking is the number one cause worldwide
ndash Environmental irritants
ndash Genetic alpha-one antitrypsin deficiency
bull Birth defects ndash Low birth weight
ndash Respiratory infections
ndash Any factor which impairs lung development during gestation
bull Other ndash HIV
ndash Connective tissue disorders
ndash Vasculitis
74
DOS CME Course 2011
COPD
bull Sometimes referred to as umbrella term for a family of diseases which cause limited airflow
ndashChronic bronchitis
ndashEmphysema
bull Inflammation of the airways
bull Increased mucous productionndash Especially in bronchitis
bull Decreased ciliary function
bull Loss of elastic recoil ndash Especially in emphysema
75
DOS CME Course 2011
COPD
bull How inflammation ruins a lung
bull Cell mediated ndash Neutrophils
ndash Macrophages
ndash Lymphocytes
bull Release cytokines which attract more cells
bull Oxidants released by cells and found in cigarette smoke
bull Proteases
bull Cause remodeling and long term structural changes
76
DOS CME Course 2011
COPDbull Alveoli lose elasticity and become distended
ndashSaggy sacs
ndashCarbon dioxide retention
ndashChronic respiratory acidosis
bull Walls of the alveoli are degraded
ndashLoss of surface area necessary for gas exchange
77
DOS CME Course 2011
What the patient looks like
bull Productive Cough
ndashEspecially in chronic bronchitis
bull Progressive dyspnea
ndashUncomfortable awareness of breathing
bull Wheezing and chest tightness
bull Increase in AP chest diameter
ndashldquoBarrel chestrdquo especially in emphysema
ndashIncreased inspiratory effort loosens costochondral cartilage
78
DOS CME Course 2011
Alpha one antitrypsin deficiency
bull Enzyme normally produced which protects the lungs
bull Deactivates neutrophil elastase
ndashReleased during inflammation
bull Estimated over 100000 in US have AATD
bull Time to diagnosis gt8 years
bull Related to increased mortality (Krowka 2010)
ndashIncreased incidence of emphysema
79
DOS CME Course 2011
Chronic bronchitis
bull Presence of cough and sputum production over three months for two consecutive years
ndashNote the months need not be consecutive
bull The patient may feel as though they are constantly sick
bull Multiple courses of antibiotics with no improvement
bull No relationship to acute bronchitis caused by bacteria or virus
80
DOS CME Course 2011
COPD
bull Break out the testing ndash CXR
ndash ECG
ndash Sputum culture
ndash CBC and electrolytes
bull ABGrsquos ndash Respiratory failure indicated by
ndash PaO2lt 60 and SaO2 lt 90
ndash with or without PaCO2 gt 50
ndash On room air
ndash Severe acidosis pHlt 736 in addition to the above is an indication for mechanical ventilation
(GOLD 2009 p 22)
81
DOS CME Course 2011
Chronic bronchitis
bull Airway of a child afflicted with chronic bronchitis compared to normal
82
DOS CME Course 2011
Chronic bronchitisbull Related to mucociliary dysfunction
ndashIncreased mucous production and thickening
ndashLoss of cilia
ndashLoss of ciliary function
ndashMobility required to sweep out particles
83
DOS CME Course 2011
Emphysemabull Permanent enlargement of the airspaces terminal to the
distal bronchioles ndashLoss of surface area for gas exchangendashDestruction of supporting structure of alveoli
ndashAirway narrowing
bull Three distinct patterns ndashCentracinar begins centrally and spreads to terminal
bronchioles and is most closely associated with cigarette smoking
ndashPanacinar destroys alveoli uniformly predominant in lower half of lungs most closely associated with AATD
ndashParaseptal destroys the distal airway structures alveolar ducts and sacs
Demirjian BG 2010
84
DOS CME Course 2011
Bullaebull Outpouchingsballooning of lung tissue due to trapped air
ndashAir is released from damaged alveoli
ndashAsymptomatic
ndashRupture can cause pneumothorax
85
DOS CME Course 2011
Diagnosis
bull History of smoking or exposure to inhaled irritants
ndashRemember to consider work and living environment
ndashCooking indoors with fossil fuels
ndashAge over 40
bull Signs and symptoms
ndashChronic cough with sputum production
ndashDyspnea which persists daily worsens with exercise and progresses over time
bull Spirometry is strongly recommended
86
DOS CME Course 2011
Diagnosis
bull Chest x-ray
ndashRule out pneumonia cardiomyopathy
ndashNot diagnostic for COPD but may reveal other causes for symptoms
bull Arterial blood gases
ndashRecommended for patients with FEVlt 50
ndashPaO2lt 60 mmHg suggests respiratory failure
bull Sputum culture
ndashRule out infectious process
87
DOS CME Course 2011
Disease stages
bull Stage Indash FEVFVC lt 70
ndash FEV gt 80
ndash Few symptoms if any patient may be unaware
bull Stage II moderate ndash FEVFVC lt 70
ndash FEV lt 80
ndash Along with shortness of breath
88
DOS CME Course 2011
Disease stages
bull Stage IV very severe ndash FEVFVC lt 70
ndash FEV lt 30
ndash At this stage exacerbations are life-threatening
ndash Quality of life is impaired further
bull Stage III severe ndash FEVFVC lt 70
ndash FEV lt 50
ndash Worsening symptoms increasing frequency of exacerbations
89
DOS CME Course 2011
COPD vs Asthma
bull COPD
ndashOnset later in life
ndashProgressive worsening symptoms
ndashSmoking history
ndashDyspnea with exercise
ndashLargely irreversible airflow limitation
bull Asthma
ndashOnset of symptoms usually earlier in life
ndashWorsening at night
ndashLargely reversible airflow limitation
ndashSymptoms vary from day to day
90
DOS CME Course 2011
COPD Treatmentbull Now that we have diagnosis what do I do about it
bull Assess and monitor diseasendash Assess for risk factors ie smoking family history
ndash Co-morbidities such as heart failure
ndash Pattern of symptoms
ndash Impact on quality of life
bull Reduce risk factors ndash Identify environmentaloccupational factors which can be modified
ndash Smoking cessation is essential
ndash Manage exacerbations
91
DOS CME Course 2011
COPDbull Manage stable COPD
ndash Determine disease severity based on frequency and severity of symptoms
ndash Educate the patient about risk factors and disease management regimen
ndash Collaborate with the patient to develop a personalized regimen
ndashFits their lifestyle
ndashAccounts for cultural preferences family involvement
ndashAvailability of testing and medications
92
DOS CME Course 2011
Pharmacologybull Goals
ndash Improve exercise tolerance
ndash Control symptoms
ndash Reduce frequency and severity of exacerbations
ndash Improve health status
bull Bronchodilators ndash Include long-acting therapy with short-acting for better control
bull Combine medications from different classes rather than increasing dosage of just onendash Minimizes side effects
93
DOS CME Course 2011
Pharmacologybull Glucocorticosteroids
ndashCan reduce the number of exacerbations
ndashIncreased risk of pneumonia
ndashNo noted reduction in mortality
bull Vaccines
ndashInfluenza vaccines decrease serious illness and death by 50
ndashRecommended annually
ndashPneumococcal vaccines recommended for all COPD sufferers even under age 65
GOLD 2009
94
DOS CME Course 2011
Antibiotics
bull Antibiotics are not a treatment for COPD nor do they manage symptoms of an exacerbation
bull Should be given only if the following are metndash Presence of three cardinal symptoms increased dyspnea
increased sputum volume increased sputum purulence
ndash Increased sputum purulence plus one other cardinal symptom
ndash Mechanically ventilated
bull May be difficult for patients to understand why antibiotics will not ldquofixrdquo what is wrong
bull Good opportunity for learning needs assessment
GOLD 2009
95
DOS CME Course 2011
COPD
bull Pulmonary rehabilitation
bull Encourage the patient to continue activities as tolerated ndash Move as much as you can before you canrsquot move
bull Uses low impact exercise to maintain physical function
bull Exercise can be done while seatedndash Monitor pulse oximetry respiratory rate and effort before during
and after activity
bull Set goals which are realistic for both of you
96
DOS CME Course 2011
COPD
bull Pulmonary rehab includes education nutrition and exercise
bull Can be a good source of social support for someone who has seen function decline
ndashTalk with others in the same situation
ndashFind out how they cope
ndashSocialize
bull Regular influenza and pneumonia vaccines
97
DOS CME Course 2011
COPD
bull Oxygen therapy
bull Recommended for stage IV disease ndash PaO2 lt or = 55 mmHg
ndash SaO2 lt or = 88
bull Increases survival improves hemodynamicsbenefits mental state
bull Surgical options reviewed on a case-by-case basisndash Bullectomy
ndash Lung volume reduction ndashNo evidence to support this as a widespread therapy
98
DOS CME Course 2011
COPD
bull Managing exacerbations
bull An event in the natural course of the disease characterized by a change in baseline dyspnea cough or sputum beyond day to day variance is acute in onset and may warrant a change in medication
bull Air pollution and tracheobronchial infections are the most common causes
bull 30 of exacerbations no cause identified
(GOLD 2009 p 22)
99
DOS CME Course 2011
COPD
bull Hospitalization is recommended for patients exhibiting the following
ndash Failure of exacerbation to respond to medical treatment
ndash Development of new symptoms ie peripheral edema cyanosis
ndash Significant co-morbidities
ndash History of frequent exacerbations
ndash Newly occurring arrhythmias
ndash Advanced age
ndash Insufficient home support
ndash Unclear diagnosis
(GOLD 2009 p 23)
100
DOS CME Course 2011
COPD
bull Mechanical ventilation is not recognized as an effective management strategy for stable COPD
bull May be required as supportive therapy during an exacerbation
bull Associated with mortality
bull Carries risks of its ownndash Ventilator acquired pneumonia
ndash Ventilator induced lung injury
ndash Failure to wean
(GOLD 2009)
101
DOS CME Course 2011DOS CME Course 2011102
Every Life Deserves World Class Care
Smoking
102
DOS CME Course 2011
Smoking bull By the numbers
bull More than 400 000 Americans die from smoking-related illnesses each yearndash Thatrsquos one of every 5 deaths
bull In a study of 2963 health care encounters smoking was discussed 633 times
bull Nicotine released into the body within 10 seconds of inhalation
bull If a person smokes one pack per day and takes ten puffs of each cigarette that equates to 200 ldquohitsrdquo of nicotine daily
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
103
DOS CME Course 2011
Nicotine
bull Nicotinic receptors occur naturally
bull N1 receptors in the adrenal medulla
bull Neuromuscular junction of autonomic ganglia
bull N2 receptors in skeletal muscle
bull Number of receptor sites increases with regular stimulation
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
104
DOS CME Course 2011
Nicotinebull Addictive
bull Vasoconstrictor
bull Releases adrenaline from the adrenal cortex
ndashFeeling of increased energy
bull Releases dopamine to produce feelings of well-beingndash Actually improves memory and cognition
bull Sensitivity actually declines overnight
bull Release of insulinndash Slightly hyperglycemic
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
105
DOS CME Course 2011
Genetic componentbull About 10 of smokers lack the gene for nicotine
dependence
ndashldquosocial or occasionalrdquo smokers
ndashThey really can quit anytime they want to
ndashNo withdrawal symptoms
ndashStill poses a health risk
bull The other 90 will demonstrate physical and psychological symptoms of withdrawal
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
106
DOS CME Course 2011
Smoking
bull Identify tobacco users ndash Ask every patient every visit
ndash Have you used tobacco in the last 12 months
ndash Clinic-wide program
bull Advise every tobacco user to quitndash Personalize the message
ndash Be clear
ndash Be firm
If at first you donrsquot succeed try tryagain Bring it up at every encounter
107
DOS CME Course 2011
Smoking cessationbull Some more good reasons to quit
ndashSmoking costs over $2000 a year in current US dollars
ndashThere is no accepted safe level of cigarette smoke
ndashSecondhand smoke carries the same hazards
ndashIncreased risk of SIDS and asthma exacerbations in children
httpwwwlungusaorgstop-smokingabout-smokingfacts-figuresgeneral-smoking-factshtml
108
DOS CME Course 2011
Smoking cessation
bull Nicotine is a powerful drug addiction
bull Treat as a chronic illness
bull All healthcare providers encouraged to participate
bull Assess willingness to quit
bull Promote motivation
109
DOS CME Course 2011
Smoking cessation
bull Prochaskarsquos change theory
bull Precontemplation
ndashNot even thinking about quitting
ndashProvide education on the risks and costs of smoking
bull Contemplation
ndashAwareness that a problem exists
ndashContinue to find motivations to stop
NorcrossJC Krebs PM Prochaska JO(2011)
110
DOS CME Course 2011
Change is good
bull Determination
ndashExpressing willingness to act
ndashSelf-efficacy
bull Action ndash Currently not smoking
ndash May relapse
bull It is not unusual for a patient to ldquoquitrdquo three or four times
bull Continue to encourage and motivate himher to stop
NorcrossJC Krebs PM Prochaska JO(2011)
111
DOS CME Course 2011
Smoking cessationbull Assist the patient
ndashCollaborate with the patient to develop a plan to quit
ndashAchievable clearly defined goals
ndashIdentify and engage social supports
ndashFamily support groups
ndashPharmacologic (more on this later)
bull Arrange follow-up
ndashAt each successive visit review progress on quitting strategy
ndashLets the patient know heshe is not alone in this effort
ndashAccountability
112
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
Physical assessment
bull Nasal discharge allergic dark circles under eyes
bull Lungs
ndashInspection percussion palpation and auscultation may all be within normal limits between attacks
ndashIn some cases wheezes persist or lung sounds will be diminished
43
DOS CME Course 2011
Pulmonary Function tests (PFTrsquoS)
bull A group of tests which measure the lungsrsquo ability to take in and release air and how well they move oxygen into circulation
bull May include total lung volume measurement spirometry arterial blood gases
bull Spirometry is the recommended test for suspected asthma
Gildea TR Retrieved (January 2011)
44
DOS CME Course 2011
PFTrsquos
bull Prepare the patient
ndashDo not smoke before the test
ndashThere will be clip on your nose
ndashDemonstrate how to achieve a tight seal on the mouthpiece
ndashNecessary for accurate results
ndashThe test requires some deep breathing which may produce fatigue
Gildea TR Retrieved (January 2011)
45
DOS CME Course 2011
How it worksbull Spirometry
ndashWhile seated the patient inhales and exhales into a tube
ndashA machine measures the volume of air exhaled ndashThe volumes are compared to the patientrsquos baseline (if
known)ndashResults less than 80 of baseline are considered
abnormal
bull Measurements ndashForced vital capacity (FVC) is the maximum amount
the patient can exhale after filling the lungs completely ndashForced expiratory volume in one second (FEV1)
Gildea TR Retrieved (January 2011)
46
Spirometry results
bull Forced Vital Capacity (FVC) is the maximum volume of gas that can be forcefully and rapidly exhaled after a maximal inhalation
bull Forced Expiratory Volume after 1 second (FEV1) is the volume of gas exhaled after one second from the beginning of the FVC maneuver
bull Forced Expiratory Flow from 25 to 75 (FEF 25-75) is the average rate of flow during the middle half of an FVC maneuver that includes the flow from medium-sized and small airways also known as mid flow rates
bull Total Lung Capacity (TLC) is the volume of gas in the lungs at the end of a maximal inhalation
DOS CME Course 201147
Spirometry results
bull Functional Residual Capacity (FRC) is the volume of gas in the lungs after exhalation of a normal breath
bull Residual Volume (RV) is the volume of gas in the lungs after complete exhalation
bull Diffusing Capacity DLCO measures the transfer of a gas usually Carbon Monoxide (CO 03) across the membrane that separates the air sacs and the blood stream
DOS CME Course 201148
DOS CME Course 2011
Asthma
bull FEV1ndash Reflects about 75 to 85 of total lung capacity ndash Decreased in patients with asthma and COPD
bull Administer an inhaled bronchodilator and repeat the test
bull A decrease in FEV1 is diagnostic for asthma ndash gt or = 12 and gt or = 200 ml
bull Peak expiratory flow (PEF) ndash Use patientrsquos own meter and compare with their baselinendash Administer bronchodilator
ndashImprovement of gt or = 20 is diagnostic
(Gildea TR Retrieved January 2011)
49
DOS CME Course 2011
Asthmabull Exercise-induced
ndash Perform spirometry following an 8-minute running protocol
bull Airway responsivenessndash Evaluate with inhaled mannitol or methacholine and histamine
ndash For the patient with normal spirometry but asthma symptoms persist
bull Elderly patients ndash May underreport symptoms
ndash Co-morbidities such as heart failure or COPD
ndash Expect fatigue and shortness of breath as normal aging
bull Occupational ndash Evaluate for correlation of symptoms with exposure to
occupational environment
50
DOS CME Course 2011
Asthma
bull Pharmacologic management
bull Stepwise approach
bull Reduce impairmentndash Prevent chronic symptoms
ndash Require 2 days or lessweek of short-acting beta agonists
ndash Maintain normal activities
ndash Maintain normal lung function
ndash Meet patient and family expectations of care
bull Reduce riskndash Prevent emergency hospitalizations
ndash Avoid adverse drug reactions
NHLBI 2007
51
DOS CME Course 2011
Pharmacology bull Beta-2 adrenergic agonists
ndashBronchodilators-smooth muscle relaxants
ndashSympathomimetic
ndashShort acting ndashalbuterolterbutalinelevalbuterol
ndashUse of short acting before exercise to improve tolerance
ndashLong acting (LABA)ndashSalmeterol formoterol
bull Side effects include
ndash tachycardia tremor hypokalemia hyperglycemia HA dizziness
52
DOS CME Course 2011
Pharmacology
bull Methylxanthines (theophylline)ndash Smooth muscle relaxants
ndashPO PR IV
bull Side effects ndash nausea irritability tachycardia dysrrhythmia seizures brain
damage death
bull Theophylline causes concern because the therapeutic and toxic ranges overlapndash Monitor after initiation with any dose increases or signs of toxicity
(Micromedex 2010)
53
DOS CME Course 2011
Pharmacology
bull Inhaled glucocorticosteroid (ICS)
ndashDecrease swelling due to inflammation
ndashBeclomethasone budesonide fluticasone triamcinolone
ndashSide effects oral candidiasis dry mouth hoarseness hypersensitivity
ndashOnset of effects 10-20 minutes
ndashRecommend using a spacer
54
DOS CME Course 2011
Pharmacologybull Leukotriene modifiers
ndash Disrupt the function or synthesis of inflammatory mediators related to asthma
ndashMontelukast zafirlukast zileuton
bull Long-term control
bull Side effects elevation of liver enzymes HA dizziness GI distress
bull Mast cell stabilizersndash Cromolyn sodium nedocromil
ndash Inhibit release of inflammatory mediators
ndash Side effects bronchospasm pharyngeal irritation
55
DOS CME Course 2011
Pharmacology
bull Anticholinergics chemically related to atropine
ndashIpratropium bromide (Atrovent)
ndashInhaled form as rescue therapy
bull Side effects
ndashurinary obstruction HA restlessness palpitations bronchospasm
56
DOS CME Course 2011
The big guns
bull Systemic corticosteroidsndash Methylprednisolone hydrocortisone dexamethasone
ndash IV or PO
ndash Treatment of acute exacerbations
bull Side effects ndash adrenal suppression weight gain fluid retention hyperglycemia
ndash Long term
ndash osteoporosis immune suppression gastric ulcers
57
DOS CME Course 2011
Right here and now
bull Nursing Intervention
bull Quick Relief
bull Short acting bronchodilator ndash Up to 3 treatments at 20 minute intervals
bull Or single nebulizer treatment
bull Course of systemic corticosteroids may be needed
DOS Wheezing protocol
58
DOS CME Course 2011
Nebulizer Treatment
bull Albuterol Solution
ndashlt5 years old 063-25 mg in 3 cc of saline q 4-6 hours as needed
ndashgt5 years old -adult 125-5 mg in 3 cc of saline q 4-8 hours as needed
bull Levalbuterol (R-albuterol solution Xopinex)
ndashlt 5 years old 031 mg-125 mg in 3 cc NS q 4-6 hrs as needed
ndash5-11 yrs old 031-063 mg q 8 hours prn symptoms
ndashgt12 yrs old063mg-125 mg q 8 hours prn symptoms
DOS Wheezing protocol
59
DOS CME Course 2011
Treatment at home
bull Nebulizers convert liquid or powder medications to aerosolized formndash Effective to deliver larger doses than metered dose inhalers
Patient safety alert Some medications in powder formcome as a capsule which is broken open The patient should not take this medication orally
60
DOS CME Course 2011
How often
do the following
happen
MILD INTERMITTENT(check appropriate box)
MILD PERSISTENT
MODERATE PERSISTENT
SEVERE PERSISTENT
Daytime wheezingshortness of breath
0-2 times per week
Greater than 2 times per week
Daily Continually
Night-time wheezing shortness of breath
0-2 times per month
Greater than 2 times per month
Greater than 1 time per week
Frequent
How often are your physical activities limited by asthma
0-2 times per week
0-2 times per week
Greater than 2 times per week
Frequent
Daily use of albuterol or ldquorescue drugsrdquo
Less than 1 time per week or less than 3 times per month
2 time per week or more
Daily Use Frequent
DOS Wheezing protocol61
DOS CME Course 2011
Plan of carebull Step 1mdashmild intermittent
ndash no daily medication
ndash should have prn short acting rescue Beta 2 inhaler on hand
bull Step 2mdashmild persistentndash low dose inhaled corticosteroids
bull Step 3mdashmoderate persistentndash low to med inhaled corticosteroids and long acting beta 2 agonists
bull Step 4mdashsevere persistentndash high dose inhaled corticosteroids and long acting inhaled beta 2
agonists
DOS Wheezing protocol
62
DOS CME Course 2011
Ongoing carebull Plan Follow-up
ndash Evaluate 2-6 weeks after treatment initiationndash Evaluate every 1-6 months when stablendash Evaluate every 3 months interval after stepping down therapyndash Annual inactivated influenza vaccine
bull ConsultationReferralndash Life threatening or severe persistent asthmandash Goals of asthma therapy not fulfilled in 3-6 monthsndash Signs and symptoms are not typicalndash Sinusitis gastroesophageal reflux or chronic pulmonary disease
complicate the asthma
DOS Wheezing protocol
63
DOS CME Course 2011
Consults
bull Continuous oral corticosteroids or 2 bursts of oral steroids in 1 year
bull Patient under 3 years with step 3 or 4 asthma
bull If omalizumab (Xolair) is considered for treatment as there is an increase in rate of anaphylaxis with this medication
bull Exacerbation requiring hospitalization
DOS Wheezing protocol
64
DOS CME Course 2011
Patient educationbull Basic understanding of asthma and how the disease
works
bull Medications ndash Names and doses of all medications
ndash Short acting vs long acting
bull Equipment ndash Metered dose inhalers (MDI)
ndash Nebulizers
bull Emergency response
bull Activity level
bull Illness management
65
DOS CME Course 2011
Patient education
bull Know your triggers and have a strategy for avoidance
bull If mold or mites are known triggers humidifiers and evaporator coolers are not recommended in the home
bull Know the early signs of an exacerbation and what to do
bull Develop an action plan based on peak flow readings
bull What to do in case of an attack at school or work
66
DOS CME Course 2011
Patient educationbull Metered dose inhalers
ndash Remove cap and invert the device several times
ndash Exhale
ndash Place the mouthpiece between your lips with a good seal
ndash Inhale while depressing the top of the MDI
ndash Hold your breath for 10 seconds
ndash Exhale
ndash Repeat as needed
67
DOS CME Course 2011
Patient educationbull Spacers are used with MDIrsquos
used to deliver inhaled steroidsndash Ease coordination of breathing
and medication delivery
ndash Decrease the amount of medication contacting the oral mucosa
ndash Fewer side effects
bull Attach the spacer to the mouthpiece of the MDI ndash Use the MDI as described
before
ndash Some models have a whistle to indicate you are inhaling too rapidly
68
DOS CME Course 201169
DOS CME Course 2011
Characteristic Controlled
(All of the following)
Partly controlled
(Any measure noted)
Uncontrolled
Daytime symptoms
None (twice or less a week)
More than twice a week
Three or more features of partly controlled asthma
Limitation of activities
None Any
Nocturnal symptomsawakening
None Any
Need for rescue treatment
None (twice or less a week)
More than twice a week
Lung function (FEV1 or PEF)
Normal lt80 predicted or personal best
70
DOS CME Course 2011
Asthma
bull Self monitoring is essential to effective management and control
bull The following are validated tools to assess asthma control
ndashAsthmacontrolcom
ndashFree web-based
ndashQoltechcouk
ndashFree in hard copy or electronic versions
ndashRequires permission
ndashAtaqinstrumentcom
ndashFree web-based
71
DOS CME Course 2011DOS CME Course 201172
Every Life Deserves World Class Care
COPD
72
DOS CME Course 2011
Chronic obstructive pulmonary disease
bull By the numbers
bull 210 million suffer worldwide
bull 3 million fatalities
bull By 2030 COPD is expected to be the third leading cause of death worldwide
bull Most important risk factors ndash Smoking
ndash Indoor pollution
ndash Outdoor pollution
ndash Occupational irritants
WHO Retrieved January 2011
73
DOS CME Course 2011
COPD
bull Causes ndash Cigarette smoking is the number one cause worldwide
ndash Environmental irritants
ndash Genetic alpha-one antitrypsin deficiency
bull Birth defects ndash Low birth weight
ndash Respiratory infections
ndash Any factor which impairs lung development during gestation
bull Other ndash HIV
ndash Connective tissue disorders
ndash Vasculitis
74
DOS CME Course 2011
COPD
bull Sometimes referred to as umbrella term for a family of diseases which cause limited airflow
ndashChronic bronchitis
ndashEmphysema
bull Inflammation of the airways
bull Increased mucous productionndash Especially in bronchitis
bull Decreased ciliary function
bull Loss of elastic recoil ndash Especially in emphysema
75
DOS CME Course 2011
COPD
bull How inflammation ruins a lung
bull Cell mediated ndash Neutrophils
ndash Macrophages
ndash Lymphocytes
bull Release cytokines which attract more cells
bull Oxidants released by cells and found in cigarette smoke
bull Proteases
bull Cause remodeling and long term structural changes
76
DOS CME Course 2011
COPDbull Alveoli lose elasticity and become distended
ndashSaggy sacs
ndashCarbon dioxide retention
ndashChronic respiratory acidosis
bull Walls of the alveoli are degraded
ndashLoss of surface area necessary for gas exchange
77
DOS CME Course 2011
What the patient looks like
bull Productive Cough
ndashEspecially in chronic bronchitis
bull Progressive dyspnea
ndashUncomfortable awareness of breathing
bull Wheezing and chest tightness
bull Increase in AP chest diameter
ndashldquoBarrel chestrdquo especially in emphysema
ndashIncreased inspiratory effort loosens costochondral cartilage
78
DOS CME Course 2011
Alpha one antitrypsin deficiency
bull Enzyme normally produced which protects the lungs
bull Deactivates neutrophil elastase
ndashReleased during inflammation
bull Estimated over 100000 in US have AATD
bull Time to diagnosis gt8 years
bull Related to increased mortality (Krowka 2010)
ndashIncreased incidence of emphysema
79
DOS CME Course 2011
Chronic bronchitis
bull Presence of cough and sputum production over three months for two consecutive years
ndashNote the months need not be consecutive
bull The patient may feel as though they are constantly sick
bull Multiple courses of antibiotics with no improvement
bull No relationship to acute bronchitis caused by bacteria or virus
80
DOS CME Course 2011
COPD
bull Break out the testing ndash CXR
ndash ECG
ndash Sputum culture
ndash CBC and electrolytes
bull ABGrsquos ndash Respiratory failure indicated by
ndash PaO2lt 60 and SaO2 lt 90
ndash with or without PaCO2 gt 50
ndash On room air
ndash Severe acidosis pHlt 736 in addition to the above is an indication for mechanical ventilation
(GOLD 2009 p 22)
81
DOS CME Course 2011
Chronic bronchitis
bull Airway of a child afflicted with chronic bronchitis compared to normal
82
DOS CME Course 2011
Chronic bronchitisbull Related to mucociliary dysfunction
ndashIncreased mucous production and thickening
ndashLoss of cilia
ndashLoss of ciliary function
ndashMobility required to sweep out particles
83
DOS CME Course 2011
Emphysemabull Permanent enlargement of the airspaces terminal to the
distal bronchioles ndashLoss of surface area for gas exchangendashDestruction of supporting structure of alveoli
ndashAirway narrowing
bull Three distinct patterns ndashCentracinar begins centrally and spreads to terminal
bronchioles and is most closely associated with cigarette smoking
ndashPanacinar destroys alveoli uniformly predominant in lower half of lungs most closely associated with AATD
ndashParaseptal destroys the distal airway structures alveolar ducts and sacs
Demirjian BG 2010
84
DOS CME Course 2011
Bullaebull Outpouchingsballooning of lung tissue due to trapped air
ndashAir is released from damaged alveoli
ndashAsymptomatic
ndashRupture can cause pneumothorax
85
DOS CME Course 2011
Diagnosis
bull History of smoking or exposure to inhaled irritants
ndashRemember to consider work and living environment
ndashCooking indoors with fossil fuels
ndashAge over 40
bull Signs and symptoms
ndashChronic cough with sputum production
ndashDyspnea which persists daily worsens with exercise and progresses over time
bull Spirometry is strongly recommended
86
DOS CME Course 2011
Diagnosis
bull Chest x-ray
ndashRule out pneumonia cardiomyopathy
ndashNot diagnostic for COPD but may reveal other causes for symptoms
bull Arterial blood gases
ndashRecommended for patients with FEVlt 50
ndashPaO2lt 60 mmHg suggests respiratory failure
bull Sputum culture
ndashRule out infectious process
87
DOS CME Course 2011
Disease stages
bull Stage Indash FEVFVC lt 70
ndash FEV gt 80
ndash Few symptoms if any patient may be unaware
bull Stage II moderate ndash FEVFVC lt 70
ndash FEV lt 80
ndash Along with shortness of breath
88
DOS CME Course 2011
Disease stages
bull Stage IV very severe ndash FEVFVC lt 70
ndash FEV lt 30
ndash At this stage exacerbations are life-threatening
ndash Quality of life is impaired further
bull Stage III severe ndash FEVFVC lt 70
ndash FEV lt 50
ndash Worsening symptoms increasing frequency of exacerbations
89
DOS CME Course 2011
COPD vs Asthma
bull COPD
ndashOnset later in life
ndashProgressive worsening symptoms
ndashSmoking history
ndashDyspnea with exercise
ndashLargely irreversible airflow limitation
bull Asthma
ndashOnset of symptoms usually earlier in life
ndashWorsening at night
ndashLargely reversible airflow limitation
ndashSymptoms vary from day to day
90
DOS CME Course 2011
COPD Treatmentbull Now that we have diagnosis what do I do about it
bull Assess and monitor diseasendash Assess for risk factors ie smoking family history
ndash Co-morbidities such as heart failure
ndash Pattern of symptoms
ndash Impact on quality of life
bull Reduce risk factors ndash Identify environmentaloccupational factors which can be modified
ndash Smoking cessation is essential
ndash Manage exacerbations
91
DOS CME Course 2011
COPDbull Manage stable COPD
ndash Determine disease severity based on frequency and severity of symptoms
ndash Educate the patient about risk factors and disease management regimen
ndash Collaborate with the patient to develop a personalized regimen
ndashFits their lifestyle
ndashAccounts for cultural preferences family involvement
ndashAvailability of testing and medications
92
DOS CME Course 2011
Pharmacologybull Goals
ndash Improve exercise tolerance
ndash Control symptoms
ndash Reduce frequency and severity of exacerbations
ndash Improve health status
bull Bronchodilators ndash Include long-acting therapy with short-acting for better control
bull Combine medications from different classes rather than increasing dosage of just onendash Minimizes side effects
93
DOS CME Course 2011
Pharmacologybull Glucocorticosteroids
ndashCan reduce the number of exacerbations
ndashIncreased risk of pneumonia
ndashNo noted reduction in mortality
bull Vaccines
ndashInfluenza vaccines decrease serious illness and death by 50
ndashRecommended annually
ndashPneumococcal vaccines recommended for all COPD sufferers even under age 65
GOLD 2009
94
DOS CME Course 2011
Antibiotics
bull Antibiotics are not a treatment for COPD nor do they manage symptoms of an exacerbation
bull Should be given only if the following are metndash Presence of three cardinal symptoms increased dyspnea
increased sputum volume increased sputum purulence
ndash Increased sputum purulence plus one other cardinal symptom
ndash Mechanically ventilated
bull May be difficult for patients to understand why antibiotics will not ldquofixrdquo what is wrong
bull Good opportunity for learning needs assessment
GOLD 2009
95
DOS CME Course 2011
COPD
bull Pulmonary rehabilitation
bull Encourage the patient to continue activities as tolerated ndash Move as much as you can before you canrsquot move
bull Uses low impact exercise to maintain physical function
bull Exercise can be done while seatedndash Monitor pulse oximetry respiratory rate and effort before during
and after activity
bull Set goals which are realistic for both of you
96
DOS CME Course 2011
COPD
bull Pulmonary rehab includes education nutrition and exercise
bull Can be a good source of social support for someone who has seen function decline
ndashTalk with others in the same situation
ndashFind out how they cope
ndashSocialize
bull Regular influenza and pneumonia vaccines
97
DOS CME Course 2011
COPD
bull Oxygen therapy
bull Recommended for stage IV disease ndash PaO2 lt or = 55 mmHg
ndash SaO2 lt or = 88
bull Increases survival improves hemodynamicsbenefits mental state
bull Surgical options reviewed on a case-by-case basisndash Bullectomy
ndash Lung volume reduction ndashNo evidence to support this as a widespread therapy
98
DOS CME Course 2011
COPD
bull Managing exacerbations
bull An event in the natural course of the disease characterized by a change in baseline dyspnea cough or sputum beyond day to day variance is acute in onset and may warrant a change in medication
bull Air pollution and tracheobronchial infections are the most common causes
bull 30 of exacerbations no cause identified
(GOLD 2009 p 22)
99
DOS CME Course 2011
COPD
bull Hospitalization is recommended for patients exhibiting the following
ndash Failure of exacerbation to respond to medical treatment
ndash Development of new symptoms ie peripheral edema cyanosis
ndash Significant co-morbidities
ndash History of frequent exacerbations
ndash Newly occurring arrhythmias
ndash Advanced age
ndash Insufficient home support
ndash Unclear diagnosis
(GOLD 2009 p 23)
100
DOS CME Course 2011
COPD
bull Mechanical ventilation is not recognized as an effective management strategy for stable COPD
bull May be required as supportive therapy during an exacerbation
bull Associated with mortality
bull Carries risks of its ownndash Ventilator acquired pneumonia
ndash Ventilator induced lung injury
ndash Failure to wean
(GOLD 2009)
101
DOS CME Course 2011DOS CME Course 2011102
Every Life Deserves World Class Care
Smoking
102
DOS CME Course 2011
Smoking bull By the numbers
bull More than 400 000 Americans die from smoking-related illnesses each yearndash Thatrsquos one of every 5 deaths
bull In a study of 2963 health care encounters smoking was discussed 633 times
bull Nicotine released into the body within 10 seconds of inhalation
bull If a person smokes one pack per day and takes ten puffs of each cigarette that equates to 200 ldquohitsrdquo of nicotine daily
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
103
DOS CME Course 2011
Nicotine
bull Nicotinic receptors occur naturally
bull N1 receptors in the adrenal medulla
bull Neuromuscular junction of autonomic ganglia
bull N2 receptors in skeletal muscle
bull Number of receptor sites increases with regular stimulation
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
104
DOS CME Course 2011
Nicotinebull Addictive
bull Vasoconstrictor
bull Releases adrenaline from the adrenal cortex
ndashFeeling of increased energy
bull Releases dopamine to produce feelings of well-beingndash Actually improves memory and cognition
bull Sensitivity actually declines overnight
bull Release of insulinndash Slightly hyperglycemic
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
105
DOS CME Course 2011
Genetic componentbull About 10 of smokers lack the gene for nicotine
dependence
ndashldquosocial or occasionalrdquo smokers
ndashThey really can quit anytime they want to
ndashNo withdrawal symptoms
ndashStill poses a health risk
bull The other 90 will demonstrate physical and psychological symptoms of withdrawal
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
106
DOS CME Course 2011
Smoking
bull Identify tobacco users ndash Ask every patient every visit
ndash Have you used tobacco in the last 12 months
ndash Clinic-wide program
bull Advise every tobacco user to quitndash Personalize the message
ndash Be clear
ndash Be firm
If at first you donrsquot succeed try tryagain Bring it up at every encounter
107
DOS CME Course 2011
Smoking cessationbull Some more good reasons to quit
ndashSmoking costs over $2000 a year in current US dollars
ndashThere is no accepted safe level of cigarette smoke
ndashSecondhand smoke carries the same hazards
ndashIncreased risk of SIDS and asthma exacerbations in children
httpwwwlungusaorgstop-smokingabout-smokingfacts-figuresgeneral-smoking-factshtml
108
DOS CME Course 2011
Smoking cessation
bull Nicotine is a powerful drug addiction
bull Treat as a chronic illness
bull All healthcare providers encouraged to participate
bull Assess willingness to quit
bull Promote motivation
109
DOS CME Course 2011
Smoking cessation
bull Prochaskarsquos change theory
bull Precontemplation
ndashNot even thinking about quitting
ndashProvide education on the risks and costs of smoking
bull Contemplation
ndashAwareness that a problem exists
ndashContinue to find motivations to stop
NorcrossJC Krebs PM Prochaska JO(2011)
110
DOS CME Course 2011
Change is good
bull Determination
ndashExpressing willingness to act
ndashSelf-efficacy
bull Action ndash Currently not smoking
ndash May relapse
bull It is not unusual for a patient to ldquoquitrdquo three or four times
bull Continue to encourage and motivate himher to stop
NorcrossJC Krebs PM Prochaska JO(2011)
111
DOS CME Course 2011
Smoking cessationbull Assist the patient
ndashCollaborate with the patient to develop a plan to quit
ndashAchievable clearly defined goals
ndashIdentify and engage social supports
ndashFamily support groups
ndashPharmacologic (more on this later)
bull Arrange follow-up
ndashAt each successive visit review progress on quitting strategy
ndashLets the patient know heshe is not alone in this effort
ndashAccountability
112
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
PFTrsquos
bull Prepare the patient
ndashDo not smoke before the test
ndashThere will be clip on your nose
ndashDemonstrate how to achieve a tight seal on the mouthpiece
ndashNecessary for accurate results
ndashThe test requires some deep breathing which may produce fatigue
Gildea TR Retrieved (January 2011)
45
DOS CME Course 2011
How it worksbull Spirometry
ndashWhile seated the patient inhales and exhales into a tube
ndashA machine measures the volume of air exhaled ndashThe volumes are compared to the patientrsquos baseline (if
known)ndashResults less than 80 of baseline are considered
abnormal
bull Measurements ndashForced vital capacity (FVC) is the maximum amount
the patient can exhale after filling the lungs completely ndashForced expiratory volume in one second (FEV1)
Gildea TR Retrieved (January 2011)
46
Spirometry results
bull Forced Vital Capacity (FVC) is the maximum volume of gas that can be forcefully and rapidly exhaled after a maximal inhalation
bull Forced Expiratory Volume after 1 second (FEV1) is the volume of gas exhaled after one second from the beginning of the FVC maneuver
bull Forced Expiratory Flow from 25 to 75 (FEF 25-75) is the average rate of flow during the middle half of an FVC maneuver that includes the flow from medium-sized and small airways also known as mid flow rates
bull Total Lung Capacity (TLC) is the volume of gas in the lungs at the end of a maximal inhalation
DOS CME Course 201147
Spirometry results
bull Functional Residual Capacity (FRC) is the volume of gas in the lungs after exhalation of a normal breath
bull Residual Volume (RV) is the volume of gas in the lungs after complete exhalation
bull Diffusing Capacity DLCO measures the transfer of a gas usually Carbon Monoxide (CO 03) across the membrane that separates the air sacs and the blood stream
DOS CME Course 201148
DOS CME Course 2011
Asthma
bull FEV1ndash Reflects about 75 to 85 of total lung capacity ndash Decreased in patients with asthma and COPD
bull Administer an inhaled bronchodilator and repeat the test
bull A decrease in FEV1 is diagnostic for asthma ndash gt or = 12 and gt or = 200 ml
bull Peak expiratory flow (PEF) ndash Use patientrsquos own meter and compare with their baselinendash Administer bronchodilator
ndashImprovement of gt or = 20 is diagnostic
(Gildea TR Retrieved January 2011)
49
DOS CME Course 2011
Asthmabull Exercise-induced
ndash Perform spirometry following an 8-minute running protocol
bull Airway responsivenessndash Evaluate with inhaled mannitol or methacholine and histamine
ndash For the patient with normal spirometry but asthma symptoms persist
bull Elderly patients ndash May underreport symptoms
ndash Co-morbidities such as heart failure or COPD
ndash Expect fatigue and shortness of breath as normal aging
bull Occupational ndash Evaluate for correlation of symptoms with exposure to
occupational environment
50
DOS CME Course 2011
Asthma
bull Pharmacologic management
bull Stepwise approach
bull Reduce impairmentndash Prevent chronic symptoms
ndash Require 2 days or lessweek of short-acting beta agonists
ndash Maintain normal activities
ndash Maintain normal lung function
ndash Meet patient and family expectations of care
bull Reduce riskndash Prevent emergency hospitalizations
ndash Avoid adverse drug reactions
NHLBI 2007
51
DOS CME Course 2011
Pharmacology bull Beta-2 adrenergic agonists
ndashBronchodilators-smooth muscle relaxants
ndashSympathomimetic
ndashShort acting ndashalbuterolterbutalinelevalbuterol
ndashUse of short acting before exercise to improve tolerance
ndashLong acting (LABA)ndashSalmeterol formoterol
bull Side effects include
ndash tachycardia tremor hypokalemia hyperglycemia HA dizziness
52
DOS CME Course 2011
Pharmacology
bull Methylxanthines (theophylline)ndash Smooth muscle relaxants
ndashPO PR IV
bull Side effects ndash nausea irritability tachycardia dysrrhythmia seizures brain
damage death
bull Theophylline causes concern because the therapeutic and toxic ranges overlapndash Monitor after initiation with any dose increases or signs of toxicity
(Micromedex 2010)
53
DOS CME Course 2011
Pharmacology
bull Inhaled glucocorticosteroid (ICS)
ndashDecrease swelling due to inflammation
ndashBeclomethasone budesonide fluticasone triamcinolone
ndashSide effects oral candidiasis dry mouth hoarseness hypersensitivity
ndashOnset of effects 10-20 minutes
ndashRecommend using a spacer
54
DOS CME Course 2011
Pharmacologybull Leukotriene modifiers
ndash Disrupt the function or synthesis of inflammatory mediators related to asthma
ndashMontelukast zafirlukast zileuton
bull Long-term control
bull Side effects elevation of liver enzymes HA dizziness GI distress
bull Mast cell stabilizersndash Cromolyn sodium nedocromil
ndash Inhibit release of inflammatory mediators
ndash Side effects bronchospasm pharyngeal irritation
55
DOS CME Course 2011
Pharmacology
bull Anticholinergics chemically related to atropine
ndashIpratropium bromide (Atrovent)
ndashInhaled form as rescue therapy
bull Side effects
ndashurinary obstruction HA restlessness palpitations bronchospasm
56
DOS CME Course 2011
The big guns
bull Systemic corticosteroidsndash Methylprednisolone hydrocortisone dexamethasone
ndash IV or PO
ndash Treatment of acute exacerbations
bull Side effects ndash adrenal suppression weight gain fluid retention hyperglycemia
ndash Long term
ndash osteoporosis immune suppression gastric ulcers
57
DOS CME Course 2011
Right here and now
bull Nursing Intervention
bull Quick Relief
bull Short acting bronchodilator ndash Up to 3 treatments at 20 minute intervals
bull Or single nebulizer treatment
bull Course of systemic corticosteroids may be needed
DOS Wheezing protocol
58
DOS CME Course 2011
Nebulizer Treatment
bull Albuterol Solution
ndashlt5 years old 063-25 mg in 3 cc of saline q 4-6 hours as needed
ndashgt5 years old -adult 125-5 mg in 3 cc of saline q 4-8 hours as needed
bull Levalbuterol (R-albuterol solution Xopinex)
ndashlt 5 years old 031 mg-125 mg in 3 cc NS q 4-6 hrs as needed
ndash5-11 yrs old 031-063 mg q 8 hours prn symptoms
ndashgt12 yrs old063mg-125 mg q 8 hours prn symptoms
DOS Wheezing protocol
59
DOS CME Course 2011
Treatment at home
bull Nebulizers convert liquid or powder medications to aerosolized formndash Effective to deliver larger doses than metered dose inhalers
Patient safety alert Some medications in powder formcome as a capsule which is broken open The patient should not take this medication orally
60
DOS CME Course 2011
How often
do the following
happen
MILD INTERMITTENT(check appropriate box)
MILD PERSISTENT
MODERATE PERSISTENT
SEVERE PERSISTENT
Daytime wheezingshortness of breath
0-2 times per week
Greater than 2 times per week
Daily Continually
Night-time wheezing shortness of breath
0-2 times per month
Greater than 2 times per month
Greater than 1 time per week
Frequent
How often are your physical activities limited by asthma
0-2 times per week
0-2 times per week
Greater than 2 times per week
Frequent
Daily use of albuterol or ldquorescue drugsrdquo
Less than 1 time per week or less than 3 times per month
2 time per week or more
Daily Use Frequent
DOS Wheezing protocol61
DOS CME Course 2011
Plan of carebull Step 1mdashmild intermittent
ndash no daily medication
ndash should have prn short acting rescue Beta 2 inhaler on hand
bull Step 2mdashmild persistentndash low dose inhaled corticosteroids
bull Step 3mdashmoderate persistentndash low to med inhaled corticosteroids and long acting beta 2 agonists
bull Step 4mdashsevere persistentndash high dose inhaled corticosteroids and long acting inhaled beta 2
agonists
DOS Wheezing protocol
62
DOS CME Course 2011
Ongoing carebull Plan Follow-up
ndash Evaluate 2-6 weeks after treatment initiationndash Evaluate every 1-6 months when stablendash Evaluate every 3 months interval after stepping down therapyndash Annual inactivated influenza vaccine
bull ConsultationReferralndash Life threatening or severe persistent asthmandash Goals of asthma therapy not fulfilled in 3-6 monthsndash Signs and symptoms are not typicalndash Sinusitis gastroesophageal reflux or chronic pulmonary disease
complicate the asthma
DOS Wheezing protocol
63
DOS CME Course 2011
Consults
bull Continuous oral corticosteroids or 2 bursts of oral steroids in 1 year
bull Patient under 3 years with step 3 or 4 asthma
bull If omalizumab (Xolair) is considered for treatment as there is an increase in rate of anaphylaxis with this medication
bull Exacerbation requiring hospitalization
DOS Wheezing protocol
64
DOS CME Course 2011
Patient educationbull Basic understanding of asthma and how the disease
works
bull Medications ndash Names and doses of all medications
ndash Short acting vs long acting
bull Equipment ndash Metered dose inhalers (MDI)
ndash Nebulizers
bull Emergency response
bull Activity level
bull Illness management
65
DOS CME Course 2011
Patient education
bull Know your triggers and have a strategy for avoidance
bull If mold or mites are known triggers humidifiers and evaporator coolers are not recommended in the home
bull Know the early signs of an exacerbation and what to do
bull Develop an action plan based on peak flow readings
bull What to do in case of an attack at school or work
66
DOS CME Course 2011
Patient educationbull Metered dose inhalers
ndash Remove cap and invert the device several times
ndash Exhale
ndash Place the mouthpiece between your lips with a good seal
ndash Inhale while depressing the top of the MDI
ndash Hold your breath for 10 seconds
ndash Exhale
ndash Repeat as needed
67
DOS CME Course 2011
Patient educationbull Spacers are used with MDIrsquos
used to deliver inhaled steroidsndash Ease coordination of breathing
and medication delivery
ndash Decrease the amount of medication contacting the oral mucosa
ndash Fewer side effects
bull Attach the spacer to the mouthpiece of the MDI ndash Use the MDI as described
before
ndash Some models have a whistle to indicate you are inhaling too rapidly
68
DOS CME Course 201169
DOS CME Course 2011
Characteristic Controlled
(All of the following)
Partly controlled
(Any measure noted)
Uncontrolled
Daytime symptoms
None (twice or less a week)
More than twice a week
Three or more features of partly controlled asthma
Limitation of activities
None Any
Nocturnal symptomsawakening
None Any
Need for rescue treatment
None (twice or less a week)
More than twice a week
Lung function (FEV1 or PEF)
Normal lt80 predicted or personal best
70
DOS CME Course 2011
Asthma
bull Self monitoring is essential to effective management and control
bull The following are validated tools to assess asthma control
ndashAsthmacontrolcom
ndashFree web-based
ndashQoltechcouk
ndashFree in hard copy or electronic versions
ndashRequires permission
ndashAtaqinstrumentcom
ndashFree web-based
71
DOS CME Course 2011DOS CME Course 201172
Every Life Deserves World Class Care
COPD
72
DOS CME Course 2011
Chronic obstructive pulmonary disease
bull By the numbers
bull 210 million suffer worldwide
bull 3 million fatalities
bull By 2030 COPD is expected to be the third leading cause of death worldwide
bull Most important risk factors ndash Smoking
ndash Indoor pollution
ndash Outdoor pollution
ndash Occupational irritants
WHO Retrieved January 2011
73
DOS CME Course 2011
COPD
bull Causes ndash Cigarette smoking is the number one cause worldwide
ndash Environmental irritants
ndash Genetic alpha-one antitrypsin deficiency
bull Birth defects ndash Low birth weight
ndash Respiratory infections
ndash Any factor which impairs lung development during gestation
bull Other ndash HIV
ndash Connective tissue disorders
ndash Vasculitis
74
DOS CME Course 2011
COPD
bull Sometimes referred to as umbrella term for a family of diseases which cause limited airflow
ndashChronic bronchitis
ndashEmphysema
bull Inflammation of the airways
bull Increased mucous productionndash Especially in bronchitis
bull Decreased ciliary function
bull Loss of elastic recoil ndash Especially in emphysema
75
DOS CME Course 2011
COPD
bull How inflammation ruins a lung
bull Cell mediated ndash Neutrophils
ndash Macrophages
ndash Lymphocytes
bull Release cytokines which attract more cells
bull Oxidants released by cells and found in cigarette smoke
bull Proteases
bull Cause remodeling and long term structural changes
76
DOS CME Course 2011
COPDbull Alveoli lose elasticity and become distended
ndashSaggy sacs
ndashCarbon dioxide retention
ndashChronic respiratory acidosis
bull Walls of the alveoli are degraded
ndashLoss of surface area necessary for gas exchange
77
DOS CME Course 2011
What the patient looks like
bull Productive Cough
ndashEspecially in chronic bronchitis
bull Progressive dyspnea
ndashUncomfortable awareness of breathing
bull Wheezing and chest tightness
bull Increase in AP chest diameter
ndashldquoBarrel chestrdquo especially in emphysema
ndashIncreased inspiratory effort loosens costochondral cartilage
78
DOS CME Course 2011
Alpha one antitrypsin deficiency
bull Enzyme normally produced which protects the lungs
bull Deactivates neutrophil elastase
ndashReleased during inflammation
bull Estimated over 100000 in US have AATD
bull Time to diagnosis gt8 years
bull Related to increased mortality (Krowka 2010)
ndashIncreased incidence of emphysema
79
DOS CME Course 2011
Chronic bronchitis
bull Presence of cough and sputum production over three months for two consecutive years
ndashNote the months need not be consecutive
bull The patient may feel as though they are constantly sick
bull Multiple courses of antibiotics with no improvement
bull No relationship to acute bronchitis caused by bacteria or virus
80
DOS CME Course 2011
COPD
bull Break out the testing ndash CXR
ndash ECG
ndash Sputum culture
ndash CBC and electrolytes
bull ABGrsquos ndash Respiratory failure indicated by
ndash PaO2lt 60 and SaO2 lt 90
ndash with or without PaCO2 gt 50
ndash On room air
ndash Severe acidosis pHlt 736 in addition to the above is an indication for mechanical ventilation
(GOLD 2009 p 22)
81
DOS CME Course 2011
Chronic bronchitis
bull Airway of a child afflicted with chronic bronchitis compared to normal
82
DOS CME Course 2011
Chronic bronchitisbull Related to mucociliary dysfunction
ndashIncreased mucous production and thickening
ndashLoss of cilia
ndashLoss of ciliary function
ndashMobility required to sweep out particles
83
DOS CME Course 2011
Emphysemabull Permanent enlargement of the airspaces terminal to the
distal bronchioles ndashLoss of surface area for gas exchangendashDestruction of supporting structure of alveoli
ndashAirway narrowing
bull Three distinct patterns ndashCentracinar begins centrally and spreads to terminal
bronchioles and is most closely associated with cigarette smoking
ndashPanacinar destroys alveoli uniformly predominant in lower half of lungs most closely associated with AATD
ndashParaseptal destroys the distal airway structures alveolar ducts and sacs
Demirjian BG 2010
84
DOS CME Course 2011
Bullaebull Outpouchingsballooning of lung tissue due to trapped air
ndashAir is released from damaged alveoli
ndashAsymptomatic
ndashRupture can cause pneumothorax
85
DOS CME Course 2011
Diagnosis
bull History of smoking or exposure to inhaled irritants
ndashRemember to consider work and living environment
ndashCooking indoors with fossil fuels
ndashAge over 40
bull Signs and symptoms
ndashChronic cough with sputum production
ndashDyspnea which persists daily worsens with exercise and progresses over time
bull Spirometry is strongly recommended
86
DOS CME Course 2011
Diagnosis
bull Chest x-ray
ndashRule out pneumonia cardiomyopathy
ndashNot diagnostic for COPD but may reveal other causes for symptoms
bull Arterial blood gases
ndashRecommended for patients with FEVlt 50
ndashPaO2lt 60 mmHg suggests respiratory failure
bull Sputum culture
ndashRule out infectious process
87
DOS CME Course 2011
Disease stages
bull Stage Indash FEVFVC lt 70
ndash FEV gt 80
ndash Few symptoms if any patient may be unaware
bull Stage II moderate ndash FEVFVC lt 70
ndash FEV lt 80
ndash Along with shortness of breath
88
DOS CME Course 2011
Disease stages
bull Stage IV very severe ndash FEVFVC lt 70
ndash FEV lt 30
ndash At this stage exacerbations are life-threatening
ndash Quality of life is impaired further
bull Stage III severe ndash FEVFVC lt 70
ndash FEV lt 50
ndash Worsening symptoms increasing frequency of exacerbations
89
DOS CME Course 2011
COPD vs Asthma
bull COPD
ndashOnset later in life
ndashProgressive worsening symptoms
ndashSmoking history
ndashDyspnea with exercise
ndashLargely irreversible airflow limitation
bull Asthma
ndashOnset of symptoms usually earlier in life
ndashWorsening at night
ndashLargely reversible airflow limitation
ndashSymptoms vary from day to day
90
DOS CME Course 2011
COPD Treatmentbull Now that we have diagnosis what do I do about it
bull Assess and monitor diseasendash Assess for risk factors ie smoking family history
ndash Co-morbidities such as heart failure
ndash Pattern of symptoms
ndash Impact on quality of life
bull Reduce risk factors ndash Identify environmentaloccupational factors which can be modified
ndash Smoking cessation is essential
ndash Manage exacerbations
91
DOS CME Course 2011
COPDbull Manage stable COPD
ndash Determine disease severity based on frequency and severity of symptoms
ndash Educate the patient about risk factors and disease management regimen
ndash Collaborate with the patient to develop a personalized regimen
ndashFits their lifestyle
ndashAccounts for cultural preferences family involvement
ndashAvailability of testing and medications
92
DOS CME Course 2011
Pharmacologybull Goals
ndash Improve exercise tolerance
ndash Control symptoms
ndash Reduce frequency and severity of exacerbations
ndash Improve health status
bull Bronchodilators ndash Include long-acting therapy with short-acting for better control
bull Combine medications from different classes rather than increasing dosage of just onendash Minimizes side effects
93
DOS CME Course 2011
Pharmacologybull Glucocorticosteroids
ndashCan reduce the number of exacerbations
ndashIncreased risk of pneumonia
ndashNo noted reduction in mortality
bull Vaccines
ndashInfluenza vaccines decrease serious illness and death by 50
ndashRecommended annually
ndashPneumococcal vaccines recommended for all COPD sufferers even under age 65
GOLD 2009
94
DOS CME Course 2011
Antibiotics
bull Antibiotics are not a treatment for COPD nor do they manage symptoms of an exacerbation
bull Should be given only if the following are metndash Presence of three cardinal symptoms increased dyspnea
increased sputum volume increased sputum purulence
ndash Increased sputum purulence plus one other cardinal symptom
ndash Mechanically ventilated
bull May be difficult for patients to understand why antibiotics will not ldquofixrdquo what is wrong
bull Good opportunity for learning needs assessment
GOLD 2009
95
DOS CME Course 2011
COPD
bull Pulmonary rehabilitation
bull Encourage the patient to continue activities as tolerated ndash Move as much as you can before you canrsquot move
bull Uses low impact exercise to maintain physical function
bull Exercise can be done while seatedndash Monitor pulse oximetry respiratory rate and effort before during
and after activity
bull Set goals which are realistic for both of you
96
DOS CME Course 2011
COPD
bull Pulmonary rehab includes education nutrition and exercise
bull Can be a good source of social support for someone who has seen function decline
ndashTalk with others in the same situation
ndashFind out how they cope
ndashSocialize
bull Regular influenza and pneumonia vaccines
97
DOS CME Course 2011
COPD
bull Oxygen therapy
bull Recommended for stage IV disease ndash PaO2 lt or = 55 mmHg
ndash SaO2 lt or = 88
bull Increases survival improves hemodynamicsbenefits mental state
bull Surgical options reviewed on a case-by-case basisndash Bullectomy
ndash Lung volume reduction ndashNo evidence to support this as a widespread therapy
98
DOS CME Course 2011
COPD
bull Managing exacerbations
bull An event in the natural course of the disease characterized by a change in baseline dyspnea cough or sputum beyond day to day variance is acute in onset and may warrant a change in medication
bull Air pollution and tracheobronchial infections are the most common causes
bull 30 of exacerbations no cause identified
(GOLD 2009 p 22)
99
DOS CME Course 2011
COPD
bull Hospitalization is recommended for patients exhibiting the following
ndash Failure of exacerbation to respond to medical treatment
ndash Development of new symptoms ie peripheral edema cyanosis
ndash Significant co-morbidities
ndash History of frequent exacerbations
ndash Newly occurring arrhythmias
ndash Advanced age
ndash Insufficient home support
ndash Unclear diagnosis
(GOLD 2009 p 23)
100
DOS CME Course 2011
COPD
bull Mechanical ventilation is not recognized as an effective management strategy for stable COPD
bull May be required as supportive therapy during an exacerbation
bull Associated with mortality
bull Carries risks of its ownndash Ventilator acquired pneumonia
ndash Ventilator induced lung injury
ndash Failure to wean
(GOLD 2009)
101
DOS CME Course 2011DOS CME Course 2011102
Every Life Deserves World Class Care
Smoking
102
DOS CME Course 2011
Smoking bull By the numbers
bull More than 400 000 Americans die from smoking-related illnesses each yearndash Thatrsquos one of every 5 deaths
bull In a study of 2963 health care encounters smoking was discussed 633 times
bull Nicotine released into the body within 10 seconds of inhalation
bull If a person smokes one pack per day and takes ten puffs of each cigarette that equates to 200 ldquohitsrdquo of nicotine daily
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
103
DOS CME Course 2011
Nicotine
bull Nicotinic receptors occur naturally
bull N1 receptors in the adrenal medulla
bull Neuromuscular junction of autonomic ganglia
bull N2 receptors in skeletal muscle
bull Number of receptor sites increases with regular stimulation
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
104
DOS CME Course 2011
Nicotinebull Addictive
bull Vasoconstrictor
bull Releases adrenaline from the adrenal cortex
ndashFeeling of increased energy
bull Releases dopamine to produce feelings of well-beingndash Actually improves memory and cognition
bull Sensitivity actually declines overnight
bull Release of insulinndash Slightly hyperglycemic
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
105
DOS CME Course 2011
Genetic componentbull About 10 of smokers lack the gene for nicotine
dependence
ndashldquosocial or occasionalrdquo smokers
ndashThey really can quit anytime they want to
ndashNo withdrawal symptoms
ndashStill poses a health risk
bull The other 90 will demonstrate physical and psychological symptoms of withdrawal
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
106
DOS CME Course 2011
Smoking
bull Identify tobacco users ndash Ask every patient every visit
ndash Have you used tobacco in the last 12 months
ndash Clinic-wide program
bull Advise every tobacco user to quitndash Personalize the message
ndash Be clear
ndash Be firm
If at first you donrsquot succeed try tryagain Bring it up at every encounter
107
DOS CME Course 2011
Smoking cessationbull Some more good reasons to quit
ndashSmoking costs over $2000 a year in current US dollars
ndashThere is no accepted safe level of cigarette smoke
ndashSecondhand smoke carries the same hazards
ndashIncreased risk of SIDS and asthma exacerbations in children
httpwwwlungusaorgstop-smokingabout-smokingfacts-figuresgeneral-smoking-factshtml
108
DOS CME Course 2011
Smoking cessation
bull Nicotine is a powerful drug addiction
bull Treat as a chronic illness
bull All healthcare providers encouraged to participate
bull Assess willingness to quit
bull Promote motivation
109
DOS CME Course 2011
Smoking cessation
bull Prochaskarsquos change theory
bull Precontemplation
ndashNot even thinking about quitting
ndashProvide education on the risks and costs of smoking
bull Contemplation
ndashAwareness that a problem exists
ndashContinue to find motivations to stop
NorcrossJC Krebs PM Prochaska JO(2011)
110
DOS CME Course 2011
Change is good
bull Determination
ndashExpressing willingness to act
ndashSelf-efficacy
bull Action ndash Currently not smoking
ndash May relapse
bull It is not unusual for a patient to ldquoquitrdquo three or four times
bull Continue to encourage and motivate himher to stop
NorcrossJC Krebs PM Prochaska JO(2011)
111
DOS CME Course 2011
Smoking cessationbull Assist the patient
ndashCollaborate with the patient to develop a plan to quit
ndashAchievable clearly defined goals
ndashIdentify and engage social supports
ndashFamily support groups
ndashPharmacologic (more on this later)
bull Arrange follow-up
ndashAt each successive visit review progress on quitting strategy
ndashLets the patient know heshe is not alone in this effort
ndashAccountability
112
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
Spirometry results
bull Forced Vital Capacity (FVC) is the maximum volume of gas that can be forcefully and rapidly exhaled after a maximal inhalation
bull Forced Expiratory Volume after 1 second (FEV1) is the volume of gas exhaled after one second from the beginning of the FVC maneuver
bull Forced Expiratory Flow from 25 to 75 (FEF 25-75) is the average rate of flow during the middle half of an FVC maneuver that includes the flow from medium-sized and small airways also known as mid flow rates
bull Total Lung Capacity (TLC) is the volume of gas in the lungs at the end of a maximal inhalation
DOS CME Course 201147
Spirometry results
bull Functional Residual Capacity (FRC) is the volume of gas in the lungs after exhalation of a normal breath
bull Residual Volume (RV) is the volume of gas in the lungs after complete exhalation
bull Diffusing Capacity DLCO measures the transfer of a gas usually Carbon Monoxide (CO 03) across the membrane that separates the air sacs and the blood stream
DOS CME Course 201148
DOS CME Course 2011
Asthma
bull FEV1ndash Reflects about 75 to 85 of total lung capacity ndash Decreased in patients with asthma and COPD
bull Administer an inhaled bronchodilator and repeat the test
bull A decrease in FEV1 is diagnostic for asthma ndash gt or = 12 and gt or = 200 ml
bull Peak expiratory flow (PEF) ndash Use patientrsquos own meter and compare with their baselinendash Administer bronchodilator
ndashImprovement of gt or = 20 is diagnostic
(Gildea TR Retrieved January 2011)
49
DOS CME Course 2011
Asthmabull Exercise-induced
ndash Perform spirometry following an 8-minute running protocol
bull Airway responsivenessndash Evaluate with inhaled mannitol or methacholine and histamine
ndash For the patient with normal spirometry but asthma symptoms persist
bull Elderly patients ndash May underreport symptoms
ndash Co-morbidities such as heart failure or COPD
ndash Expect fatigue and shortness of breath as normal aging
bull Occupational ndash Evaluate for correlation of symptoms with exposure to
occupational environment
50
DOS CME Course 2011
Asthma
bull Pharmacologic management
bull Stepwise approach
bull Reduce impairmentndash Prevent chronic symptoms
ndash Require 2 days or lessweek of short-acting beta agonists
ndash Maintain normal activities
ndash Maintain normal lung function
ndash Meet patient and family expectations of care
bull Reduce riskndash Prevent emergency hospitalizations
ndash Avoid adverse drug reactions
NHLBI 2007
51
DOS CME Course 2011
Pharmacology bull Beta-2 adrenergic agonists
ndashBronchodilators-smooth muscle relaxants
ndashSympathomimetic
ndashShort acting ndashalbuterolterbutalinelevalbuterol
ndashUse of short acting before exercise to improve tolerance
ndashLong acting (LABA)ndashSalmeterol formoterol
bull Side effects include
ndash tachycardia tremor hypokalemia hyperglycemia HA dizziness
52
DOS CME Course 2011
Pharmacology
bull Methylxanthines (theophylline)ndash Smooth muscle relaxants
ndashPO PR IV
bull Side effects ndash nausea irritability tachycardia dysrrhythmia seizures brain
damage death
bull Theophylline causes concern because the therapeutic and toxic ranges overlapndash Monitor after initiation with any dose increases or signs of toxicity
(Micromedex 2010)
53
DOS CME Course 2011
Pharmacology
bull Inhaled glucocorticosteroid (ICS)
ndashDecrease swelling due to inflammation
ndashBeclomethasone budesonide fluticasone triamcinolone
ndashSide effects oral candidiasis dry mouth hoarseness hypersensitivity
ndashOnset of effects 10-20 minutes
ndashRecommend using a spacer
54
DOS CME Course 2011
Pharmacologybull Leukotriene modifiers
ndash Disrupt the function or synthesis of inflammatory mediators related to asthma
ndashMontelukast zafirlukast zileuton
bull Long-term control
bull Side effects elevation of liver enzymes HA dizziness GI distress
bull Mast cell stabilizersndash Cromolyn sodium nedocromil
ndash Inhibit release of inflammatory mediators
ndash Side effects bronchospasm pharyngeal irritation
55
DOS CME Course 2011
Pharmacology
bull Anticholinergics chemically related to atropine
ndashIpratropium bromide (Atrovent)
ndashInhaled form as rescue therapy
bull Side effects
ndashurinary obstruction HA restlessness palpitations bronchospasm
56
DOS CME Course 2011
The big guns
bull Systemic corticosteroidsndash Methylprednisolone hydrocortisone dexamethasone
ndash IV or PO
ndash Treatment of acute exacerbations
bull Side effects ndash adrenal suppression weight gain fluid retention hyperglycemia
ndash Long term
ndash osteoporosis immune suppression gastric ulcers
57
DOS CME Course 2011
Right here and now
bull Nursing Intervention
bull Quick Relief
bull Short acting bronchodilator ndash Up to 3 treatments at 20 minute intervals
bull Or single nebulizer treatment
bull Course of systemic corticosteroids may be needed
DOS Wheezing protocol
58
DOS CME Course 2011
Nebulizer Treatment
bull Albuterol Solution
ndashlt5 years old 063-25 mg in 3 cc of saline q 4-6 hours as needed
ndashgt5 years old -adult 125-5 mg in 3 cc of saline q 4-8 hours as needed
bull Levalbuterol (R-albuterol solution Xopinex)
ndashlt 5 years old 031 mg-125 mg in 3 cc NS q 4-6 hrs as needed
ndash5-11 yrs old 031-063 mg q 8 hours prn symptoms
ndashgt12 yrs old063mg-125 mg q 8 hours prn symptoms
DOS Wheezing protocol
59
DOS CME Course 2011
Treatment at home
bull Nebulizers convert liquid or powder medications to aerosolized formndash Effective to deliver larger doses than metered dose inhalers
Patient safety alert Some medications in powder formcome as a capsule which is broken open The patient should not take this medication orally
60
DOS CME Course 2011
How often
do the following
happen
MILD INTERMITTENT(check appropriate box)
MILD PERSISTENT
MODERATE PERSISTENT
SEVERE PERSISTENT
Daytime wheezingshortness of breath
0-2 times per week
Greater than 2 times per week
Daily Continually
Night-time wheezing shortness of breath
0-2 times per month
Greater than 2 times per month
Greater than 1 time per week
Frequent
How often are your physical activities limited by asthma
0-2 times per week
0-2 times per week
Greater than 2 times per week
Frequent
Daily use of albuterol or ldquorescue drugsrdquo
Less than 1 time per week or less than 3 times per month
2 time per week or more
Daily Use Frequent
DOS Wheezing protocol61
DOS CME Course 2011
Plan of carebull Step 1mdashmild intermittent
ndash no daily medication
ndash should have prn short acting rescue Beta 2 inhaler on hand
bull Step 2mdashmild persistentndash low dose inhaled corticosteroids
bull Step 3mdashmoderate persistentndash low to med inhaled corticosteroids and long acting beta 2 agonists
bull Step 4mdashsevere persistentndash high dose inhaled corticosteroids and long acting inhaled beta 2
agonists
DOS Wheezing protocol
62
DOS CME Course 2011
Ongoing carebull Plan Follow-up
ndash Evaluate 2-6 weeks after treatment initiationndash Evaluate every 1-6 months when stablendash Evaluate every 3 months interval after stepping down therapyndash Annual inactivated influenza vaccine
bull ConsultationReferralndash Life threatening or severe persistent asthmandash Goals of asthma therapy not fulfilled in 3-6 monthsndash Signs and symptoms are not typicalndash Sinusitis gastroesophageal reflux or chronic pulmonary disease
complicate the asthma
DOS Wheezing protocol
63
DOS CME Course 2011
Consults
bull Continuous oral corticosteroids or 2 bursts of oral steroids in 1 year
bull Patient under 3 years with step 3 or 4 asthma
bull If omalizumab (Xolair) is considered for treatment as there is an increase in rate of anaphylaxis with this medication
bull Exacerbation requiring hospitalization
DOS Wheezing protocol
64
DOS CME Course 2011
Patient educationbull Basic understanding of asthma and how the disease
works
bull Medications ndash Names and doses of all medications
ndash Short acting vs long acting
bull Equipment ndash Metered dose inhalers (MDI)
ndash Nebulizers
bull Emergency response
bull Activity level
bull Illness management
65
DOS CME Course 2011
Patient education
bull Know your triggers and have a strategy for avoidance
bull If mold or mites are known triggers humidifiers and evaporator coolers are not recommended in the home
bull Know the early signs of an exacerbation and what to do
bull Develop an action plan based on peak flow readings
bull What to do in case of an attack at school or work
66
DOS CME Course 2011
Patient educationbull Metered dose inhalers
ndash Remove cap and invert the device several times
ndash Exhale
ndash Place the mouthpiece between your lips with a good seal
ndash Inhale while depressing the top of the MDI
ndash Hold your breath for 10 seconds
ndash Exhale
ndash Repeat as needed
67
DOS CME Course 2011
Patient educationbull Spacers are used with MDIrsquos
used to deliver inhaled steroidsndash Ease coordination of breathing
and medication delivery
ndash Decrease the amount of medication contacting the oral mucosa
ndash Fewer side effects
bull Attach the spacer to the mouthpiece of the MDI ndash Use the MDI as described
before
ndash Some models have a whistle to indicate you are inhaling too rapidly
68
DOS CME Course 201169
DOS CME Course 2011
Characteristic Controlled
(All of the following)
Partly controlled
(Any measure noted)
Uncontrolled
Daytime symptoms
None (twice or less a week)
More than twice a week
Three or more features of partly controlled asthma
Limitation of activities
None Any
Nocturnal symptomsawakening
None Any
Need for rescue treatment
None (twice or less a week)
More than twice a week
Lung function (FEV1 or PEF)
Normal lt80 predicted or personal best
70
DOS CME Course 2011
Asthma
bull Self monitoring is essential to effective management and control
bull The following are validated tools to assess asthma control
ndashAsthmacontrolcom
ndashFree web-based
ndashQoltechcouk
ndashFree in hard copy or electronic versions
ndashRequires permission
ndashAtaqinstrumentcom
ndashFree web-based
71
DOS CME Course 2011DOS CME Course 201172
Every Life Deserves World Class Care
COPD
72
DOS CME Course 2011
Chronic obstructive pulmonary disease
bull By the numbers
bull 210 million suffer worldwide
bull 3 million fatalities
bull By 2030 COPD is expected to be the third leading cause of death worldwide
bull Most important risk factors ndash Smoking
ndash Indoor pollution
ndash Outdoor pollution
ndash Occupational irritants
WHO Retrieved January 2011
73
DOS CME Course 2011
COPD
bull Causes ndash Cigarette smoking is the number one cause worldwide
ndash Environmental irritants
ndash Genetic alpha-one antitrypsin deficiency
bull Birth defects ndash Low birth weight
ndash Respiratory infections
ndash Any factor which impairs lung development during gestation
bull Other ndash HIV
ndash Connective tissue disorders
ndash Vasculitis
74
DOS CME Course 2011
COPD
bull Sometimes referred to as umbrella term for a family of diseases which cause limited airflow
ndashChronic bronchitis
ndashEmphysema
bull Inflammation of the airways
bull Increased mucous productionndash Especially in bronchitis
bull Decreased ciliary function
bull Loss of elastic recoil ndash Especially in emphysema
75
DOS CME Course 2011
COPD
bull How inflammation ruins a lung
bull Cell mediated ndash Neutrophils
ndash Macrophages
ndash Lymphocytes
bull Release cytokines which attract more cells
bull Oxidants released by cells and found in cigarette smoke
bull Proteases
bull Cause remodeling and long term structural changes
76
DOS CME Course 2011
COPDbull Alveoli lose elasticity and become distended
ndashSaggy sacs
ndashCarbon dioxide retention
ndashChronic respiratory acidosis
bull Walls of the alveoli are degraded
ndashLoss of surface area necessary for gas exchange
77
DOS CME Course 2011
What the patient looks like
bull Productive Cough
ndashEspecially in chronic bronchitis
bull Progressive dyspnea
ndashUncomfortable awareness of breathing
bull Wheezing and chest tightness
bull Increase in AP chest diameter
ndashldquoBarrel chestrdquo especially in emphysema
ndashIncreased inspiratory effort loosens costochondral cartilage
78
DOS CME Course 2011
Alpha one antitrypsin deficiency
bull Enzyme normally produced which protects the lungs
bull Deactivates neutrophil elastase
ndashReleased during inflammation
bull Estimated over 100000 in US have AATD
bull Time to diagnosis gt8 years
bull Related to increased mortality (Krowka 2010)
ndashIncreased incidence of emphysema
79
DOS CME Course 2011
Chronic bronchitis
bull Presence of cough and sputum production over three months for two consecutive years
ndashNote the months need not be consecutive
bull The patient may feel as though they are constantly sick
bull Multiple courses of antibiotics with no improvement
bull No relationship to acute bronchitis caused by bacteria or virus
80
DOS CME Course 2011
COPD
bull Break out the testing ndash CXR
ndash ECG
ndash Sputum culture
ndash CBC and electrolytes
bull ABGrsquos ndash Respiratory failure indicated by
ndash PaO2lt 60 and SaO2 lt 90
ndash with or without PaCO2 gt 50
ndash On room air
ndash Severe acidosis pHlt 736 in addition to the above is an indication for mechanical ventilation
(GOLD 2009 p 22)
81
DOS CME Course 2011
Chronic bronchitis
bull Airway of a child afflicted with chronic bronchitis compared to normal
82
DOS CME Course 2011
Chronic bronchitisbull Related to mucociliary dysfunction
ndashIncreased mucous production and thickening
ndashLoss of cilia
ndashLoss of ciliary function
ndashMobility required to sweep out particles
83
DOS CME Course 2011
Emphysemabull Permanent enlargement of the airspaces terminal to the
distal bronchioles ndashLoss of surface area for gas exchangendashDestruction of supporting structure of alveoli
ndashAirway narrowing
bull Three distinct patterns ndashCentracinar begins centrally and spreads to terminal
bronchioles and is most closely associated with cigarette smoking
ndashPanacinar destroys alveoli uniformly predominant in lower half of lungs most closely associated with AATD
ndashParaseptal destroys the distal airway structures alveolar ducts and sacs
Demirjian BG 2010
84
DOS CME Course 2011
Bullaebull Outpouchingsballooning of lung tissue due to trapped air
ndashAir is released from damaged alveoli
ndashAsymptomatic
ndashRupture can cause pneumothorax
85
DOS CME Course 2011
Diagnosis
bull History of smoking or exposure to inhaled irritants
ndashRemember to consider work and living environment
ndashCooking indoors with fossil fuels
ndashAge over 40
bull Signs and symptoms
ndashChronic cough with sputum production
ndashDyspnea which persists daily worsens with exercise and progresses over time
bull Spirometry is strongly recommended
86
DOS CME Course 2011
Diagnosis
bull Chest x-ray
ndashRule out pneumonia cardiomyopathy
ndashNot diagnostic for COPD but may reveal other causes for symptoms
bull Arterial blood gases
ndashRecommended for patients with FEVlt 50
ndashPaO2lt 60 mmHg suggests respiratory failure
bull Sputum culture
ndashRule out infectious process
87
DOS CME Course 2011
Disease stages
bull Stage Indash FEVFVC lt 70
ndash FEV gt 80
ndash Few symptoms if any patient may be unaware
bull Stage II moderate ndash FEVFVC lt 70
ndash FEV lt 80
ndash Along with shortness of breath
88
DOS CME Course 2011
Disease stages
bull Stage IV very severe ndash FEVFVC lt 70
ndash FEV lt 30
ndash At this stage exacerbations are life-threatening
ndash Quality of life is impaired further
bull Stage III severe ndash FEVFVC lt 70
ndash FEV lt 50
ndash Worsening symptoms increasing frequency of exacerbations
89
DOS CME Course 2011
COPD vs Asthma
bull COPD
ndashOnset later in life
ndashProgressive worsening symptoms
ndashSmoking history
ndashDyspnea with exercise
ndashLargely irreversible airflow limitation
bull Asthma
ndashOnset of symptoms usually earlier in life
ndashWorsening at night
ndashLargely reversible airflow limitation
ndashSymptoms vary from day to day
90
DOS CME Course 2011
COPD Treatmentbull Now that we have diagnosis what do I do about it
bull Assess and monitor diseasendash Assess for risk factors ie smoking family history
ndash Co-morbidities such as heart failure
ndash Pattern of symptoms
ndash Impact on quality of life
bull Reduce risk factors ndash Identify environmentaloccupational factors which can be modified
ndash Smoking cessation is essential
ndash Manage exacerbations
91
DOS CME Course 2011
COPDbull Manage stable COPD
ndash Determine disease severity based on frequency and severity of symptoms
ndash Educate the patient about risk factors and disease management regimen
ndash Collaborate with the patient to develop a personalized regimen
ndashFits their lifestyle
ndashAccounts for cultural preferences family involvement
ndashAvailability of testing and medications
92
DOS CME Course 2011
Pharmacologybull Goals
ndash Improve exercise tolerance
ndash Control symptoms
ndash Reduce frequency and severity of exacerbations
ndash Improve health status
bull Bronchodilators ndash Include long-acting therapy with short-acting for better control
bull Combine medications from different classes rather than increasing dosage of just onendash Minimizes side effects
93
DOS CME Course 2011
Pharmacologybull Glucocorticosteroids
ndashCan reduce the number of exacerbations
ndashIncreased risk of pneumonia
ndashNo noted reduction in mortality
bull Vaccines
ndashInfluenza vaccines decrease serious illness and death by 50
ndashRecommended annually
ndashPneumococcal vaccines recommended for all COPD sufferers even under age 65
GOLD 2009
94
DOS CME Course 2011
Antibiotics
bull Antibiotics are not a treatment for COPD nor do they manage symptoms of an exacerbation
bull Should be given only if the following are metndash Presence of three cardinal symptoms increased dyspnea
increased sputum volume increased sputum purulence
ndash Increased sputum purulence plus one other cardinal symptom
ndash Mechanically ventilated
bull May be difficult for patients to understand why antibiotics will not ldquofixrdquo what is wrong
bull Good opportunity for learning needs assessment
GOLD 2009
95
DOS CME Course 2011
COPD
bull Pulmonary rehabilitation
bull Encourage the patient to continue activities as tolerated ndash Move as much as you can before you canrsquot move
bull Uses low impact exercise to maintain physical function
bull Exercise can be done while seatedndash Monitor pulse oximetry respiratory rate and effort before during
and after activity
bull Set goals which are realistic for both of you
96
DOS CME Course 2011
COPD
bull Pulmonary rehab includes education nutrition and exercise
bull Can be a good source of social support for someone who has seen function decline
ndashTalk with others in the same situation
ndashFind out how they cope
ndashSocialize
bull Regular influenza and pneumonia vaccines
97
DOS CME Course 2011
COPD
bull Oxygen therapy
bull Recommended for stage IV disease ndash PaO2 lt or = 55 mmHg
ndash SaO2 lt or = 88
bull Increases survival improves hemodynamicsbenefits mental state
bull Surgical options reviewed on a case-by-case basisndash Bullectomy
ndash Lung volume reduction ndashNo evidence to support this as a widespread therapy
98
DOS CME Course 2011
COPD
bull Managing exacerbations
bull An event in the natural course of the disease characterized by a change in baseline dyspnea cough or sputum beyond day to day variance is acute in onset and may warrant a change in medication
bull Air pollution and tracheobronchial infections are the most common causes
bull 30 of exacerbations no cause identified
(GOLD 2009 p 22)
99
DOS CME Course 2011
COPD
bull Hospitalization is recommended for patients exhibiting the following
ndash Failure of exacerbation to respond to medical treatment
ndash Development of new symptoms ie peripheral edema cyanosis
ndash Significant co-morbidities
ndash History of frequent exacerbations
ndash Newly occurring arrhythmias
ndash Advanced age
ndash Insufficient home support
ndash Unclear diagnosis
(GOLD 2009 p 23)
100
DOS CME Course 2011
COPD
bull Mechanical ventilation is not recognized as an effective management strategy for stable COPD
bull May be required as supportive therapy during an exacerbation
bull Associated with mortality
bull Carries risks of its ownndash Ventilator acquired pneumonia
ndash Ventilator induced lung injury
ndash Failure to wean
(GOLD 2009)
101
DOS CME Course 2011DOS CME Course 2011102
Every Life Deserves World Class Care
Smoking
102
DOS CME Course 2011
Smoking bull By the numbers
bull More than 400 000 Americans die from smoking-related illnesses each yearndash Thatrsquos one of every 5 deaths
bull In a study of 2963 health care encounters smoking was discussed 633 times
bull Nicotine released into the body within 10 seconds of inhalation
bull If a person smokes one pack per day and takes ten puffs of each cigarette that equates to 200 ldquohitsrdquo of nicotine daily
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
103
DOS CME Course 2011
Nicotine
bull Nicotinic receptors occur naturally
bull N1 receptors in the adrenal medulla
bull Neuromuscular junction of autonomic ganglia
bull N2 receptors in skeletal muscle
bull Number of receptor sites increases with regular stimulation
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
104
DOS CME Course 2011
Nicotinebull Addictive
bull Vasoconstrictor
bull Releases adrenaline from the adrenal cortex
ndashFeeling of increased energy
bull Releases dopamine to produce feelings of well-beingndash Actually improves memory and cognition
bull Sensitivity actually declines overnight
bull Release of insulinndash Slightly hyperglycemic
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
105
DOS CME Course 2011
Genetic componentbull About 10 of smokers lack the gene for nicotine
dependence
ndashldquosocial or occasionalrdquo smokers
ndashThey really can quit anytime they want to
ndashNo withdrawal symptoms
ndashStill poses a health risk
bull The other 90 will demonstrate physical and psychological symptoms of withdrawal
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
106
DOS CME Course 2011
Smoking
bull Identify tobacco users ndash Ask every patient every visit
ndash Have you used tobacco in the last 12 months
ndash Clinic-wide program
bull Advise every tobacco user to quitndash Personalize the message
ndash Be clear
ndash Be firm
If at first you donrsquot succeed try tryagain Bring it up at every encounter
107
DOS CME Course 2011
Smoking cessationbull Some more good reasons to quit
ndashSmoking costs over $2000 a year in current US dollars
ndashThere is no accepted safe level of cigarette smoke
ndashSecondhand smoke carries the same hazards
ndashIncreased risk of SIDS and asthma exacerbations in children
httpwwwlungusaorgstop-smokingabout-smokingfacts-figuresgeneral-smoking-factshtml
108
DOS CME Course 2011
Smoking cessation
bull Nicotine is a powerful drug addiction
bull Treat as a chronic illness
bull All healthcare providers encouraged to participate
bull Assess willingness to quit
bull Promote motivation
109
DOS CME Course 2011
Smoking cessation
bull Prochaskarsquos change theory
bull Precontemplation
ndashNot even thinking about quitting
ndashProvide education on the risks and costs of smoking
bull Contemplation
ndashAwareness that a problem exists
ndashContinue to find motivations to stop
NorcrossJC Krebs PM Prochaska JO(2011)
110
DOS CME Course 2011
Change is good
bull Determination
ndashExpressing willingness to act
ndashSelf-efficacy
bull Action ndash Currently not smoking
ndash May relapse
bull It is not unusual for a patient to ldquoquitrdquo three or four times
bull Continue to encourage and motivate himher to stop
NorcrossJC Krebs PM Prochaska JO(2011)
111
DOS CME Course 2011
Smoking cessationbull Assist the patient
ndashCollaborate with the patient to develop a plan to quit
ndashAchievable clearly defined goals
ndashIdentify and engage social supports
ndashFamily support groups
ndashPharmacologic (more on this later)
bull Arrange follow-up
ndashAt each successive visit review progress on quitting strategy
ndashLets the patient know heshe is not alone in this effort
ndashAccountability
112
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
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DOS CME Course 2011
Asthma
bull FEV1ndash Reflects about 75 to 85 of total lung capacity ndash Decreased in patients with asthma and COPD
bull Administer an inhaled bronchodilator and repeat the test
bull A decrease in FEV1 is diagnostic for asthma ndash gt or = 12 and gt or = 200 ml
bull Peak expiratory flow (PEF) ndash Use patientrsquos own meter and compare with their baselinendash Administer bronchodilator
ndashImprovement of gt or = 20 is diagnostic
(Gildea TR Retrieved January 2011)
49
DOS CME Course 2011
Asthmabull Exercise-induced
ndash Perform spirometry following an 8-minute running protocol
bull Airway responsivenessndash Evaluate with inhaled mannitol or methacholine and histamine
ndash For the patient with normal spirometry but asthma symptoms persist
bull Elderly patients ndash May underreport symptoms
ndash Co-morbidities such as heart failure or COPD
ndash Expect fatigue and shortness of breath as normal aging
bull Occupational ndash Evaluate for correlation of symptoms with exposure to
occupational environment
50
DOS CME Course 2011
Asthma
bull Pharmacologic management
bull Stepwise approach
bull Reduce impairmentndash Prevent chronic symptoms
ndash Require 2 days or lessweek of short-acting beta agonists
ndash Maintain normal activities
ndash Maintain normal lung function
ndash Meet patient and family expectations of care
bull Reduce riskndash Prevent emergency hospitalizations
ndash Avoid adverse drug reactions
NHLBI 2007
51
DOS CME Course 2011
Pharmacology bull Beta-2 adrenergic agonists
ndashBronchodilators-smooth muscle relaxants
ndashSympathomimetic
ndashShort acting ndashalbuterolterbutalinelevalbuterol
ndashUse of short acting before exercise to improve tolerance
ndashLong acting (LABA)ndashSalmeterol formoterol
bull Side effects include
ndash tachycardia tremor hypokalemia hyperglycemia HA dizziness
52
DOS CME Course 2011
Pharmacology
bull Methylxanthines (theophylline)ndash Smooth muscle relaxants
ndashPO PR IV
bull Side effects ndash nausea irritability tachycardia dysrrhythmia seizures brain
damage death
bull Theophylline causes concern because the therapeutic and toxic ranges overlapndash Monitor after initiation with any dose increases or signs of toxicity
(Micromedex 2010)
53
DOS CME Course 2011
Pharmacology
bull Inhaled glucocorticosteroid (ICS)
ndashDecrease swelling due to inflammation
ndashBeclomethasone budesonide fluticasone triamcinolone
ndashSide effects oral candidiasis dry mouth hoarseness hypersensitivity
ndashOnset of effects 10-20 minutes
ndashRecommend using a spacer
54
DOS CME Course 2011
Pharmacologybull Leukotriene modifiers
ndash Disrupt the function or synthesis of inflammatory mediators related to asthma
ndashMontelukast zafirlukast zileuton
bull Long-term control
bull Side effects elevation of liver enzymes HA dizziness GI distress
bull Mast cell stabilizersndash Cromolyn sodium nedocromil
ndash Inhibit release of inflammatory mediators
ndash Side effects bronchospasm pharyngeal irritation
55
DOS CME Course 2011
Pharmacology
bull Anticholinergics chemically related to atropine
ndashIpratropium bromide (Atrovent)
ndashInhaled form as rescue therapy
bull Side effects
ndashurinary obstruction HA restlessness palpitations bronchospasm
56
DOS CME Course 2011
The big guns
bull Systemic corticosteroidsndash Methylprednisolone hydrocortisone dexamethasone
ndash IV or PO
ndash Treatment of acute exacerbations
bull Side effects ndash adrenal suppression weight gain fluid retention hyperglycemia
ndash Long term
ndash osteoporosis immune suppression gastric ulcers
57
DOS CME Course 2011
Right here and now
bull Nursing Intervention
bull Quick Relief
bull Short acting bronchodilator ndash Up to 3 treatments at 20 minute intervals
bull Or single nebulizer treatment
bull Course of systemic corticosteroids may be needed
DOS Wheezing protocol
58
DOS CME Course 2011
Nebulizer Treatment
bull Albuterol Solution
ndashlt5 years old 063-25 mg in 3 cc of saline q 4-6 hours as needed
ndashgt5 years old -adult 125-5 mg in 3 cc of saline q 4-8 hours as needed
bull Levalbuterol (R-albuterol solution Xopinex)
ndashlt 5 years old 031 mg-125 mg in 3 cc NS q 4-6 hrs as needed
ndash5-11 yrs old 031-063 mg q 8 hours prn symptoms
ndashgt12 yrs old063mg-125 mg q 8 hours prn symptoms
DOS Wheezing protocol
59
DOS CME Course 2011
Treatment at home
bull Nebulizers convert liquid or powder medications to aerosolized formndash Effective to deliver larger doses than metered dose inhalers
Patient safety alert Some medications in powder formcome as a capsule which is broken open The patient should not take this medication orally
60
DOS CME Course 2011
How often
do the following
happen
MILD INTERMITTENT(check appropriate box)
MILD PERSISTENT
MODERATE PERSISTENT
SEVERE PERSISTENT
Daytime wheezingshortness of breath
0-2 times per week
Greater than 2 times per week
Daily Continually
Night-time wheezing shortness of breath
0-2 times per month
Greater than 2 times per month
Greater than 1 time per week
Frequent
How often are your physical activities limited by asthma
0-2 times per week
0-2 times per week
Greater than 2 times per week
Frequent
Daily use of albuterol or ldquorescue drugsrdquo
Less than 1 time per week or less than 3 times per month
2 time per week or more
Daily Use Frequent
DOS Wheezing protocol61
DOS CME Course 2011
Plan of carebull Step 1mdashmild intermittent
ndash no daily medication
ndash should have prn short acting rescue Beta 2 inhaler on hand
bull Step 2mdashmild persistentndash low dose inhaled corticosteroids
bull Step 3mdashmoderate persistentndash low to med inhaled corticosteroids and long acting beta 2 agonists
bull Step 4mdashsevere persistentndash high dose inhaled corticosteroids and long acting inhaled beta 2
agonists
DOS Wheezing protocol
62
DOS CME Course 2011
Ongoing carebull Plan Follow-up
ndash Evaluate 2-6 weeks after treatment initiationndash Evaluate every 1-6 months when stablendash Evaluate every 3 months interval after stepping down therapyndash Annual inactivated influenza vaccine
bull ConsultationReferralndash Life threatening or severe persistent asthmandash Goals of asthma therapy not fulfilled in 3-6 monthsndash Signs and symptoms are not typicalndash Sinusitis gastroesophageal reflux or chronic pulmonary disease
complicate the asthma
DOS Wheezing protocol
63
DOS CME Course 2011
Consults
bull Continuous oral corticosteroids or 2 bursts of oral steroids in 1 year
bull Patient under 3 years with step 3 or 4 asthma
bull If omalizumab (Xolair) is considered for treatment as there is an increase in rate of anaphylaxis with this medication
bull Exacerbation requiring hospitalization
DOS Wheezing protocol
64
DOS CME Course 2011
Patient educationbull Basic understanding of asthma and how the disease
works
bull Medications ndash Names and doses of all medications
ndash Short acting vs long acting
bull Equipment ndash Metered dose inhalers (MDI)
ndash Nebulizers
bull Emergency response
bull Activity level
bull Illness management
65
DOS CME Course 2011
Patient education
bull Know your triggers and have a strategy for avoidance
bull If mold or mites are known triggers humidifiers and evaporator coolers are not recommended in the home
bull Know the early signs of an exacerbation and what to do
bull Develop an action plan based on peak flow readings
bull What to do in case of an attack at school or work
66
DOS CME Course 2011
Patient educationbull Metered dose inhalers
ndash Remove cap and invert the device several times
ndash Exhale
ndash Place the mouthpiece between your lips with a good seal
ndash Inhale while depressing the top of the MDI
ndash Hold your breath for 10 seconds
ndash Exhale
ndash Repeat as needed
67
DOS CME Course 2011
Patient educationbull Spacers are used with MDIrsquos
used to deliver inhaled steroidsndash Ease coordination of breathing
and medication delivery
ndash Decrease the amount of medication contacting the oral mucosa
ndash Fewer side effects
bull Attach the spacer to the mouthpiece of the MDI ndash Use the MDI as described
before
ndash Some models have a whistle to indicate you are inhaling too rapidly
68
DOS CME Course 201169
DOS CME Course 2011
Characteristic Controlled
(All of the following)
Partly controlled
(Any measure noted)
Uncontrolled
Daytime symptoms
None (twice or less a week)
More than twice a week
Three or more features of partly controlled asthma
Limitation of activities
None Any
Nocturnal symptomsawakening
None Any
Need for rescue treatment
None (twice or less a week)
More than twice a week
Lung function (FEV1 or PEF)
Normal lt80 predicted or personal best
70
DOS CME Course 2011
Asthma
bull Self monitoring is essential to effective management and control
bull The following are validated tools to assess asthma control
ndashAsthmacontrolcom
ndashFree web-based
ndashQoltechcouk
ndashFree in hard copy or electronic versions
ndashRequires permission
ndashAtaqinstrumentcom
ndashFree web-based
71
DOS CME Course 2011DOS CME Course 201172
Every Life Deserves World Class Care
COPD
72
DOS CME Course 2011
Chronic obstructive pulmonary disease
bull By the numbers
bull 210 million suffer worldwide
bull 3 million fatalities
bull By 2030 COPD is expected to be the third leading cause of death worldwide
bull Most important risk factors ndash Smoking
ndash Indoor pollution
ndash Outdoor pollution
ndash Occupational irritants
WHO Retrieved January 2011
73
DOS CME Course 2011
COPD
bull Causes ndash Cigarette smoking is the number one cause worldwide
ndash Environmental irritants
ndash Genetic alpha-one antitrypsin deficiency
bull Birth defects ndash Low birth weight
ndash Respiratory infections
ndash Any factor which impairs lung development during gestation
bull Other ndash HIV
ndash Connective tissue disorders
ndash Vasculitis
74
DOS CME Course 2011
COPD
bull Sometimes referred to as umbrella term for a family of diseases which cause limited airflow
ndashChronic bronchitis
ndashEmphysema
bull Inflammation of the airways
bull Increased mucous productionndash Especially in bronchitis
bull Decreased ciliary function
bull Loss of elastic recoil ndash Especially in emphysema
75
DOS CME Course 2011
COPD
bull How inflammation ruins a lung
bull Cell mediated ndash Neutrophils
ndash Macrophages
ndash Lymphocytes
bull Release cytokines which attract more cells
bull Oxidants released by cells and found in cigarette smoke
bull Proteases
bull Cause remodeling and long term structural changes
76
DOS CME Course 2011
COPDbull Alveoli lose elasticity and become distended
ndashSaggy sacs
ndashCarbon dioxide retention
ndashChronic respiratory acidosis
bull Walls of the alveoli are degraded
ndashLoss of surface area necessary for gas exchange
77
DOS CME Course 2011
What the patient looks like
bull Productive Cough
ndashEspecially in chronic bronchitis
bull Progressive dyspnea
ndashUncomfortable awareness of breathing
bull Wheezing and chest tightness
bull Increase in AP chest diameter
ndashldquoBarrel chestrdquo especially in emphysema
ndashIncreased inspiratory effort loosens costochondral cartilage
78
DOS CME Course 2011
Alpha one antitrypsin deficiency
bull Enzyme normally produced which protects the lungs
bull Deactivates neutrophil elastase
ndashReleased during inflammation
bull Estimated over 100000 in US have AATD
bull Time to diagnosis gt8 years
bull Related to increased mortality (Krowka 2010)
ndashIncreased incidence of emphysema
79
DOS CME Course 2011
Chronic bronchitis
bull Presence of cough and sputum production over three months for two consecutive years
ndashNote the months need not be consecutive
bull The patient may feel as though they are constantly sick
bull Multiple courses of antibiotics with no improvement
bull No relationship to acute bronchitis caused by bacteria or virus
80
DOS CME Course 2011
COPD
bull Break out the testing ndash CXR
ndash ECG
ndash Sputum culture
ndash CBC and electrolytes
bull ABGrsquos ndash Respiratory failure indicated by
ndash PaO2lt 60 and SaO2 lt 90
ndash with or without PaCO2 gt 50
ndash On room air
ndash Severe acidosis pHlt 736 in addition to the above is an indication for mechanical ventilation
(GOLD 2009 p 22)
81
DOS CME Course 2011
Chronic bronchitis
bull Airway of a child afflicted with chronic bronchitis compared to normal
82
DOS CME Course 2011
Chronic bronchitisbull Related to mucociliary dysfunction
ndashIncreased mucous production and thickening
ndashLoss of cilia
ndashLoss of ciliary function
ndashMobility required to sweep out particles
83
DOS CME Course 2011
Emphysemabull Permanent enlargement of the airspaces terminal to the
distal bronchioles ndashLoss of surface area for gas exchangendashDestruction of supporting structure of alveoli
ndashAirway narrowing
bull Three distinct patterns ndashCentracinar begins centrally and spreads to terminal
bronchioles and is most closely associated with cigarette smoking
ndashPanacinar destroys alveoli uniformly predominant in lower half of lungs most closely associated with AATD
ndashParaseptal destroys the distal airway structures alveolar ducts and sacs
Demirjian BG 2010
84
DOS CME Course 2011
Bullaebull Outpouchingsballooning of lung tissue due to trapped air
ndashAir is released from damaged alveoli
ndashAsymptomatic
ndashRupture can cause pneumothorax
85
DOS CME Course 2011
Diagnosis
bull History of smoking or exposure to inhaled irritants
ndashRemember to consider work and living environment
ndashCooking indoors with fossil fuels
ndashAge over 40
bull Signs and symptoms
ndashChronic cough with sputum production
ndashDyspnea which persists daily worsens with exercise and progresses over time
bull Spirometry is strongly recommended
86
DOS CME Course 2011
Diagnosis
bull Chest x-ray
ndashRule out pneumonia cardiomyopathy
ndashNot diagnostic for COPD but may reveal other causes for symptoms
bull Arterial blood gases
ndashRecommended for patients with FEVlt 50
ndashPaO2lt 60 mmHg suggests respiratory failure
bull Sputum culture
ndashRule out infectious process
87
DOS CME Course 2011
Disease stages
bull Stage Indash FEVFVC lt 70
ndash FEV gt 80
ndash Few symptoms if any patient may be unaware
bull Stage II moderate ndash FEVFVC lt 70
ndash FEV lt 80
ndash Along with shortness of breath
88
DOS CME Course 2011
Disease stages
bull Stage IV very severe ndash FEVFVC lt 70
ndash FEV lt 30
ndash At this stage exacerbations are life-threatening
ndash Quality of life is impaired further
bull Stage III severe ndash FEVFVC lt 70
ndash FEV lt 50
ndash Worsening symptoms increasing frequency of exacerbations
89
DOS CME Course 2011
COPD vs Asthma
bull COPD
ndashOnset later in life
ndashProgressive worsening symptoms
ndashSmoking history
ndashDyspnea with exercise
ndashLargely irreversible airflow limitation
bull Asthma
ndashOnset of symptoms usually earlier in life
ndashWorsening at night
ndashLargely reversible airflow limitation
ndashSymptoms vary from day to day
90
DOS CME Course 2011
COPD Treatmentbull Now that we have diagnosis what do I do about it
bull Assess and monitor diseasendash Assess for risk factors ie smoking family history
ndash Co-morbidities such as heart failure
ndash Pattern of symptoms
ndash Impact on quality of life
bull Reduce risk factors ndash Identify environmentaloccupational factors which can be modified
ndash Smoking cessation is essential
ndash Manage exacerbations
91
DOS CME Course 2011
COPDbull Manage stable COPD
ndash Determine disease severity based on frequency and severity of symptoms
ndash Educate the patient about risk factors and disease management regimen
ndash Collaborate with the patient to develop a personalized regimen
ndashFits their lifestyle
ndashAccounts for cultural preferences family involvement
ndashAvailability of testing and medications
92
DOS CME Course 2011
Pharmacologybull Goals
ndash Improve exercise tolerance
ndash Control symptoms
ndash Reduce frequency and severity of exacerbations
ndash Improve health status
bull Bronchodilators ndash Include long-acting therapy with short-acting for better control
bull Combine medications from different classes rather than increasing dosage of just onendash Minimizes side effects
93
DOS CME Course 2011
Pharmacologybull Glucocorticosteroids
ndashCan reduce the number of exacerbations
ndashIncreased risk of pneumonia
ndashNo noted reduction in mortality
bull Vaccines
ndashInfluenza vaccines decrease serious illness and death by 50
ndashRecommended annually
ndashPneumococcal vaccines recommended for all COPD sufferers even under age 65
GOLD 2009
94
DOS CME Course 2011
Antibiotics
bull Antibiotics are not a treatment for COPD nor do they manage symptoms of an exacerbation
bull Should be given only if the following are metndash Presence of three cardinal symptoms increased dyspnea
increased sputum volume increased sputum purulence
ndash Increased sputum purulence plus one other cardinal symptom
ndash Mechanically ventilated
bull May be difficult for patients to understand why antibiotics will not ldquofixrdquo what is wrong
bull Good opportunity for learning needs assessment
GOLD 2009
95
DOS CME Course 2011
COPD
bull Pulmonary rehabilitation
bull Encourage the patient to continue activities as tolerated ndash Move as much as you can before you canrsquot move
bull Uses low impact exercise to maintain physical function
bull Exercise can be done while seatedndash Monitor pulse oximetry respiratory rate and effort before during
and after activity
bull Set goals which are realistic for both of you
96
DOS CME Course 2011
COPD
bull Pulmonary rehab includes education nutrition and exercise
bull Can be a good source of social support for someone who has seen function decline
ndashTalk with others in the same situation
ndashFind out how they cope
ndashSocialize
bull Regular influenza and pneumonia vaccines
97
DOS CME Course 2011
COPD
bull Oxygen therapy
bull Recommended for stage IV disease ndash PaO2 lt or = 55 mmHg
ndash SaO2 lt or = 88
bull Increases survival improves hemodynamicsbenefits mental state
bull Surgical options reviewed on a case-by-case basisndash Bullectomy
ndash Lung volume reduction ndashNo evidence to support this as a widespread therapy
98
DOS CME Course 2011
COPD
bull Managing exacerbations
bull An event in the natural course of the disease characterized by a change in baseline dyspnea cough or sputum beyond day to day variance is acute in onset and may warrant a change in medication
bull Air pollution and tracheobronchial infections are the most common causes
bull 30 of exacerbations no cause identified
(GOLD 2009 p 22)
99
DOS CME Course 2011
COPD
bull Hospitalization is recommended for patients exhibiting the following
ndash Failure of exacerbation to respond to medical treatment
ndash Development of new symptoms ie peripheral edema cyanosis
ndash Significant co-morbidities
ndash History of frequent exacerbations
ndash Newly occurring arrhythmias
ndash Advanced age
ndash Insufficient home support
ndash Unclear diagnosis
(GOLD 2009 p 23)
100
DOS CME Course 2011
COPD
bull Mechanical ventilation is not recognized as an effective management strategy for stable COPD
bull May be required as supportive therapy during an exacerbation
bull Associated with mortality
bull Carries risks of its ownndash Ventilator acquired pneumonia
ndash Ventilator induced lung injury
ndash Failure to wean
(GOLD 2009)
101
DOS CME Course 2011DOS CME Course 2011102
Every Life Deserves World Class Care
Smoking
102
DOS CME Course 2011
Smoking bull By the numbers
bull More than 400 000 Americans die from smoking-related illnesses each yearndash Thatrsquos one of every 5 deaths
bull In a study of 2963 health care encounters smoking was discussed 633 times
bull Nicotine released into the body within 10 seconds of inhalation
bull If a person smokes one pack per day and takes ten puffs of each cigarette that equates to 200 ldquohitsrdquo of nicotine daily
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
103
DOS CME Course 2011
Nicotine
bull Nicotinic receptors occur naturally
bull N1 receptors in the adrenal medulla
bull Neuromuscular junction of autonomic ganglia
bull N2 receptors in skeletal muscle
bull Number of receptor sites increases with regular stimulation
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
104
DOS CME Course 2011
Nicotinebull Addictive
bull Vasoconstrictor
bull Releases adrenaline from the adrenal cortex
ndashFeeling of increased energy
bull Releases dopamine to produce feelings of well-beingndash Actually improves memory and cognition
bull Sensitivity actually declines overnight
bull Release of insulinndash Slightly hyperglycemic
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
105
DOS CME Course 2011
Genetic componentbull About 10 of smokers lack the gene for nicotine
dependence
ndashldquosocial or occasionalrdquo smokers
ndashThey really can quit anytime they want to
ndashNo withdrawal symptoms
ndashStill poses a health risk
bull The other 90 will demonstrate physical and psychological symptoms of withdrawal
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
106
DOS CME Course 2011
Smoking
bull Identify tobacco users ndash Ask every patient every visit
ndash Have you used tobacco in the last 12 months
ndash Clinic-wide program
bull Advise every tobacco user to quitndash Personalize the message
ndash Be clear
ndash Be firm
If at first you donrsquot succeed try tryagain Bring it up at every encounter
107
DOS CME Course 2011
Smoking cessationbull Some more good reasons to quit
ndashSmoking costs over $2000 a year in current US dollars
ndashThere is no accepted safe level of cigarette smoke
ndashSecondhand smoke carries the same hazards
ndashIncreased risk of SIDS and asthma exacerbations in children
httpwwwlungusaorgstop-smokingabout-smokingfacts-figuresgeneral-smoking-factshtml
108
DOS CME Course 2011
Smoking cessation
bull Nicotine is a powerful drug addiction
bull Treat as a chronic illness
bull All healthcare providers encouraged to participate
bull Assess willingness to quit
bull Promote motivation
109
DOS CME Course 2011
Smoking cessation
bull Prochaskarsquos change theory
bull Precontemplation
ndashNot even thinking about quitting
ndashProvide education on the risks and costs of smoking
bull Contemplation
ndashAwareness that a problem exists
ndashContinue to find motivations to stop
NorcrossJC Krebs PM Prochaska JO(2011)
110
DOS CME Course 2011
Change is good
bull Determination
ndashExpressing willingness to act
ndashSelf-efficacy
bull Action ndash Currently not smoking
ndash May relapse
bull It is not unusual for a patient to ldquoquitrdquo three or four times
bull Continue to encourage and motivate himher to stop
NorcrossJC Krebs PM Prochaska JO(2011)
111
DOS CME Course 2011
Smoking cessationbull Assist the patient
ndashCollaborate with the patient to develop a plan to quit
ndashAchievable clearly defined goals
ndashIdentify and engage social supports
ndashFamily support groups
ndashPharmacologic (more on this later)
bull Arrange follow-up
ndashAt each successive visit review progress on quitting strategy
ndashLets the patient know heshe is not alone in this effort
ndashAccountability
112
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
Asthma
bull Pharmacologic management
bull Stepwise approach
bull Reduce impairmentndash Prevent chronic symptoms
ndash Require 2 days or lessweek of short-acting beta agonists
ndash Maintain normal activities
ndash Maintain normal lung function
ndash Meet patient and family expectations of care
bull Reduce riskndash Prevent emergency hospitalizations
ndash Avoid adverse drug reactions
NHLBI 2007
51
DOS CME Course 2011
Pharmacology bull Beta-2 adrenergic agonists
ndashBronchodilators-smooth muscle relaxants
ndashSympathomimetic
ndashShort acting ndashalbuterolterbutalinelevalbuterol
ndashUse of short acting before exercise to improve tolerance
ndashLong acting (LABA)ndashSalmeterol formoterol
bull Side effects include
ndash tachycardia tremor hypokalemia hyperglycemia HA dizziness
52
DOS CME Course 2011
Pharmacology
bull Methylxanthines (theophylline)ndash Smooth muscle relaxants
ndashPO PR IV
bull Side effects ndash nausea irritability tachycardia dysrrhythmia seizures brain
damage death
bull Theophylline causes concern because the therapeutic and toxic ranges overlapndash Monitor after initiation with any dose increases or signs of toxicity
(Micromedex 2010)
53
DOS CME Course 2011
Pharmacology
bull Inhaled glucocorticosteroid (ICS)
ndashDecrease swelling due to inflammation
ndashBeclomethasone budesonide fluticasone triamcinolone
ndashSide effects oral candidiasis dry mouth hoarseness hypersensitivity
ndashOnset of effects 10-20 minutes
ndashRecommend using a spacer
54
DOS CME Course 2011
Pharmacologybull Leukotriene modifiers
ndash Disrupt the function or synthesis of inflammatory mediators related to asthma
ndashMontelukast zafirlukast zileuton
bull Long-term control
bull Side effects elevation of liver enzymes HA dizziness GI distress
bull Mast cell stabilizersndash Cromolyn sodium nedocromil
ndash Inhibit release of inflammatory mediators
ndash Side effects bronchospasm pharyngeal irritation
55
DOS CME Course 2011
Pharmacology
bull Anticholinergics chemically related to atropine
ndashIpratropium bromide (Atrovent)
ndashInhaled form as rescue therapy
bull Side effects
ndashurinary obstruction HA restlessness palpitations bronchospasm
56
DOS CME Course 2011
The big guns
bull Systemic corticosteroidsndash Methylprednisolone hydrocortisone dexamethasone
ndash IV or PO
ndash Treatment of acute exacerbations
bull Side effects ndash adrenal suppression weight gain fluid retention hyperglycemia
ndash Long term
ndash osteoporosis immune suppression gastric ulcers
57
DOS CME Course 2011
Right here and now
bull Nursing Intervention
bull Quick Relief
bull Short acting bronchodilator ndash Up to 3 treatments at 20 minute intervals
bull Or single nebulizer treatment
bull Course of systemic corticosteroids may be needed
DOS Wheezing protocol
58
DOS CME Course 2011
Nebulizer Treatment
bull Albuterol Solution
ndashlt5 years old 063-25 mg in 3 cc of saline q 4-6 hours as needed
ndashgt5 years old -adult 125-5 mg in 3 cc of saline q 4-8 hours as needed
bull Levalbuterol (R-albuterol solution Xopinex)
ndashlt 5 years old 031 mg-125 mg in 3 cc NS q 4-6 hrs as needed
ndash5-11 yrs old 031-063 mg q 8 hours prn symptoms
ndashgt12 yrs old063mg-125 mg q 8 hours prn symptoms
DOS Wheezing protocol
59
DOS CME Course 2011
Treatment at home
bull Nebulizers convert liquid or powder medications to aerosolized formndash Effective to deliver larger doses than metered dose inhalers
Patient safety alert Some medications in powder formcome as a capsule which is broken open The patient should not take this medication orally
60
DOS CME Course 2011
How often
do the following
happen
MILD INTERMITTENT(check appropriate box)
MILD PERSISTENT
MODERATE PERSISTENT
SEVERE PERSISTENT
Daytime wheezingshortness of breath
0-2 times per week
Greater than 2 times per week
Daily Continually
Night-time wheezing shortness of breath
0-2 times per month
Greater than 2 times per month
Greater than 1 time per week
Frequent
How often are your physical activities limited by asthma
0-2 times per week
0-2 times per week
Greater than 2 times per week
Frequent
Daily use of albuterol or ldquorescue drugsrdquo
Less than 1 time per week or less than 3 times per month
2 time per week or more
Daily Use Frequent
DOS Wheezing protocol61
DOS CME Course 2011
Plan of carebull Step 1mdashmild intermittent
ndash no daily medication
ndash should have prn short acting rescue Beta 2 inhaler on hand
bull Step 2mdashmild persistentndash low dose inhaled corticosteroids
bull Step 3mdashmoderate persistentndash low to med inhaled corticosteroids and long acting beta 2 agonists
bull Step 4mdashsevere persistentndash high dose inhaled corticosteroids and long acting inhaled beta 2
agonists
DOS Wheezing protocol
62
DOS CME Course 2011
Ongoing carebull Plan Follow-up
ndash Evaluate 2-6 weeks after treatment initiationndash Evaluate every 1-6 months when stablendash Evaluate every 3 months interval after stepping down therapyndash Annual inactivated influenza vaccine
bull ConsultationReferralndash Life threatening or severe persistent asthmandash Goals of asthma therapy not fulfilled in 3-6 monthsndash Signs and symptoms are not typicalndash Sinusitis gastroesophageal reflux or chronic pulmonary disease
complicate the asthma
DOS Wheezing protocol
63
DOS CME Course 2011
Consults
bull Continuous oral corticosteroids or 2 bursts of oral steroids in 1 year
bull Patient under 3 years with step 3 or 4 asthma
bull If omalizumab (Xolair) is considered for treatment as there is an increase in rate of anaphylaxis with this medication
bull Exacerbation requiring hospitalization
DOS Wheezing protocol
64
DOS CME Course 2011
Patient educationbull Basic understanding of asthma and how the disease
works
bull Medications ndash Names and doses of all medications
ndash Short acting vs long acting
bull Equipment ndash Metered dose inhalers (MDI)
ndash Nebulizers
bull Emergency response
bull Activity level
bull Illness management
65
DOS CME Course 2011
Patient education
bull Know your triggers and have a strategy for avoidance
bull If mold or mites are known triggers humidifiers and evaporator coolers are not recommended in the home
bull Know the early signs of an exacerbation and what to do
bull Develop an action plan based on peak flow readings
bull What to do in case of an attack at school or work
66
DOS CME Course 2011
Patient educationbull Metered dose inhalers
ndash Remove cap and invert the device several times
ndash Exhale
ndash Place the mouthpiece between your lips with a good seal
ndash Inhale while depressing the top of the MDI
ndash Hold your breath for 10 seconds
ndash Exhale
ndash Repeat as needed
67
DOS CME Course 2011
Patient educationbull Spacers are used with MDIrsquos
used to deliver inhaled steroidsndash Ease coordination of breathing
and medication delivery
ndash Decrease the amount of medication contacting the oral mucosa
ndash Fewer side effects
bull Attach the spacer to the mouthpiece of the MDI ndash Use the MDI as described
before
ndash Some models have a whistle to indicate you are inhaling too rapidly
68
DOS CME Course 201169
DOS CME Course 2011
Characteristic Controlled
(All of the following)
Partly controlled
(Any measure noted)
Uncontrolled
Daytime symptoms
None (twice or less a week)
More than twice a week
Three or more features of partly controlled asthma
Limitation of activities
None Any
Nocturnal symptomsawakening
None Any
Need for rescue treatment
None (twice or less a week)
More than twice a week
Lung function (FEV1 or PEF)
Normal lt80 predicted or personal best
70
DOS CME Course 2011
Asthma
bull Self monitoring is essential to effective management and control
bull The following are validated tools to assess asthma control
ndashAsthmacontrolcom
ndashFree web-based
ndashQoltechcouk
ndashFree in hard copy or electronic versions
ndashRequires permission
ndashAtaqinstrumentcom
ndashFree web-based
71
DOS CME Course 2011DOS CME Course 201172
Every Life Deserves World Class Care
COPD
72
DOS CME Course 2011
Chronic obstructive pulmonary disease
bull By the numbers
bull 210 million suffer worldwide
bull 3 million fatalities
bull By 2030 COPD is expected to be the third leading cause of death worldwide
bull Most important risk factors ndash Smoking
ndash Indoor pollution
ndash Outdoor pollution
ndash Occupational irritants
WHO Retrieved January 2011
73
DOS CME Course 2011
COPD
bull Causes ndash Cigarette smoking is the number one cause worldwide
ndash Environmental irritants
ndash Genetic alpha-one antitrypsin deficiency
bull Birth defects ndash Low birth weight
ndash Respiratory infections
ndash Any factor which impairs lung development during gestation
bull Other ndash HIV
ndash Connective tissue disorders
ndash Vasculitis
74
DOS CME Course 2011
COPD
bull Sometimes referred to as umbrella term for a family of diseases which cause limited airflow
ndashChronic bronchitis
ndashEmphysema
bull Inflammation of the airways
bull Increased mucous productionndash Especially in bronchitis
bull Decreased ciliary function
bull Loss of elastic recoil ndash Especially in emphysema
75
DOS CME Course 2011
COPD
bull How inflammation ruins a lung
bull Cell mediated ndash Neutrophils
ndash Macrophages
ndash Lymphocytes
bull Release cytokines which attract more cells
bull Oxidants released by cells and found in cigarette smoke
bull Proteases
bull Cause remodeling and long term structural changes
76
DOS CME Course 2011
COPDbull Alveoli lose elasticity and become distended
ndashSaggy sacs
ndashCarbon dioxide retention
ndashChronic respiratory acidosis
bull Walls of the alveoli are degraded
ndashLoss of surface area necessary for gas exchange
77
DOS CME Course 2011
What the patient looks like
bull Productive Cough
ndashEspecially in chronic bronchitis
bull Progressive dyspnea
ndashUncomfortable awareness of breathing
bull Wheezing and chest tightness
bull Increase in AP chest diameter
ndashldquoBarrel chestrdquo especially in emphysema
ndashIncreased inspiratory effort loosens costochondral cartilage
78
DOS CME Course 2011
Alpha one antitrypsin deficiency
bull Enzyme normally produced which protects the lungs
bull Deactivates neutrophil elastase
ndashReleased during inflammation
bull Estimated over 100000 in US have AATD
bull Time to diagnosis gt8 years
bull Related to increased mortality (Krowka 2010)
ndashIncreased incidence of emphysema
79
DOS CME Course 2011
Chronic bronchitis
bull Presence of cough and sputum production over three months for two consecutive years
ndashNote the months need not be consecutive
bull The patient may feel as though they are constantly sick
bull Multiple courses of antibiotics with no improvement
bull No relationship to acute bronchitis caused by bacteria or virus
80
DOS CME Course 2011
COPD
bull Break out the testing ndash CXR
ndash ECG
ndash Sputum culture
ndash CBC and electrolytes
bull ABGrsquos ndash Respiratory failure indicated by
ndash PaO2lt 60 and SaO2 lt 90
ndash with or without PaCO2 gt 50
ndash On room air
ndash Severe acidosis pHlt 736 in addition to the above is an indication for mechanical ventilation
(GOLD 2009 p 22)
81
DOS CME Course 2011
Chronic bronchitis
bull Airway of a child afflicted with chronic bronchitis compared to normal
82
DOS CME Course 2011
Chronic bronchitisbull Related to mucociliary dysfunction
ndashIncreased mucous production and thickening
ndashLoss of cilia
ndashLoss of ciliary function
ndashMobility required to sweep out particles
83
DOS CME Course 2011
Emphysemabull Permanent enlargement of the airspaces terminal to the
distal bronchioles ndashLoss of surface area for gas exchangendashDestruction of supporting structure of alveoli
ndashAirway narrowing
bull Three distinct patterns ndashCentracinar begins centrally and spreads to terminal
bronchioles and is most closely associated with cigarette smoking
ndashPanacinar destroys alveoli uniformly predominant in lower half of lungs most closely associated with AATD
ndashParaseptal destroys the distal airway structures alveolar ducts and sacs
Demirjian BG 2010
84
DOS CME Course 2011
Bullaebull Outpouchingsballooning of lung tissue due to trapped air
ndashAir is released from damaged alveoli
ndashAsymptomatic
ndashRupture can cause pneumothorax
85
DOS CME Course 2011
Diagnosis
bull History of smoking or exposure to inhaled irritants
ndashRemember to consider work and living environment
ndashCooking indoors with fossil fuels
ndashAge over 40
bull Signs and symptoms
ndashChronic cough with sputum production
ndashDyspnea which persists daily worsens with exercise and progresses over time
bull Spirometry is strongly recommended
86
DOS CME Course 2011
Diagnosis
bull Chest x-ray
ndashRule out pneumonia cardiomyopathy
ndashNot diagnostic for COPD but may reveal other causes for symptoms
bull Arterial blood gases
ndashRecommended for patients with FEVlt 50
ndashPaO2lt 60 mmHg suggests respiratory failure
bull Sputum culture
ndashRule out infectious process
87
DOS CME Course 2011
Disease stages
bull Stage Indash FEVFVC lt 70
ndash FEV gt 80
ndash Few symptoms if any patient may be unaware
bull Stage II moderate ndash FEVFVC lt 70
ndash FEV lt 80
ndash Along with shortness of breath
88
DOS CME Course 2011
Disease stages
bull Stage IV very severe ndash FEVFVC lt 70
ndash FEV lt 30
ndash At this stage exacerbations are life-threatening
ndash Quality of life is impaired further
bull Stage III severe ndash FEVFVC lt 70
ndash FEV lt 50
ndash Worsening symptoms increasing frequency of exacerbations
89
DOS CME Course 2011
COPD vs Asthma
bull COPD
ndashOnset later in life
ndashProgressive worsening symptoms
ndashSmoking history
ndashDyspnea with exercise
ndashLargely irreversible airflow limitation
bull Asthma
ndashOnset of symptoms usually earlier in life
ndashWorsening at night
ndashLargely reversible airflow limitation
ndashSymptoms vary from day to day
90
DOS CME Course 2011
COPD Treatmentbull Now that we have diagnosis what do I do about it
bull Assess and monitor diseasendash Assess for risk factors ie smoking family history
ndash Co-morbidities such as heart failure
ndash Pattern of symptoms
ndash Impact on quality of life
bull Reduce risk factors ndash Identify environmentaloccupational factors which can be modified
ndash Smoking cessation is essential
ndash Manage exacerbations
91
DOS CME Course 2011
COPDbull Manage stable COPD
ndash Determine disease severity based on frequency and severity of symptoms
ndash Educate the patient about risk factors and disease management regimen
ndash Collaborate with the patient to develop a personalized regimen
ndashFits their lifestyle
ndashAccounts for cultural preferences family involvement
ndashAvailability of testing and medications
92
DOS CME Course 2011
Pharmacologybull Goals
ndash Improve exercise tolerance
ndash Control symptoms
ndash Reduce frequency and severity of exacerbations
ndash Improve health status
bull Bronchodilators ndash Include long-acting therapy with short-acting for better control
bull Combine medications from different classes rather than increasing dosage of just onendash Minimizes side effects
93
DOS CME Course 2011
Pharmacologybull Glucocorticosteroids
ndashCan reduce the number of exacerbations
ndashIncreased risk of pneumonia
ndashNo noted reduction in mortality
bull Vaccines
ndashInfluenza vaccines decrease serious illness and death by 50
ndashRecommended annually
ndashPneumococcal vaccines recommended for all COPD sufferers even under age 65
GOLD 2009
94
DOS CME Course 2011
Antibiotics
bull Antibiotics are not a treatment for COPD nor do they manage symptoms of an exacerbation
bull Should be given only if the following are metndash Presence of three cardinal symptoms increased dyspnea
increased sputum volume increased sputum purulence
ndash Increased sputum purulence plus one other cardinal symptom
ndash Mechanically ventilated
bull May be difficult for patients to understand why antibiotics will not ldquofixrdquo what is wrong
bull Good opportunity for learning needs assessment
GOLD 2009
95
DOS CME Course 2011
COPD
bull Pulmonary rehabilitation
bull Encourage the patient to continue activities as tolerated ndash Move as much as you can before you canrsquot move
bull Uses low impact exercise to maintain physical function
bull Exercise can be done while seatedndash Monitor pulse oximetry respiratory rate and effort before during
and after activity
bull Set goals which are realistic for both of you
96
DOS CME Course 2011
COPD
bull Pulmonary rehab includes education nutrition and exercise
bull Can be a good source of social support for someone who has seen function decline
ndashTalk with others in the same situation
ndashFind out how they cope
ndashSocialize
bull Regular influenza and pneumonia vaccines
97
DOS CME Course 2011
COPD
bull Oxygen therapy
bull Recommended for stage IV disease ndash PaO2 lt or = 55 mmHg
ndash SaO2 lt or = 88
bull Increases survival improves hemodynamicsbenefits mental state
bull Surgical options reviewed on a case-by-case basisndash Bullectomy
ndash Lung volume reduction ndashNo evidence to support this as a widespread therapy
98
DOS CME Course 2011
COPD
bull Managing exacerbations
bull An event in the natural course of the disease characterized by a change in baseline dyspnea cough or sputum beyond day to day variance is acute in onset and may warrant a change in medication
bull Air pollution and tracheobronchial infections are the most common causes
bull 30 of exacerbations no cause identified
(GOLD 2009 p 22)
99
DOS CME Course 2011
COPD
bull Hospitalization is recommended for patients exhibiting the following
ndash Failure of exacerbation to respond to medical treatment
ndash Development of new symptoms ie peripheral edema cyanosis
ndash Significant co-morbidities
ndash History of frequent exacerbations
ndash Newly occurring arrhythmias
ndash Advanced age
ndash Insufficient home support
ndash Unclear diagnosis
(GOLD 2009 p 23)
100
DOS CME Course 2011
COPD
bull Mechanical ventilation is not recognized as an effective management strategy for stable COPD
bull May be required as supportive therapy during an exacerbation
bull Associated with mortality
bull Carries risks of its ownndash Ventilator acquired pneumonia
ndash Ventilator induced lung injury
ndash Failure to wean
(GOLD 2009)
101
DOS CME Course 2011DOS CME Course 2011102
Every Life Deserves World Class Care
Smoking
102
DOS CME Course 2011
Smoking bull By the numbers
bull More than 400 000 Americans die from smoking-related illnesses each yearndash Thatrsquos one of every 5 deaths
bull In a study of 2963 health care encounters smoking was discussed 633 times
bull Nicotine released into the body within 10 seconds of inhalation
bull If a person smokes one pack per day and takes ten puffs of each cigarette that equates to 200 ldquohitsrdquo of nicotine daily
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
103
DOS CME Course 2011
Nicotine
bull Nicotinic receptors occur naturally
bull N1 receptors in the adrenal medulla
bull Neuromuscular junction of autonomic ganglia
bull N2 receptors in skeletal muscle
bull Number of receptor sites increases with regular stimulation
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
104
DOS CME Course 2011
Nicotinebull Addictive
bull Vasoconstrictor
bull Releases adrenaline from the adrenal cortex
ndashFeeling of increased energy
bull Releases dopamine to produce feelings of well-beingndash Actually improves memory and cognition
bull Sensitivity actually declines overnight
bull Release of insulinndash Slightly hyperglycemic
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
105
DOS CME Course 2011
Genetic componentbull About 10 of smokers lack the gene for nicotine
dependence
ndashldquosocial or occasionalrdquo smokers
ndashThey really can quit anytime they want to
ndashNo withdrawal symptoms
ndashStill poses a health risk
bull The other 90 will demonstrate physical and psychological symptoms of withdrawal
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
106
DOS CME Course 2011
Smoking
bull Identify tobacco users ndash Ask every patient every visit
ndash Have you used tobacco in the last 12 months
ndash Clinic-wide program
bull Advise every tobacco user to quitndash Personalize the message
ndash Be clear
ndash Be firm
If at first you donrsquot succeed try tryagain Bring it up at every encounter
107
DOS CME Course 2011
Smoking cessationbull Some more good reasons to quit
ndashSmoking costs over $2000 a year in current US dollars
ndashThere is no accepted safe level of cigarette smoke
ndashSecondhand smoke carries the same hazards
ndashIncreased risk of SIDS and asthma exacerbations in children
httpwwwlungusaorgstop-smokingabout-smokingfacts-figuresgeneral-smoking-factshtml
108
DOS CME Course 2011
Smoking cessation
bull Nicotine is a powerful drug addiction
bull Treat as a chronic illness
bull All healthcare providers encouraged to participate
bull Assess willingness to quit
bull Promote motivation
109
DOS CME Course 2011
Smoking cessation
bull Prochaskarsquos change theory
bull Precontemplation
ndashNot even thinking about quitting
ndashProvide education on the risks and costs of smoking
bull Contemplation
ndashAwareness that a problem exists
ndashContinue to find motivations to stop
NorcrossJC Krebs PM Prochaska JO(2011)
110
DOS CME Course 2011
Change is good
bull Determination
ndashExpressing willingness to act
ndashSelf-efficacy
bull Action ndash Currently not smoking
ndash May relapse
bull It is not unusual for a patient to ldquoquitrdquo three or four times
bull Continue to encourage and motivate himher to stop
NorcrossJC Krebs PM Prochaska JO(2011)
111
DOS CME Course 2011
Smoking cessationbull Assist the patient
ndashCollaborate with the patient to develop a plan to quit
ndashAchievable clearly defined goals
ndashIdentify and engage social supports
ndashFamily support groups
ndashPharmacologic (more on this later)
bull Arrange follow-up
ndashAt each successive visit review progress on quitting strategy
ndashLets the patient know heshe is not alone in this effort
ndashAccountability
112
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
Pharmacology
bull Methylxanthines (theophylline)ndash Smooth muscle relaxants
ndashPO PR IV
bull Side effects ndash nausea irritability tachycardia dysrrhythmia seizures brain
damage death
bull Theophylline causes concern because the therapeutic and toxic ranges overlapndash Monitor after initiation with any dose increases or signs of toxicity
(Micromedex 2010)
53
DOS CME Course 2011
Pharmacology
bull Inhaled glucocorticosteroid (ICS)
ndashDecrease swelling due to inflammation
ndashBeclomethasone budesonide fluticasone triamcinolone
ndashSide effects oral candidiasis dry mouth hoarseness hypersensitivity
ndashOnset of effects 10-20 minutes
ndashRecommend using a spacer
54
DOS CME Course 2011
Pharmacologybull Leukotriene modifiers
ndash Disrupt the function or synthesis of inflammatory mediators related to asthma
ndashMontelukast zafirlukast zileuton
bull Long-term control
bull Side effects elevation of liver enzymes HA dizziness GI distress
bull Mast cell stabilizersndash Cromolyn sodium nedocromil
ndash Inhibit release of inflammatory mediators
ndash Side effects bronchospasm pharyngeal irritation
55
DOS CME Course 2011
Pharmacology
bull Anticholinergics chemically related to atropine
ndashIpratropium bromide (Atrovent)
ndashInhaled form as rescue therapy
bull Side effects
ndashurinary obstruction HA restlessness palpitations bronchospasm
56
DOS CME Course 2011
The big guns
bull Systemic corticosteroidsndash Methylprednisolone hydrocortisone dexamethasone
ndash IV or PO
ndash Treatment of acute exacerbations
bull Side effects ndash adrenal suppression weight gain fluid retention hyperglycemia
ndash Long term
ndash osteoporosis immune suppression gastric ulcers
57
DOS CME Course 2011
Right here and now
bull Nursing Intervention
bull Quick Relief
bull Short acting bronchodilator ndash Up to 3 treatments at 20 minute intervals
bull Or single nebulizer treatment
bull Course of systemic corticosteroids may be needed
DOS Wheezing protocol
58
DOS CME Course 2011
Nebulizer Treatment
bull Albuterol Solution
ndashlt5 years old 063-25 mg in 3 cc of saline q 4-6 hours as needed
ndashgt5 years old -adult 125-5 mg in 3 cc of saline q 4-8 hours as needed
bull Levalbuterol (R-albuterol solution Xopinex)
ndashlt 5 years old 031 mg-125 mg in 3 cc NS q 4-6 hrs as needed
ndash5-11 yrs old 031-063 mg q 8 hours prn symptoms
ndashgt12 yrs old063mg-125 mg q 8 hours prn symptoms
DOS Wheezing protocol
59
DOS CME Course 2011
Treatment at home
bull Nebulizers convert liquid or powder medications to aerosolized formndash Effective to deliver larger doses than metered dose inhalers
Patient safety alert Some medications in powder formcome as a capsule which is broken open The patient should not take this medication orally
60
DOS CME Course 2011
How often
do the following
happen
MILD INTERMITTENT(check appropriate box)
MILD PERSISTENT
MODERATE PERSISTENT
SEVERE PERSISTENT
Daytime wheezingshortness of breath
0-2 times per week
Greater than 2 times per week
Daily Continually
Night-time wheezing shortness of breath
0-2 times per month
Greater than 2 times per month
Greater than 1 time per week
Frequent
How often are your physical activities limited by asthma
0-2 times per week
0-2 times per week
Greater than 2 times per week
Frequent
Daily use of albuterol or ldquorescue drugsrdquo
Less than 1 time per week or less than 3 times per month
2 time per week or more
Daily Use Frequent
DOS Wheezing protocol61
DOS CME Course 2011
Plan of carebull Step 1mdashmild intermittent
ndash no daily medication
ndash should have prn short acting rescue Beta 2 inhaler on hand
bull Step 2mdashmild persistentndash low dose inhaled corticosteroids
bull Step 3mdashmoderate persistentndash low to med inhaled corticosteroids and long acting beta 2 agonists
bull Step 4mdashsevere persistentndash high dose inhaled corticosteroids and long acting inhaled beta 2
agonists
DOS Wheezing protocol
62
DOS CME Course 2011
Ongoing carebull Plan Follow-up
ndash Evaluate 2-6 weeks after treatment initiationndash Evaluate every 1-6 months when stablendash Evaluate every 3 months interval after stepping down therapyndash Annual inactivated influenza vaccine
bull ConsultationReferralndash Life threatening or severe persistent asthmandash Goals of asthma therapy not fulfilled in 3-6 monthsndash Signs and symptoms are not typicalndash Sinusitis gastroesophageal reflux or chronic pulmonary disease
complicate the asthma
DOS Wheezing protocol
63
DOS CME Course 2011
Consults
bull Continuous oral corticosteroids or 2 bursts of oral steroids in 1 year
bull Patient under 3 years with step 3 or 4 asthma
bull If omalizumab (Xolair) is considered for treatment as there is an increase in rate of anaphylaxis with this medication
bull Exacerbation requiring hospitalization
DOS Wheezing protocol
64
DOS CME Course 2011
Patient educationbull Basic understanding of asthma and how the disease
works
bull Medications ndash Names and doses of all medications
ndash Short acting vs long acting
bull Equipment ndash Metered dose inhalers (MDI)
ndash Nebulizers
bull Emergency response
bull Activity level
bull Illness management
65
DOS CME Course 2011
Patient education
bull Know your triggers and have a strategy for avoidance
bull If mold or mites are known triggers humidifiers and evaporator coolers are not recommended in the home
bull Know the early signs of an exacerbation and what to do
bull Develop an action plan based on peak flow readings
bull What to do in case of an attack at school or work
66
DOS CME Course 2011
Patient educationbull Metered dose inhalers
ndash Remove cap and invert the device several times
ndash Exhale
ndash Place the mouthpiece between your lips with a good seal
ndash Inhale while depressing the top of the MDI
ndash Hold your breath for 10 seconds
ndash Exhale
ndash Repeat as needed
67
DOS CME Course 2011
Patient educationbull Spacers are used with MDIrsquos
used to deliver inhaled steroidsndash Ease coordination of breathing
and medication delivery
ndash Decrease the amount of medication contacting the oral mucosa
ndash Fewer side effects
bull Attach the spacer to the mouthpiece of the MDI ndash Use the MDI as described
before
ndash Some models have a whistle to indicate you are inhaling too rapidly
68
DOS CME Course 201169
DOS CME Course 2011
Characteristic Controlled
(All of the following)
Partly controlled
(Any measure noted)
Uncontrolled
Daytime symptoms
None (twice or less a week)
More than twice a week
Three or more features of partly controlled asthma
Limitation of activities
None Any
Nocturnal symptomsawakening
None Any
Need for rescue treatment
None (twice or less a week)
More than twice a week
Lung function (FEV1 or PEF)
Normal lt80 predicted or personal best
70
DOS CME Course 2011
Asthma
bull Self monitoring is essential to effective management and control
bull The following are validated tools to assess asthma control
ndashAsthmacontrolcom
ndashFree web-based
ndashQoltechcouk
ndashFree in hard copy or electronic versions
ndashRequires permission
ndashAtaqinstrumentcom
ndashFree web-based
71
DOS CME Course 2011DOS CME Course 201172
Every Life Deserves World Class Care
COPD
72
DOS CME Course 2011
Chronic obstructive pulmonary disease
bull By the numbers
bull 210 million suffer worldwide
bull 3 million fatalities
bull By 2030 COPD is expected to be the third leading cause of death worldwide
bull Most important risk factors ndash Smoking
ndash Indoor pollution
ndash Outdoor pollution
ndash Occupational irritants
WHO Retrieved January 2011
73
DOS CME Course 2011
COPD
bull Causes ndash Cigarette smoking is the number one cause worldwide
ndash Environmental irritants
ndash Genetic alpha-one antitrypsin deficiency
bull Birth defects ndash Low birth weight
ndash Respiratory infections
ndash Any factor which impairs lung development during gestation
bull Other ndash HIV
ndash Connective tissue disorders
ndash Vasculitis
74
DOS CME Course 2011
COPD
bull Sometimes referred to as umbrella term for a family of diseases which cause limited airflow
ndashChronic bronchitis
ndashEmphysema
bull Inflammation of the airways
bull Increased mucous productionndash Especially in bronchitis
bull Decreased ciliary function
bull Loss of elastic recoil ndash Especially in emphysema
75
DOS CME Course 2011
COPD
bull How inflammation ruins a lung
bull Cell mediated ndash Neutrophils
ndash Macrophages
ndash Lymphocytes
bull Release cytokines which attract more cells
bull Oxidants released by cells and found in cigarette smoke
bull Proteases
bull Cause remodeling and long term structural changes
76
DOS CME Course 2011
COPDbull Alveoli lose elasticity and become distended
ndashSaggy sacs
ndashCarbon dioxide retention
ndashChronic respiratory acidosis
bull Walls of the alveoli are degraded
ndashLoss of surface area necessary for gas exchange
77
DOS CME Course 2011
What the patient looks like
bull Productive Cough
ndashEspecially in chronic bronchitis
bull Progressive dyspnea
ndashUncomfortable awareness of breathing
bull Wheezing and chest tightness
bull Increase in AP chest diameter
ndashldquoBarrel chestrdquo especially in emphysema
ndashIncreased inspiratory effort loosens costochondral cartilage
78
DOS CME Course 2011
Alpha one antitrypsin deficiency
bull Enzyme normally produced which protects the lungs
bull Deactivates neutrophil elastase
ndashReleased during inflammation
bull Estimated over 100000 in US have AATD
bull Time to diagnosis gt8 years
bull Related to increased mortality (Krowka 2010)
ndashIncreased incidence of emphysema
79
DOS CME Course 2011
Chronic bronchitis
bull Presence of cough and sputum production over three months for two consecutive years
ndashNote the months need not be consecutive
bull The patient may feel as though they are constantly sick
bull Multiple courses of antibiotics with no improvement
bull No relationship to acute bronchitis caused by bacteria or virus
80
DOS CME Course 2011
COPD
bull Break out the testing ndash CXR
ndash ECG
ndash Sputum culture
ndash CBC and electrolytes
bull ABGrsquos ndash Respiratory failure indicated by
ndash PaO2lt 60 and SaO2 lt 90
ndash with or without PaCO2 gt 50
ndash On room air
ndash Severe acidosis pHlt 736 in addition to the above is an indication for mechanical ventilation
(GOLD 2009 p 22)
81
DOS CME Course 2011
Chronic bronchitis
bull Airway of a child afflicted with chronic bronchitis compared to normal
82
DOS CME Course 2011
Chronic bronchitisbull Related to mucociliary dysfunction
ndashIncreased mucous production and thickening
ndashLoss of cilia
ndashLoss of ciliary function
ndashMobility required to sweep out particles
83
DOS CME Course 2011
Emphysemabull Permanent enlargement of the airspaces terminal to the
distal bronchioles ndashLoss of surface area for gas exchangendashDestruction of supporting structure of alveoli
ndashAirway narrowing
bull Three distinct patterns ndashCentracinar begins centrally and spreads to terminal
bronchioles and is most closely associated with cigarette smoking
ndashPanacinar destroys alveoli uniformly predominant in lower half of lungs most closely associated with AATD
ndashParaseptal destroys the distal airway structures alveolar ducts and sacs
Demirjian BG 2010
84
DOS CME Course 2011
Bullaebull Outpouchingsballooning of lung tissue due to trapped air
ndashAir is released from damaged alveoli
ndashAsymptomatic
ndashRupture can cause pneumothorax
85
DOS CME Course 2011
Diagnosis
bull History of smoking or exposure to inhaled irritants
ndashRemember to consider work and living environment
ndashCooking indoors with fossil fuels
ndashAge over 40
bull Signs and symptoms
ndashChronic cough with sputum production
ndashDyspnea which persists daily worsens with exercise and progresses over time
bull Spirometry is strongly recommended
86
DOS CME Course 2011
Diagnosis
bull Chest x-ray
ndashRule out pneumonia cardiomyopathy
ndashNot diagnostic for COPD but may reveal other causes for symptoms
bull Arterial blood gases
ndashRecommended for patients with FEVlt 50
ndashPaO2lt 60 mmHg suggests respiratory failure
bull Sputum culture
ndashRule out infectious process
87
DOS CME Course 2011
Disease stages
bull Stage Indash FEVFVC lt 70
ndash FEV gt 80
ndash Few symptoms if any patient may be unaware
bull Stage II moderate ndash FEVFVC lt 70
ndash FEV lt 80
ndash Along with shortness of breath
88
DOS CME Course 2011
Disease stages
bull Stage IV very severe ndash FEVFVC lt 70
ndash FEV lt 30
ndash At this stage exacerbations are life-threatening
ndash Quality of life is impaired further
bull Stage III severe ndash FEVFVC lt 70
ndash FEV lt 50
ndash Worsening symptoms increasing frequency of exacerbations
89
DOS CME Course 2011
COPD vs Asthma
bull COPD
ndashOnset later in life
ndashProgressive worsening symptoms
ndashSmoking history
ndashDyspnea with exercise
ndashLargely irreversible airflow limitation
bull Asthma
ndashOnset of symptoms usually earlier in life
ndashWorsening at night
ndashLargely reversible airflow limitation
ndashSymptoms vary from day to day
90
DOS CME Course 2011
COPD Treatmentbull Now that we have diagnosis what do I do about it
bull Assess and monitor diseasendash Assess for risk factors ie smoking family history
ndash Co-morbidities such as heart failure
ndash Pattern of symptoms
ndash Impact on quality of life
bull Reduce risk factors ndash Identify environmentaloccupational factors which can be modified
ndash Smoking cessation is essential
ndash Manage exacerbations
91
DOS CME Course 2011
COPDbull Manage stable COPD
ndash Determine disease severity based on frequency and severity of symptoms
ndash Educate the patient about risk factors and disease management regimen
ndash Collaborate with the patient to develop a personalized regimen
ndashFits their lifestyle
ndashAccounts for cultural preferences family involvement
ndashAvailability of testing and medications
92
DOS CME Course 2011
Pharmacologybull Goals
ndash Improve exercise tolerance
ndash Control symptoms
ndash Reduce frequency and severity of exacerbations
ndash Improve health status
bull Bronchodilators ndash Include long-acting therapy with short-acting for better control
bull Combine medications from different classes rather than increasing dosage of just onendash Minimizes side effects
93
DOS CME Course 2011
Pharmacologybull Glucocorticosteroids
ndashCan reduce the number of exacerbations
ndashIncreased risk of pneumonia
ndashNo noted reduction in mortality
bull Vaccines
ndashInfluenza vaccines decrease serious illness and death by 50
ndashRecommended annually
ndashPneumococcal vaccines recommended for all COPD sufferers even under age 65
GOLD 2009
94
DOS CME Course 2011
Antibiotics
bull Antibiotics are not a treatment for COPD nor do they manage symptoms of an exacerbation
bull Should be given only if the following are metndash Presence of three cardinal symptoms increased dyspnea
increased sputum volume increased sputum purulence
ndash Increased sputum purulence plus one other cardinal symptom
ndash Mechanically ventilated
bull May be difficult for patients to understand why antibiotics will not ldquofixrdquo what is wrong
bull Good opportunity for learning needs assessment
GOLD 2009
95
DOS CME Course 2011
COPD
bull Pulmonary rehabilitation
bull Encourage the patient to continue activities as tolerated ndash Move as much as you can before you canrsquot move
bull Uses low impact exercise to maintain physical function
bull Exercise can be done while seatedndash Monitor pulse oximetry respiratory rate and effort before during
and after activity
bull Set goals which are realistic for both of you
96
DOS CME Course 2011
COPD
bull Pulmonary rehab includes education nutrition and exercise
bull Can be a good source of social support for someone who has seen function decline
ndashTalk with others in the same situation
ndashFind out how they cope
ndashSocialize
bull Regular influenza and pneumonia vaccines
97
DOS CME Course 2011
COPD
bull Oxygen therapy
bull Recommended for stage IV disease ndash PaO2 lt or = 55 mmHg
ndash SaO2 lt or = 88
bull Increases survival improves hemodynamicsbenefits mental state
bull Surgical options reviewed on a case-by-case basisndash Bullectomy
ndash Lung volume reduction ndashNo evidence to support this as a widespread therapy
98
DOS CME Course 2011
COPD
bull Managing exacerbations
bull An event in the natural course of the disease characterized by a change in baseline dyspnea cough or sputum beyond day to day variance is acute in onset and may warrant a change in medication
bull Air pollution and tracheobronchial infections are the most common causes
bull 30 of exacerbations no cause identified
(GOLD 2009 p 22)
99
DOS CME Course 2011
COPD
bull Hospitalization is recommended for patients exhibiting the following
ndash Failure of exacerbation to respond to medical treatment
ndash Development of new symptoms ie peripheral edema cyanosis
ndash Significant co-morbidities
ndash History of frequent exacerbations
ndash Newly occurring arrhythmias
ndash Advanced age
ndash Insufficient home support
ndash Unclear diagnosis
(GOLD 2009 p 23)
100
DOS CME Course 2011
COPD
bull Mechanical ventilation is not recognized as an effective management strategy for stable COPD
bull May be required as supportive therapy during an exacerbation
bull Associated with mortality
bull Carries risks of its ownndash Ventilator acquired pneumonia
ndash Ventilator induced lung injury
ndash Failure to wean
(GOLD 2009)
101
DOS CME Course 2011DOS CME Course 2011102
Every Life Deserves World Class Care
Smoking
102
DOS CME Course 2011
Smoking bull By the numbers
bull More than 400 000 Americans die from smoking-related illnesses each yearndash Thatrsquos one of every 5 deaths
bull In a study of 2963 health care encounters smoking was discussed 633 times
bull Nicotine released into the body within 10 seconds of inhalation
bull If a person smokes one pack per day and takes ten puffs of each cigarette that equates to 200 ldquohitsrdquo of nicotine daily
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
103
DOS CME Course 2011
Nicotine
bull Nicotinic receptors occur naturally
bull N1 receptors in the adrenal medulla
bull Neuromuscular junction of autonomic ganglia
bull N2 receptors in skeletal muscle
bull Number of receptor sites increases with regular stimulation
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
104
DOS CME Course 2011
Nicotinebull Addictive
bull Vasoconstrictor
bull Releases adrenaline from the adrenal cortex
ndashFeeling of increased energy
bull Releases dopamine to produce feelings of well-beingndash Actually improves memory and cognition
bull Sensitivity actually declines overnight
bull Release of insulinndash Slightly hyperglycemic
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
105
DOS CME Course 2011
Genetic componentbull About 10 of smokers lack the gene for nicotine
dependence
ndashldquosocial or occasionalrdquo smokers
ndashThey really can quit anytime they want to
ndashNo withdrawal symptoms
ndashStill poses a health risk
bull The other 90 will demonstrate physical and psychological symptoms of withdrawal
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
106
DOS CME Course 2011
Smoking
bull Identify tobacco users ndash Ask every patient every visit
ndash Have you used tobacco in the last 12 months
ndash Clinic-wide program
bull Advise every tobacco user to quitndash Personalize the message
ndash Be clear
ndash Be firm
If at first you donrsquot succeed try tryagain Bring it up at every encounter
107
DOS CME Course 2011
Smoking cessationbull Some more good reasons to quit
ndashSmoking costs over $2000 a year in current US dollars
ndashThere is no accepted safe level of cigarette smoke
ndashSecondhand smoke carries the same hazards
ndashIncreased risk of SIDS and asthma exacerbations in children
httpwwwlungusaorgstop-smokingabout-smokingfacts-figuresgeneral-smoking-factshtml
108
DOS CME Course 2011
Smoking cessation
bull Nicotine is a powerful drug addiction
bull Treat as a chronic illness
bull All healthcare providers encouraged to participate
bull Assess willingness to quit
bull Promote motivation
109
DOS CME Course 2011
Smoking cessation
bull Prochaskarsquos change theory
bull Precontemplation
ndashNot even thinking about quitting
ndashProvide education on the risks and costs of smoking
bull Contemplation
ndashAwareness that a problem exists
ndashContinue to find motivations to stop
NorcrossJC Krebs PM Prochaska JO(2011)
110
DOS CME Course 2011
Change is good
bull Determination
ndashExpressing willingness to act
ndashSelf-efficacy
bull Action ndash Currently not smoking
ndash May relapse
bull It is not unusual for a patient to ldquoquitrdquo three or four times
bull Continue to encourage and motivate himher to stop
NorcrossJC Krebs PM Prochaska JO(2011)
111
DOS CME Course 2011
Smoking cessationbull Assist the patient
ndashCollaborate with the patient to develop a plan to quit
ndashAchievable clearly defined goals
ndashIdentify and engage social supports
ndashFamily support groups
ndashPharmacologic (more on this later)
bull Arrange follow-up
ndashAt each successive visit review progress on quitting strategy
ndashLets the patient know heshe is not alone in this effort
ndashAccountability
112
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
Pharmacologybull Leukotriene modifiers
ndash Disrupt the function or synthesis of inflammatory mediators related to asthma
ndashMontelukast zafirlukast zileuton
bull Long-term control
bull Side effects elevation of liver enzymes HA dizziness GI distress
bull Mast cell stabilizersndash Cromolyn sodium nedocromil
ndash Inhibit release of inflammatory mediators
ndash Side effects bronchospasm pharyngeal irritation
55
DOS CME Course 2011
Pharmacology
bull Anticholinergics chemically related to atropine
ndashIpratropium bromide (Atrovent)
ndashInhaled form as rescue therapy
bull Side effects
ndashurinary obstruction HA restlessness palpitations bronchospasm
56
DOS CME Course 2011
The big guns
bull Systemic corticosteroidsndash Methylprednisolone hydrocortisone dexamethasone
ndash IV or PO
ndash Treatment of acute exacerbations
bull Side effects ndash adrenal suppression weight gain fluid retention hyperglycemia
ndash Long term
ndash osteoporosis immune suppression gastric ulcers
57
DOS CME Course 2011
Right here and now
bull Nursing Intervention
bull Quick Relief
bull Short acting bronchodilator ndash Up to 3 treatments at 20 minute intervals
bull Or single nebulizer treatment
bull Course of systemic corticosteroids may be needed
DOS Wheezing protocol
58
DOS CME Course 2011
Nebulizer Treatment
bull Albuterol Solution
ndashlt5 years old 063-25 mg in 3 cc of saline q 4-6 hours as needed
ndashgt5 years old -adult 125-5 mg in 3 cc of saline q 4-8 hours as needed
bull Levalbuterol (R-albuterol solution Xopinex)
ndashlt 5 years old 031 mg-125 mg in 3 cc NS q 4-6 hrs as needed
ndash5-11 yrs old 031-063 mg q 8 hours prn symptoms
ndashgt12 yrs old063mg-125 mg q 8 hours prn symptoms
DOS Wheezing protocol
59
DOS CME Course 2011
Treatment at home
bull Nebulizers convert liquid or powder medications to aerosolized formndash Effective to deliver larger doses than metered dose inhalers
Patient safety alert Some medications in powder formcome as a capsule which is broken open The patient should not take this medication orally
60
DOS CME Course 2011
How often
do the following
happen
MILD INTERMITTENT(check appropriate box)
MILD PERSISTENT
MODERATE PERSISTENT
SEVERE PERSISTENT
Daytime wheezingshortness of breath
0-2 times per week
Greater than 2 times per week
Daily Continually
Night-time wheezing shortness of breath
0-2 times per month
Greater than 2 times per month
Greater than 1 time per week
Frequent
How often are your physical activities limited by asthma
0-2 times per week
0-2 times per week
Greater than 2 times per week
Frequent
Daily use of albuterol or ldquorescue drugsrdquo
Less than 1 time per week or less than 3 times per month
2 time per week or more
Daily Use Frequent
DOS Wheezing protocol61
DOS CME Course 2011
Plan of carebull Step 1mdashmild intermittent
ndash no daily medication
ndash should have prn short acting rescue Beta 2 inhaler on hand
bull Step 2mdashmild persistentndash low dose inhaled corticosteroids
bull Step 3mdashmoderate persistentndash low to med inhaled corticosteroids and long acting beta 2 agonists
bull Step 4mdashsevere persistentndash high dose inhaled corticosteroids and long acting inhaled beta 2
agonists
DOS Wheezing protocol
62
DOS CME Course 2011
Ongoing carebull Plan Follow-up
ndash Evaluate 2-6 weeks after treatment initiationndash Evaluate every 1-6 months when stablendash Evaluate every 3 months interval after stepping down therapyndash Annual inactivated influenza vaccine
bull ConsultationReferralndash Life threatening or severe persistent asthmandash Goals of asthma therapy not fulfilled in 3-6 monthsndash Signs and symptoms are not typicalndash Sinusitis gastroesophageal reflux or chronic pulmonary disease
complicate the asthma
DOS Wheezing protocol
63
DOS CME Course 2011
Consults
bull Continuous oral corticosteroids or 2 bursts of oral steroids in 1 year
bull Patient under 3 years with step 3 or 4 asthma
bull If omalizumab (Xolair) is considered for treatment as there is an increase in rate of anaphylaxis with this medication
bull Exacerbation requiring hospitalization
DOS Wheezing protocol
64
DOS CME Course 2011
Patient educationbull Basic understanding of asthma and how the disease
works
bull Medications ndash Names and doses of all medications
ndash Short acting vs long acting
bull Equipment ndash Metered dose inhalers (MDI)
ndash Nebulizers
bull Emergency response
bull Activity level
bull Illness management
65
DOS CME Course 2011
Patient education
bull Know your triggers and have a strategy for avoidance
bull If mold or mites are known triggers humidifiers and evaporator coolers are not recommended in the home
bull Know the early signs of an exacerbation and what to do
bull Develop an action plan based on peak flow readings
bull What to do in case of an attack at school or work
66
DOS CME Course 2011
Patient educationbull Metered dose inhalers
ndash Remove cap and invert the device several times
ndash Exhale
ndash Place the mouthpiece between your lips with a good seal
ndash Inhale while depressing the top of the MDI
ndash Hold your breath for 10 seconds
ndash Exhale
ndash Repeat as needed
67
DOS CME Course 2011
Patient educationbull Spacers are used with MDIrsquos
used to deliver inhaled steroidsndash Ease coordination of breathing
and medication delivery
ndash Decrease the amount of medication contacting the oral mucosa
ndash Fewer side effects
bull Attach the spacer to the mouthpiece of the MDI ndash Use the MDI as described
before
ndash Some models have a whistle to indicate you are inhaling too rapidly
68
DOS CME Course 201169
DOS CME Course 2011
Characteristic Controlled
(All of the following)
Partly controlled
(Any measure noted)
Uncontrolled
Daytime symptoms
None (twice or less a week)
More than twice a week
Three or more features of partly controlled asthma
Limitation of activities
None Any
Nocturnal symptomsawakening
None Any
Need for rescue treatment
None (twice or less a week)
More than twice a week
Lung function (FEV1 or PEF)
Normal lt80 predicted or personal best
70
DOS CME Course 2011
Asthma
bull Self monitoring is essential to effective management and control
bull The following are validated tools to assess asthma control
ndashAsthmacontrolcom
ndashFree web-based
ndashQoltechcouk
ndashFree in hard copy or electronic versions
ndashRequires permission
ndashAtaqinstrumentcom
ndashFree web-based
71
DOS CME Course 2011DOS CME Course 201172
Every Life Deserves World Class Care
COPD
72
DOS CME Course 2011
Chronic obstructive pulmonary disease
bull By the numbers
bull 210 million suffer worldwide
bull 3 million fatalities
bull By 2030 COPD is expected to be the third leading cause of death worldwide
bull Most important risk factors ndash Smoking
ndash Indoor pollution
ndash Outdoor pollution
ndash Occupational irritants
WHO Retrieved January 2011
73
DOS CME Course 2011
COPD
bull Causes ndash Cigarette smoking is the number one cause worldwide
ndash Environmental irritants
ndash Genetic alpha-one antitrypsin deficiency
bull Birth defects ndash Low birth weight
ndash Respiratory infections
ndash Any factor which impairs lung development during gestation
bull Other ndash HIV
ndash Connective tissue disorders
ndash Vasculitis
74
DOS CME Course 2011
COPD
bull Sometimes referred to as umbrella term for a family of diseases which cause limited airflow
ndashChronic bronchitis
ndashEmphysema
bull Inflammation of the airways
bull Increased mucous productionndash Especially in bronchitis
bull Decreased ciliary function
bull Loss of elastic recoil ndash Especially in emphysema
75
DOS CME Course 2011
COPD
bull How inflammation ruins a lung
bull Cell mediated ndash Neutrophils
ndash Macrophages
ndash Lymphocytes
bull Release cytokines which attract more cells
bull Oxidants released by cells and found in cigarette smoke
bull Proteases
bull Cause remodeling and long term structural changes
76
DOS CME Course 2011
COPDbull Alveoli lose elasticity and become distended
ndashSaggy sacs
ndashCarbon dioxide retention
ndashChronic respiratory acidosis
bull Walls of the alveoli are degraded
ndashLoss of surface area necessary for gas exchange
77
DOS CME Course 2011
What the patient looks like
bull Productive Cough
ndashEspecially in chronic bronchitis
bull Progressive dyspnea
ndashUncomfortable awareness of breathing
bull Wheezing and chest tightness
bull Increase in AP chest diameter
ndashldquoBarrel chestrdquo especially in emphysema
ndashIncreased inspiratory effort loosens costochondral cartilage
78
DOS CME Course 2011
Alpha one antitrypsin deficiency
bull Enzyme normally produced which protects the lungs
bull Deactivates neutrophil elastase
ndashReleased during inflammation
bull Estimated over 100000 in US have AATD
bull Time to diagnosis gt8 years
bull Related to increased mortality (Krowka 2010)
ndashIncreased incidence of emphysema
79
DOS CME Course 2011
Chronic bronchitis
bull Presence of cough and sputum production over three months for two consecutive years
ndashNote the months need not be consecutive
bull The patient may feel as though they are constantly sick
bull Multiple courses of antibiotics with no improvement
bull No relationship to acute bronchitis caused by bacteria or virus
80
DOS CME Course 2011
COPD
bull Break out the testing ndash CXR
ndash ECG
ndash Sputum culture
ndash CBC and electrolytes
bull ABGrsquos ndash Respiratory failure indicated by
ndash PaO2lt 60 and SaO2 lt 90
ndash with or without PaCO2 gt 50
ndash On room air
ndash Severe acidosis pHlt 736 in addition to the above is an indication for mechanical ventilation
(GOLD 2009 p 22)
81
DOS CME Course 2011
Chronic bronchitis
bull Airway of a child afflicted with chronic bronchitis compared to normal
82
DOS CME Course 2011
Chronic bronchitisbull Related to mucociliary dysfunction
ndashIncreased mucous production and thickening
ndashLoss of cilia
ndashLoss of ciliary function
ndashMobility required to sweep out particles
83
DOS CME Course 2011
Emphysemabull Permanent enlargement of the airspaces terminal to the
distal bronchioles ndashLoss of surface area for gas exchangendashDestruction of supporting structure of alveoli
ndashAirway narrowing
bull Three distinct patterns ndashCentracinar begins centrally and spreads to terminal
bronchioles and is most closely associated with cigarette smoking
ndashPanacinar destroys alveoli uniformly predominant in lower half of lungs most closely associated with AATD
ndashParaseptal destroys the distal airway structures alveolar ducts and sacs
Demirjian BG 2010
84
DOS CME Course 2011
Bullaebull Outpouchingsballooning of lung tissue due to trapped air
ndashAir is released from damaged alveoli
ndashAsymptomatic
ndashRupture can cause pneumothorax
85
DOS CME Course 2011
Diagnosis
bull History of smoking or exposure to inhaled irritants
ndashRemember to consider work and living environment
ndashCooking indoors with fossil fuels
ndashAge over 40
bull Signs and symptoms
ndashChronic cough with sputum production
ndashDyspnea which persists daily worsens with exercise and progresses over time
bull Spirometry is strongly recommended
86
DOS CME Course 2011
Diagnosis
bull Chest x-ray
ndashRule out pneumonia cardiomyopathy
ndashNot diagnostic for COPD but may reveal other causes for symptoms
bull Arterial blood gases
ndashRecommended for patients with FEVlt 50
ndashPaO2lt 60 mmHg suggests respiratory failure
bull Sputum culture
ndashRule out infectious process
87
DOS CME Course 2011
Disease stages
bull Stage Indash FEVFVC lt 70
ndash FEV gt 80
ndash Few symptoms if any patient may be unaware
bull Stage II moderate ndash FEVFVC lt 70
ndash FEV lt 80
ndash Along with shortness of breath
88
DOS CME Course 2011
Disease stages
bull Stage IV very severe ndash FEVFVC lt 70
ndash FEV lt 30
ndash At this stage exacerbations are life-threatening
ndash Quality of life is impaired further
bull Stage III severe ndash FEVFVC lt 70
ndash FEV lt 50
ndash Worsening symptoms increasing frequency of exacerbations
89
DOS CME Course 2011
COPD vs Asthma
bull COPD
ndashOnset later in life
ndashProgressive worsening symptoms
ndashSmoking history
ndashDyspnea with exercise
ndashLargely irreversible airflow limitation
bull Asthma
ndashOnset of symptoms usually earlier in life
ndashWorsening at night
ndashLargely reversible airflow limitation
ndashSymptoms vary from day to day
90
DOS CME Course 2011
COPD Treatmentbull Now that we have diagnosis what do I do about it
bull Assess and monitor diseasendash Assess for risk factors ie smoking family history
ndash Co-morbidities such as heart failure
ndash Pattern of symptoms
ndash Impact on quality of life
bull Reduce risk factors ndash Identify environmentaloccupational factors which can be modified
ndash Smoking cessation is essential
ndash Manage exacerbations
91
DOS CME Course 2011
COPDbull Manage stable COPD
ndash Determine disease severity based on frequency and severity of symptoms
ndash Educate the patient about risk factors and disease management regimen
ndash Collaborate with the patient to develop a personalized regimen
ndashFits their lifestyle
ndashAccounts for cultural preferences family involvement
ndashAvailability of testing and medications
92
DOS CME Course 2011
Pharmacologybull Goals
ndash Improve exercise tolerance
ndash Control symptoms
ndash Reduce frequency and severity of exacerbations
ndash Improve health status
bull Bronchodilators ndash Include long-acting therapy with short-acting for better control
bull Combine medications from different classes rather than increasing dosage of just onendash Minimizes side effects
93
DOS CME Course 2011
Pharmacologybull Glucocorticosteroids
ndashCan reduce the number of exacerbations
ndashIncreased risk of pneumonia
ndashNo noted reduction in mortality
bull Vaccines
ndashInfluenza vaccines decrease serious illness and death by 50
ndashRecommended annually
ndashPneumococcal vaccines recommended for all COPD sufferers even under age 65
GOLD 2009
94
DOS CME Course 2011
Antibiotics
bull Antibiotics are not a treatment for COPD nor do they manage symptoms of an exacerbation
bull Should be given only if the following are metndash Presence of three cardinal symptoms increased dyspnea
increased sputum volume increased sputum purulence
ndash Increased sputum purulence plus one other cardinal symptom
ndash Mechanically ventilated
bull May be difficult for patients to understand why antibiotics will not ldquofixrdquo what is wrong
bull Good opportunity for learning needs assessment
GOLD 2009
95
DOS CME Course 2011
COPD
bull Pulmonary rehabilitation
bull Encourage the patient to continue activities as tolerated ndash Move as much as you can before you canrsquot move
bull Uses low impact exercise to maintain physical function
bull Exercise can be done while seatedndash Monitor pulse oximetry respiratory rate and effort before during
and after activity
bull Set goals which are realistic for both of you
96
DOS CME Course 2011
COPD
bull Pulmonary rehab includes education nutrition and exercise
bull Can be a good source of social support for someone who has seen function decline
ndashTalk with others in the same situation
ndashFind out how they cope
ndashSocialize
bull Regular influenza and pneumonia vaccines
97
DOS CME Course 2011
COPD
bull Oxygen therapy
bull Recommended for stage IV disease ndash PaO2 lt or = 55 mmHg
ndash SaO2 lt or = 88
bull Increases survival improves hemodynamicsbenefits mental state
bull Surgical options reviewed on a case-by-case basisndash Bullectomy
ndash Lung volume reduction ndashNo evidence to support this as a widespread therapy
98
DOS CME Course 2011
COPD
bull Managing exacerbations
bull An event in the natural course of the disease characterized by a change in baseline dyspnea cough or sputum beyond day to day variance is acute in onset and may warrant a change in medication
bull Air pollution and tracheobronchial infections are the most common causes
bull 30 of exacerbations no cause identified
(GOLD 2009 p 22)
99
DOS CME Course 2011
COPD
bull Hospitalization is recommended for patients exhibiting the following
ndash Failure of exacerbation to respond to medical treatment
ndash Development of new symptoms ie peripheral edema cyanosis
ndash Significant co-morbidities
ndash History of frequent exacerbations
ndash Newly occurring arrhythmias
ndash Advanced age
ndash Insufficient home support
ndash Unclear diagnosis
(GOLD 2009 p 23)
100
DOS CME Course 2011
COPD
bull Mechanical ventilation is not recognized as an effective management strategy for stable COPD
bull May be required as supportive therapy during an exacerbation
bull Associated with mortality
bull Carries risks of its ownndash Ventilator acquired pneumonia
ndash Ventilator induced lung injury
ndash Failure to wean
(GOLD 2009)
101
DOS CME Course 2011DOS CME Course 2011102
Every Life Deserves World Class Care
Smoking
102
DOS CME Course 2011
Smoking bull By the numbers
bull More than 400 000 Americans die from smoking-related illnesses each yearndash Thatrsquos one of every 5 deaths
bull In a study of 2963 health care encounters smoking was discussed 633 times
bull Nicotine released into the body within 10 seconds of inhalation
bull If a person smokes one pack per day and takes ten puffs of each cigarette that equates to 200 ldquohitsrdquo of nicotine daily
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
103
DOS CME Course 2011
Nicotine
bull Nicotinic receptors occur naturally
bull N1 receptors in the adrenal medulla
bull Neuromuscular junction of autonomic ganglia
bull N2 receptors in skeletal muscle
bull Number of receptor sites increases with regular stimulation
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
104
DOS CME Course 2011
Nicotinebull Addictive
bull Vasoconstrictor
bull Releases adrenaline from the adrenal cortex
ndashFeeling of increased energy
bull Releases dopamine to produce feelings of well-beingndash Actually improves memory and cognition
bull Sensitivity actually declines overnight
bull Release of insulinndash Slightly hyperglycemic
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
105
DOS CME Course 2011
Genetic componentbull About 10 of smokers lack the gene for nicotine
dependence
ndashldquosocial or occasionalrdquo smokers
ndashThey really can quit anytime they want to
ndashNo withdrawal symptoms
ndashStill poses a health risk
bull The other 90 will demonstrate physical and psychological symptoms of withdrawal
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
106
DOS CME Course 2011
Smoking
bull Identify tobacco users ndash Ask every patient every visit
ndash Have you used tobacco in the last 12 months
ndash Clinic-wide program
bull Advise every tobacco user to quitndash Personalize the message
ndash Be clear
ndash Be firm
If at first you donrsquot succeed try tryagain Bring it up at every encounter
107
DOS CME Course 2011
Smoking cessationbull Some more good reasons to quit
ndashSmoking costs over $2000 a year in current US dollars
ndashThere is no accepted safe level of cigarette smoke
ndashSecondhand smoke carries the same hazards
ndashIncreased risk of SIDS and asthma exacerbations in children
httpwwwlungusaorgstop-smokingabout-smokingfacts-figuresgeneral-smoking-factshtml
108
DOS CME Course 2011
Smoking cessation
bull Nicotine is a powerful drug addiction
bull Treat as a chronic illness
bull All healthcare providers encouraged to participate
bull Assess willingness to quit
bull Promote motivation
109
DOS CME Course 2011
Smoking cessation
bull Prochaskarsquos change theory
bull Precontemplation
ndashNot even thinking about quitting
ndashProvide education on the risks and costs of smoking
bull Contemplation
ndashAwareness that a problem exists
ndashContinue to find motivations to stop
NorcrossJC Krebs PM Prochaska JO(2011)
110
DOS CME Course 2011
Change is good
bull Determination
ndashExpressing willingness to act
ndashSelf-efficacy
bull Action ndash Currently not smoking
ndash May relapse
bull It is not unusual for a patient to ldquoquitrdquo three or four times
bull Continue to encourage and motivate himher to stop
NorcrossJC Krebs PM Prochaska JO(2011)
111
DOS CME Course 2011
Smoking cessationbull Assist the patient
ndashCollaborate with the patient to develop a plan to quit
ndashAchievable clearly defined goals
ndashIdentify and engage social supports
ndashFamily support groups
ndashPharmacologic (more on this later)
bull Arrange follow-up
ndashAt each successive visit review progress on quitting strategy
ndashLets the patient know heshe is not alone in this effort
ndashAccountability
112
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
The big guns
bull Systemic corticosteroidsndash Methylprednisolone hydrocortisone dexamethasone
ndash IV or PO
ndash Treatment of acute exacerbations
bull Side effects ndash adrenal suppression weight gain fluid retention hyperglycemia
ndash Long term
ndash osteoporosis immune suppression gastric ulcers
57
DOS CME Course 2011
Right here and now
bull Nursing Intervention
bull Quick Relief
bull Short acting bronchodilator ndash Up to 3 treatments at 20 minute intervals
bull Or single nebulizer treatment
bull Course of systemic corticosteroids may be needed
DOS Wheezing protocol
58
DOS CME Course 2011
Nebulizer Treatment
bull Albuterol Solution
ndashlt5 years old 063-25 mg in 3 cc of saline q 4-6 hours as needed
ndashgt5 years old -adult 125-5 mg in 3 cc of saline q 4-8 hours as needed
bull Levalbuterol (R-albuterol solution Xopinex)
ndashlt 5 years old 031 mg-125 mg in 3 cc NS q 4-6 hrs as needed
ndash5-11 yrs old 031-063 mg q 8 hours prn symptoms
ndashgt12 yrs old063mg-125 mg q 8 hours prn symptoms
DOS Wheezing protocol
59
DOS CME Course 2011
Treatment at home
bull Nebulizers convert liquid or powder medications to aerosolized formndash Effective to deliver larger doses than metered dose inhalers
Patient safety alert Some medications in powder formcome as a capsule which is broken open The patient should not take this medication orally
60
DOS CME Course 2011
How often
do the following
happen
MILD INTERMITTENT(check appropriate box)
MILD PERSISTENT
MODERATE PERSISTENT
SEVERE PERSISTENT
Daytime wheezingshortness of breath
0-2 times per week
Greater than 2 times per week
Daily Continually
Night-time wheezing shortness of breath
0-2 times per month
Greater than 2 times per month
Greater than 1 time per week
Frequent
How often are your physical activities limited by asthma
0-2 times per week
0-2 times per week
Greater than 2 times per week
Frequent
Daily use of albuterol or ldquorescue drugsrdquo
Less than 1 time per week or less than 3 times per month
2 time per week or more
Daily Use Frequent
DOS Wheezing protocol61
DOS CME Course 2011
Plan of carebull Step 1mdashmild intermittent
ndash no daily medication
ndash should have prn short acting rescue Beta 2 inhaler on hand
bull Step 2mdashmild persistentndash low dose inhaled corticosteroids
bull Step 3mdashmoderate persistentndash low to med inhaled corticosteroids and long acting beta 2 agonists
bull Step 4mdashsevere persistentndash high dose inhaled corticosteroids and long acting inhaled beta 2
agonists
DOS Wheezing protocol
62
DOS CME Course 2011
Ongoing carebull Plan Follow-up
ndash Evaluate 2-6 weeks after treatment initiationndash Evaluate every 1-6 months when stablendash Evaluate every 3 months interval after stepping down therapyndash Annual inactivated influenza vaccine
bull ConsultationReferralndash Life threatening or severe persistent asthmandash Goals of asthma therapy not fulfilled in 3-6 monthsndash Signs and symptoms are not typicalndash Sinusitis gastroesophageal reflux or chronic pulmonary disease
complicate the asthma
DOS Wheezing protocol
63
DOS CME Course 2011
Consults
bull Continuous oral corticosteroids or 2 bursts of oral steroids in 1 year
bull Patient under 3 years with step 3 or 4 asthma
bull If omalizumab (Xolair) is considered for treatment as there is an increase in rate of anaphylaxis with this medication
bull Exacerbation requiring hospitalization
DOS Wheezing protocol
64
DOS CME Course 2011
Patient educationbull Basic understanding of asthma and how the disease
works
bull Medications ndash Names and doses of all medications
ndash Short acting vs long acting
bull Equipment ndash Metered dose inhalers (MDI)
ndash Nebulizers
bull Emergency response
bull Activity level
bull Illness management
65
DOS CME Course 2011
Patient education
bull Know your triggers and have a strategy for avoidance
bull If mold or mites are known triggers humidifiers and evaporator coolers are not recommended in the home
bull Know the early signs of an exacerbation and what to do
bull Develop an action plan based on peak flow readings
bull What to do in case of an attack at school or work
66
DOS CME Course 2011
Patient educationbull Metered dose inhalers
ndash Remove cap and invert the device several times
ndash Exhale
ndash Place the mouthpiece between your lips with a good seal
ndash Inhale while depressing the top of the MDI
ndash Hold your breath for 10 seconds
ndash Exhale
ndash Repeat as needed
67
DOS CME Course 2011
Patient educationbull Spacers are used with MDIrsquos
used to deliver inhaled steroidsndash Ease coordination of breathing
and medication delivery
ndash Decrease the amount of medication contacting the oral mucosa
ndash Fewer side effects
bull Attach the spacer to the mouthpiece of the MDI ndash Use the MDI as described
before
ndash Some models have a whistle to indicate you are inhaling too rapidly
68
DOS CME Course 201169
DOS CME Course 2011
Characteristic Controlled
(All of the following)
Partly controlled
(Any measure noted)
Uncontrolled
Daytime symptoms
None (twice or less a week)
More than twice a week
Three or more features of partly controlled asthma
Limitation of activities
None Any
Nocturnal symptomsawakening
None Any
Need for rescue treatment
None (twice or less a week)
More than twice a week
Lung function (FEV1 or PEF)
Normal lt80 predicted or personal best
70
DOS CME Course 2011
Asthma
bull Self monitoring is essential to effective management and control
bull The following are validated tools to assess asthma control
ndashAsthmacontrolcom
ndashFree web-based
ndashQoltechcouk
ndashFree in hard copy or electronic versions
ndashRequires permission
ndashAtaqinstrumentcom
ndashFree web-based
71
DOS CME Course 2011DOS CME Course 201172
Every Life Deserves World Class Care
COPD
72
DOS CME Course 2011
Chronic obstructive pulmonary disease
bull By the numbers
bull 210 million suffer worldwide
bull 3 million fatalities
bull By 2030 COPD is expected to be the third leading cause of death worldwide
bull Most important risk factors ndash Smoking
ndash Indoor pollution
ndash Outdoor pollution
ndash Occupational irritants
WHO Retrieved January 2011
73
DOS CME Course 2011
COPD
bull Causes ndash Cigarette smoking is the number one cause worldwide
ndash Environmental irritants
ndash Genetic alpha-one antitrypsin deficiency
bull Birth defects ndash Low birth weight
ndash Respiratory infections
ndash Any factor which impairs lung development during gestation
bull Other ndash HIV
ndash Connective tissue disorders
ndash Vasculitis
74
DOS CME Course 2011
COPD
bull Sometimes referred to as umbrella term for a family of diseases which cause limited airflow
ndashChronic bronchitis
ndashEmphysema
bull Inflammation of the airways
bull Increased mucous productionndash Especially in bronchitis
bull Decreased ciliary function
bull Loss of elastic recoil ndash Especially in emphysema
75
DOS CME Course 2011
COPD
bull How inflammation ruins a lung
bull Cell mediated ndash Neutrophils
ndash Macrophages
ndash Lymphocytes
bull Release cytokines which attract more cells
bull Oxidants released by cells and found in cigarette smoke
bull Proteases
bull Cause remodeling and long term structural changes
76
DOS CME Course 2011
COPDbull Alveoli lose elasticity and become distended
ndashSaggy sacs
ndashCarbon dioxide retention
ndashChronic respiratory acidosis
bull Walls of the alveoli are degraded
ndashLoss of surface area necessary for gas exchange
77
DOS CME Course 2011
What the patient looks like
bull Productive Cough
ndashEspecially in chronic bronchitis
bull Progressive dyspnea
ndashUncomfortable awareness of breathing
bull Wheezing and chest tightness
bull Increase in AP chest diameter
ndashldquoBarrel chestrdquo especially in emphysema
ndashIncreased inspiratory effort loosens costochondral cartilage
78
DOS CME Course 2011
Alpha one antitrypsin deficiency
bull Enzyme normally produced which protects the lungs
bull Deactivates neutrophil elastase
ndashReleased during inflammation
bull Estimated over 100000 in US have AATD
bull Time to diagnosis gt8 years
bull Related to increased mortality (Krowka 2010)
ndashIncreased incidence of emphysema
79
DOS CME Course 2011
Chronic bronchitis
bull Presence of cough and sputum production over three months for two consecutive years
ndashNote the months need not be consecutive
bull The patient may feel as though they are constantly sick
bull Multiple courses of antibiotics with no improvement
bull No relationship to acute bronchitis caused by bacteria or virus
80
DOS CME Course 2011
COPD
bull Break out the testing ndash CXR
ndash ECG
ndash Sputum culture
ndash CBC and electrolytes
bull ABGrsquos ndash Respiratory failure indicated by
ndash PaO2lt 60 and SaO2 lt 90
ndash with or without PaCO2 gt 50
ndash On room air
ndash Severe acidosis pHlt 736 in addition to the above is an indication for mechanical ventilation
(GOLD 2009 p 22)
81
DOS CME Course 2011
Chronic bronchitis
bull Airway of a child afflicted with chronic bronchitis compared to normal
82
DOS CME Course 2011
Chronic bronchitisbull Related to mucociliary dysfunction
ndashIncreased mucous production and thickening
ndashLoss of cilia
ndashLoss of ciliary function
ndashMobility required to sweep out particles
83
DOS CME Course 2011
Emphysemabull Permanent enlargement of the airspaces terminal to the
distal bronchioles ndashLoss of surface area for gas exchangendashDestruction of supporting structure of alveoli
ndashAirway narrowing
bull Three distinct patterns ndashCentracinar begins centrally and spreads to terminal
bronchioles and is most closely associated with cigarette smoking
ndashPanacinar destroys alveoli uniformly predominant in lower half of lungs most closely associated with AATD
ndashParaseptal destroys the distal airway structures alveolar ducts and sacs
Demirjian BG 2010
84
DOS CME Course 2011
Bullaebull Outpouchingsballooning of lung tissue due to trapped air
ndashAir is released from damaged alveoli
ndashAsymptomatic
ndashRupture can cause pneumothorax
85
DOS CME Course 2011
Diagnosis
bull History of smoking or exposure to inhaled irritants
ndashRemember to consider work and living environment
ndashCooking indoors with fossil fuels
ndashAge over 40
bull Signs and symptoms
ndashChronic cough with sputum production
ndashDyspnea which persists daily worsens with exercise and progresses over time
bull Spirometry is strongly recommended
86
DOS CME Course 2011
Diagnosis
bull Chest x-ray
ndashRule out pneumonia cardiomyopathy
ndashNot diagnostic for COPD but may reveal other causes for symptoms
bull Arterial blood gases
ndashRecommended for patients with FEVlt 50
ndashPaO2lt 60 mmHg suggests respiratory failure
bull Sputum culture
ndashRule out infectious process
87
DOS CME Course 2011
Disease stages
bull Stage Indash FEVFVC lt 70
ndash FEV gt 80
ndash Few symptoms if any patient may be unaware
bull Stage II moderate ndash FEVFVC lt 70
ndash FEV lt 80
ndash Along with shortness of breath
88
DOS CME Course 2011
Disease stages
bull Stage IV very severe ndash FEVFVC lt 70
ndash FEV lt 30
ndash At this stage exacerbations are life-threatening
ndash Quality of life is impaired further
bull Stage III severe ndash FEVFVC lt 70
ndash FEV lt 50
ndash Worsening symptoms increasing frequency of exacerbations
89
DOS CME Course 2011
COPD vs Asthma
bull COPD
ndashOnset later in life
ndashProgressive worsening symptoms
ndashSmoking history
ndashDyspnea with exercise
ndashLargely irreversible airflow limitation
bull Asthma
ndashOnset of symptoms usually earlier in life
ndashWorsening at night
ndashLargely reversible airflow limitation
ndashSymptoms vary from day to day
90
DOS CME Course 2011
COPD Treatmentbull Now that we have diagnosis what do I do about it
bull Assess and monitor diseasendash Assess for risk factors ie smoking family history
ndash Co-morbidities such as heart failure
ndash Pattern of symptoms
ndash Impact on quality of life
bull Reduce risk factors ndash Identify environmentaloccupational factors which can be modified
ndash Smoking cessation is essential
ndash Manage exacerbations
91
DOS CME Course 2011
COPDbull Manage stable COPD
ndash Determine disease severity based on frequency and severity of symptoms
ndash Educate the patient about risk factors and disease management regimen
ndash Collaborate with the patient to develop a personalized regimen
ndashFits their lifestyle
ndashAccounts for cultural preferences family involvement
ndashAvailability of testing and medications
92
DOS CME Course 2011
Pharmacologybull Goals
ndash Improve exercise tolerance
ndash Control symptoms
ndash Reduce frequency and severity of exacerbations
ndash Improve health status
bull Bronchodilators ndash Include long-acting therapy with short-acting for better control
bull Combine medications from different classes rather than increasing dosage of just onendash Minimizes side effects
93
DOS CME Course 2011
Pharmacologybull Glucocorticosteroids
ndashCan reduce the number of exacerbations
ndashIncreased risk of pneumonia
ndashNo noted reduction in mortality
bull Vaccines
ndashInfluenza vaccines decrease serious illness and death by 50
ndashRecommended annually
ndashPneumococcal vaccines recommended for all COPD sufferers even under age 65
GOLD 2009
94
DOS CME Course 2011
Antibiotics
bull Antibiotics are not a treatment for COPD nor do they manage symptoms of an exacerbation
bull Should be given only if the following are metndash Presence of three cardinal symptoms increased dyspnea
increased sputum volume increased sputum purulence
ndash Increased sputum purulence plus one other cardinal symptom
ndash Mechanically ventilated
bull May be difficult for patients to understand why antibiotics will not ldquofixrdquo what is wrong
bull Good opportunity for learning needs assessment
GOLD 2009
95
DOS CME Course 2011
COPD
bull Pulmonary rehabilitation
bull Encourage the patient to continue activities as tolerated ndash Move as much as you can before you canrsquot move
bull Uses low impact exercise to maintain physical function
bull Exercise can be done while seatedndash Monitor pulse oximetry respiratory rate and effort before during
and after activity
bull Set goals which are realistic for both of you
96
DOS CME Course 2011
COPD
bull Pulmonary rehab includes education nutrition and exercise
bull Can be a good source of social support for someone who has seen function decline
ndashTalk with others in the same situation
ndashFind out how they cope
ndashSocialize
bull Regular influenza and pneumonia vaccines
97
DOS CME Course 2011
COPD
bull Oxygen therapy
bull Recommended for stage IV disease ndash PaO2 lt or = 55 mmHg
ndash SaO2 lt or = 88
bull Increases survival improves hemodynamicsbenefits mental state
bull Surgical options reviewed on a case-by-case basisndash Bullectomy
ndash Lung volume reduction ndashNo evidence to support this as a widespread therapy
98
DOS CME Course 2011
COPD
bull Managing exacerbations
bull An event in the natural course of the disease characterized by a change in baseline dyspnea cough or sputum beyond day to day variance is acute in onset and may warrant a change in medication
bull Air pollution and tracheobronchial infections are the most common causes
bull 30 of exacerbations no cause identified
(GOLD 2009 p 22)
99
DOS CME Course 2011
COPD
bull Hospitalization is recommended for patients exhibiting the following
ndash Failure of exacerbation to respond to medical treatment
ndash Development of new symptoms ie peripheral edema cyanosis
ndash Significant co-morbidities
ndash History of frequent exacerbations
ndash Newly occurring arrhythmias
ndash Advanced age
ndash Insufficient home support
ndash Unclear diagnosis
(GOLD 2009 p 23)
100
DOS CME Course 2011
COPD
bull Mechanical ventilation is not recognized as an effective management strategy for stable COPD
bull May be required as supportive therapy during an exacerbation
bull Associated with mortality
bull Carries risks of its ownndash Ventilator acquired pneumonia
ndash Ventilator induced lung injury
ndash Failure to wean
(GOLD 2009)
101
DOS CME Course 2011DOS CME Course 2011102
Every Life Deserves World Class Care
Smoking
102
DOS CME Course 2011
Smoking bull By the numbers
bull More than 400 000 Americans die from smoking-related illnesses each yearndash Thatrsquos one of every 5 deaths
bull In a study of 2963 health care encounters smoking was discussed 633 times
bull Nicotine released into the body within 10 seconds of inhalation
bull If a person smokes one pack per day and takes ten puffs of each cigarette that equates to 200 ldquohitsrdquo of nicotine daily
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
103
DOS CME Course 2011
Nicotine
bull Nicotinic receptors occur naturally
bull N1 receptors in the adrenal medulla
bull Neuromuscular junction of autonomic ganglia
bull N2 receptors in skeletal muscle
bull Number of receptor sites increases with regular stimulation
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
104
DOS CME Course 2011
Nicotinebull Addictive
bull Vasoconstrictor
bull Releases adrenaline from the adrenal cortex
ndashFeeling of increased energy
bull Releases dopamine to produce feelings of well-beingndash Actually improves memory and cognition
bull Sensitivity actually declines overnight
bull Release of insulinndash Slightly hyperglycemic
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
105
DOS CME Course 2011
Genetic componentbull About 10 of smokers lack the gene for nicotine
dependence
ndashldquosocial or occasionalrdquo smokers
ndashThey really can quit anytime they want to
ndashNo withdrawal symptoms
ndashStill poses a health risk
bull The other 90 will demonstrate physical and psychological symptoms of withdrawal
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
106
DOS CME Course 2011
Smoking
bull Identify tobacco users ndash Ask every patient every visit
ndash Have you used tobacco in the last 12 months
ndash Clinic-wide program
bull Advise every tobacco user to quitndash Personalize the message
ndash Be clear
ndash Be firm
If at first you donrsquot succeed try tryagain Bring it up at every encounter
107
DOS CME Course 2011
Smoking cessationbull Some more good reasons to quit
ndashSmoking costs over $2000 a year in current US dollars
ndashThere is no accepted safe level of cigarette smoke
ndashSecondhand smoke carries the same hazards
ndashIncreased risk of SIDS and asthma exacerbations in children
httpwwwlungusaorgstop-smokingabout-smokingfacts-figuresgeneral-smoking-factshtml
108
DOS CME Course 2011
Smoking cessation
bull Nicotine is a powerful drug addiction
bull Treat as a chronic illness
bull All healthcare providers encouraged to participate
bull Assess willingness to quit
bull Promote motivation
109
DOS CME Course 2011
Smoking cessation
bull Prochaskarsquos change theory
bull Precontemplation
ndashNot even thinking about quitting
ndashProvide education on the risks and costs of smoking
bull Contemplation
ndashAwareness that a problem exists
ndashContinue to find motivations to stop
NorcrossJC Krebs PM Prochaska JO(2011)
110
DOS CME Course 2011
Change is good
bull Determination
ndashExpressing willingness to act
ndashSelf-efficacy
bull Action ndash Currently not smoking
ndash May relapse
bull It is not unusual for a patient to ldquoquitrdquo three or four times
bull Continue to encourage and motivate himher to stop
NorcrossJC Krebs PM Prochaska JO(2011)
111
DOS CME Course 2011
Smoking cessationbull Assist the patient
ndashCollaborate with the patient to develop a plan to quit
ndashAchievable clearly defined goals
ndashIdentify and engage social supports
ndashFamily support groups
ndashPharmacologic (more on this later)
bull Arrange follow-up
ndashAt each successive visit review progress on quitting strategy
ndashLets the patient know heshe is not alone in this effort
ndashAccountability
112
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
Nebulizer Treatment
bull Albuterol Solution
ndashlt5 years old 063-25 mg in 3 cc of saline q 4-6 hours as needed
ndashgt5 years old -adult 125-5 mg in 3 cc of saline q 4-8 hours as needed
bull Levalbuterol (R-albuterol solution Xopinex)
ndashlt 5 years old 031 mg-125 mg in 3 cc NS q 4-6 hrs as needed
ndash5-11 yrs old 031-063 mg q 8 hours prn symptoms
ndashgt12 yrs old063mg-125 mg q 8 hours prn symptoms
DOS Wheezing protocol
59
DOS CME Course 2011
Treatment at home
bull Nebulizers convert liquid or powder medications to aerosolized formndash Effective to deliver larger doses than metered dose inhalers
Patient safety alert Some medications in powder formcome as a capsule which is broken open The patient should not take this medication orally
60
DOS CME Course 2011
How often
do the following
happen
MILD INTERMITTENT(check appropriate box)
MILD PERSISTENT
MODERATE PERSISTENT
SEVERE PERSISTENT
Daytime wheezingshortness of breath
0-2 times per week
Greater than 2 times per week
Daily Continually
Night-time wheezing shortness of breath
0-2 times per month
Greater than 2 times per month
Greater than 1 time per week
Frequent
How often are your physical activities limited by asthma
0-2 times per week
0-2 times per week
Greater than 2 times per week
Frequent
Daily use of albuterol or ldquorescue drugsrdquo
Less than 1 time per week or less than 3 times per month
2 time per week or more
Daily Use Frequent
DOS Wheezing protocol61
DOS CME Course 2011
Plan of carebull Step 1mdashmild intermittent
ndash no daily medication
ndash should have prn short acting rescue Beta 2 inhaler on hand
bull Step 2mdashmild persistentndash low dose inhaled corticosteroids
bull Step 3mdashmoderate persistentndash low to med inhaled corticosteroids and long acting beta 2 agonists
bull Step 4mdashsevere persistentndash high dose inhaled corticosteroids and long acting inhaled beta 2
agonists
DOS Wheezing protocol
62
DOS CME Course 2011
Ongoing carebull Plan Follow-up
ndash Evaluate 2-6 weeks after treatment initiationndash Evaluate every 1-6 months when stablendash Evaluate every 3 months interval after stepping down therapyndash Annual inactivated influenza vaccine
bull ConsultationReferralndash Life threatening or severe persistent asthmandash Goals of asthma therapy not fulfilled in 3-6 monthsndash Signs and symptoms are not typicalndash Sinusitis gastroesophageal reflux or chronic pulmonary disease
complicate the asthma
DOS Wheezing protocol
63
DOS CME Course 2011
Consults
bull Continuous oral corticosteroids or 2 bursts of oral steroids in 1 year
bull Patient under 3 years with step 3 or 4 asthma
bull If omalizumab (Xolair) is considered for treatment as there is an increase in rate of anaphylaxis with this medication
bull Exacerbation requiring hospitalization
DOS Wheezing protocol
64
DOS CME Course 2011
Patient educationbull Basic understanding of asthma and how the disease
works
bull Medications ndash Names and doses of all medications
ndash Short acting vs long acting
bull Equipment ndash Metered dose inhalers (MDI)
ndash Nebulizers
bull Emergency response
bull Activity level
bull Illness management
65
DOS CME Course 2011
Patient education
bull Know your triggers and have a strategy for avoidance
bull If mold or mites are known triggers humidifiers and evaporator coolers are not recommended in the home
bull Know the early signs of an exacerbation and what to do
bull Develop an action plan based on peak flow readings
bull What to do in case of an attack at school or work
66
DOS CME Course 2011
Patient educationbull Metered dose inhalers
ndash Remove cap and invert the device several times
ndash Exhale
ndash Place the mouthpiece between your lips with a good seal
ndash Inhale while depressing the top of the MDI
ndash Hold your breath for 10 seconds
ndash Exhale
ndash Repeat as needed
67
DOS CME Course 2011
Patient educationbull Spacers are used with MDIrsquos
used to deliver inhaled steroidsndash Ease coordination of breathing
and medication delivery
ndash Decrease the amount of medication contacting the oral mucosa
ndash Fewer side effects
bull Attach the spacer to the mouthpiece of the MDI ndash Use the MDI as described
before
ndash Some models have a whistle to indicate you are inhaling too rapidly
68
DOS CME Course 201169
DOS CME Course 2011
Characteristic Controlled
(All of the following)
Partly controlled
(Any measure noted)
Uncontrolled
Daytime symptoms
None (twice or less a week)
More than twice a week
Three or more features of partly controlled asthma
Limitation of activities
None Any
Nocturnal symptomsawakening
None Any
Need for rescue treatment
None (twice or less a week)
More than twice a week
Lung function (FEV1 or PEF)
Normal lt80 predicted or personal best
70
DOS CME Course 2011
Asthma
bull Self monitoring is essential to effective management and control
bull The following are validated tools to assess asthma control
ndashAsthmacontrolcom
ndashFree web-based
ndashQoltechcouk
ndashFree in hard copy or electronic versions
ndashRequires permission
ndashAtaqinstrumentcom
ndashFree web-based
71
DOS CME Course 2011DOS CME Course 201172
Every Life Deserves World Class Care
COPD
72
DOS CME Course 2011
Chronic obstructive pulmonary disease
bull By the numbers
bull 210 million suffer worldwide
bull 3 million fatalities
bull By 2030 COPD is expected to be the third leading cause of death worldwide
bull Most important risk factors ndash Smoking
ndash Indoor pollution
ndash Outdoor pollution
ndash Occupational irritants
WHO Retrieved January 2011
73
DOS CME Course 2011
COPD
bull Causes ndash Cigarette smoking is the number one cause worldwide
ndash Environmental irritants
ndash Genetic alpha-one antitrypsin deficiency
bull Birth defects ndash Low birth weight
ndash Respiratory infections
ndash Any factor which impairs lung development during gestation
bull Other ndash HIV
ndash Connective tissue disorders
ndash Vasculitis
74
DOS CME Course 2011
COPD
bull Sometimes referred to as umbrella term for a family of diseases which cause limited airflow
ndashChronic bronchitis
ndashEmphysema
bull Inflammation of the airways
bull Increased mucous productionndash Especially in bronchitis
bull Decreased ciliary function
bull Loss of elastic recoil ndash Especially in emphysema
75
DOS CME Course 2011
COPD
bull How inflammation ruins a lung
bull Cell mediated ndash Neutrophils
ndash Macrophages
ndash Lymphocytes
bull Release cytokines which attract more cells
bull Oxidants released by cells and found in cigarette smoke
bull Proteases
bull Cause remodeling and long term structural changes
76
DOS CME Course 2011
COPDbull Alveoli lose elasticity and become distended
ndashSaggy sacs
ndashCarbon dioxide retention
ndashChronic respiratory acidosis
bull Walls of the alveoli are degraded
ndashLoss of surface area necessary for gas exchange
77
DOS CME Course 2011
What the patient looks like
bull Productive Cough
ndashEspecially in chronic bronchitis
bull Progressive dyspnea
ndashUncomfortable awareness of breathing
bull Wheezing and chest tightness
bull Increase in AP chest diameter
ndashldquoBarrel chestrdquo especially in emphysema
ndashIncreased inspiratory effort loosens costochondral cartilage
78
DOS CME Course 2011
Alpha one antitrypsin deficiency
bull Enzyme normally produced which protects the lungs
bull Deactivates neutrophil elastase
ndashReleased during inflammation
bull Estimated over 100000 in US have AATD
bull Time to diagnosis gt8 years
bull Related to increased mortality (Krowka 2010)
ndashIncreased incidence of emphysema
79
DOS CME Course 2011
Chronic bronchitis
bull Presence of cough and sputum production over three months for two consecutive years
ndashNote the months need not be consecutive
bull The patient may feel as though they are constantly sick
bull Multiple courses of antibiotics with no improvement
bull No relationship to acute bronchitis caused by bacteria or virus
80
DOS CME Course 2011
COPD
bull Break out the testing ndash CXR
ndash ECG
ndash Sputum culture
ndash CBC and electrolytes
bull ABGrsquos ndash Respiratory failure indicated by
ndash PaO2lt 60 and SaO2 lt 90
ndash with or without PaCO2 gt 50
ndash On room air
ndash Severe acidosis pHlt 736 in addition to the above is an indication for mechanical ventilation
(GOLD 2009 p 22)
81
DOS CME Course 2011
Chronic bronchitis
bull Airway of a child afflicted with chronic bronchitis compared to normal
82
DOS CME Course 2011
Chronic bronchitisbull Related to mucociliary dysfunction
ndashIncreased mucous production and thickening
ndashLoss of cilia
ndashLoss of ciliary function
ndashMobility required to sweep out particles
83
DOS CME Course 2011
Emphysemabull Permanent enlargement of the airspaces terminal to the
distal bronchioles ndashLoss of surface area for gas exchangendashDestruction of supporting structure of alveoli
ndashAirway narrowing
bull Three distinct patterns ndashCentracinar begins centrally and spreads to terminal
bronchioles and is most closely associated with cigarette smoking
ndashPanacinar destroys alveoli uniformly predominant in lower half of lungs most closely associated with AATD
ndashParaseptal destroys the distal airway structures alveolar ducts and sacs
Demirjian BG 2010
84
DOS CME Course 2011
Bullaebull Outpouchingsballooning of lung tissue due to trapped air
ndashAir is released from damaged alveoli
ndashAsymptomatic
ndashRupture can cause pneumothorax
85
DOS CME Course 2011
Diagnosis
bull History of smoking or exposure to inhaled irritants
ndashRemember to consider work and living environment
ndashCooking indoors with fossil fuels
ndashAge over 40
bull Signs and symptoms
ndashChronic cough with sputum production
ndashDyspnea which persists daily worsens with exercise and progresses over time
bull Spirometry is strongly recommended
86
DOS CME Course 2011
Diagnosis
bull Chest x-ray
ndashRule out pneumonia cardiomyopathy
ndashNot diagnostic for COPD but may reveal other causes for symptoms
bull Arterial blood gases
ndashRecommended for patients with FEVlt 50
ndashPaO2lt 60 mmHg suggests respiratory failure
bull Sputum culture
ndashRule out infectious process
87
DOS CME Course 2011
Disease stages
bull Stage Indash FEVFVC lt 70
ndash FEV gt 80
ndash Few symptoms if any patient may be unaware
bull Stage II moderate ndash FEVFVC lt 70
ndash FEV lt 80
ndash Along with shortness of breath
88
DOS CME Course 2011
Disease stages
bull Stage IV very severe ndash FEVFVC lt 70
ndash FEV lt 30
ndash At this stage exacerbations are life-threatening
ndash Quality of life is impaired further
bull Stage III severe ndash FEVFVC lt 70
ndash FEV lt 50
ndash Worsening symptoms increasing frequency of exacerbations
89
DOS CME Course 2011
COPD vs Asthma
bull COPD
ndashOnset later in life
ndashProgressive worsening symptoms
ndashSmoking history
ndashDyspnea with exercise
ndashLargely irreversible airflow limitation
bull Asthma
ndashOnset of symptoms usually earlier in life
ndashWorsening at night
ndashLargely reversible airflow limitation
ndashSymptoms vary from day to day
90
DOS CME Course 2011
COPD Treatmentbull Now that we have diagnosis what do I do about it
bull Assess and monitor diseasendash Assess for risk factors ie smoking family history
ndash Co-morbidities such as heart failure
ndash Pattern of symptoms
ndash Impact on quality of life
bull Reduce risk factors ndash Identify environmentaloccupational factors which can be modified
ndash Smoking cessation is essential
ndash Manage exacerbations
91
DOS CME Course 2011
COPDbull Manage stable COPD
ndash Determine disease severity based on frequency and severity of symptoms
ndash Educate the patient about risk factors and disease management regimen
ndash Collaborate with the patient to develop a personalized regimen
ndashFits their lifestyle
ndashAccounts for cultural preferences family involvement
ndashAvailability of testing and medications
92
DOS CME Course 2011
Pharmacologybull Goals
ndash Improve exercise tolerance
ndash Control symptoms
ndash Reduce frequency and severity of exacerbations
ndash Improve health status
bull Bronchodilators ndash Include long-acting therapy with short-acting for better control
bull Combine medications from different classes rather than increasing dosage of just onendash Minimizes side effects
93
DOS CME Course 2011
Pharmacologybull Glucocorticosteroids
ndashCan reduce the number of exacerbations
ndashIncreased risk of pneumonia
ndashNo noted reduction in mortality
bull Vaccines
ndashInfluenza vaccines decrease serious illness and death by 50
ndashRecommended annually
ndashPneumococcal vaccines recommended for all COPD sufferers even under age 65
GOLD 2009
94
DOS CME Course 2011
Antibiotics
bull Antibiotics are not a treatment for COPD nor do they manage symptoms of an exacerbation
bull Should be given only if the following are metndash Presence of three cardinal symptoms increased dyspnea
increased sputum volume increased sputum purulence
ndash Increased sputum purulence plus one other cardinal symptom
ndash Mechanically ventilated
bull May be difficult for patients to understand why antibiotics will not ldquofixrdquo what is wrong
bull Good opportunity for learning needs assessment
GOLD 2009
95
DOS CME Course 2011
COPD
bull Pulmonary rehabilitation
bull Encourage the patient to continue activities as tolerated ndash Move as much as you can before you canrsquot move
bull Uses low impact exercise to maintain physical function
bull Exercise can be done while seatedndash Monitor pulse oximetry respiratory rate and effort before during
and after activity
bull Set goals which are realistic for both of you
96
DOS CME Course 2011
COPD
bull Pulmonary rehab includes education nutrition and exercise
bull Can be a good source of social support for someone who has seen function decline
ndashTalk with others in the same situation
ndashFind out how they cope
ndashSocialize
bull Regular influenza and pneumonia vaccines
97
DOS CME Course 2011
COPD
bull Oxygen therapy
bull Recommended for stage IV disease ndash PaO2 lt or = 55 mmHg
ndash SaO2 lt or = 88
bull Increases survival improves hemodynamicsbenefits mental state
bull Surgical options reviewed on a case-by-case basisndash Bullectomy
ndash Lung volume reduction ndashNo evidence to support this as a widespread therapy
98
DOS CME Course 2011
COPD
bull Managing exacerbations
bull An event in the natural course of the disease characterized by a change in baseline dyspnea cough or sputum beyond day to day variance is acute in onset and may warrant a change in medication
bull Air pollution and tracheobronchial infections are the most common causes
bull 30 of exacerbations no cause identified
(GOLD 2009 p 22)
99
DOS CME Course 2011
COPD
bull Hospitalization is recommended for patients exhibiting the following
ndash Failure of exacerbation to respond to medical treatment
ndash Development of new symptoms ie peripheral edema cyanosis
ndash Significant co-morbidities
ndash History of frequent exacerbations
ndash Newly occurring arrhythmias
ndash Advanced age
ndash Insufficient home support
ndash Unclear diagnosis
(GOLD 2009 p 23)
100
DOS CME Course 2011
COPD
bull Mechanical ventilation is not recognized as an effective management strategy for stable COPD
bull May be required as supportive therapy during an exacerbation
bull Associated with mortality
bull Carries risks of its ownndash Ventilator acquired pneumonia
ndash Ventilator induced lung injury
ndash Failure to wean
(GOLD 2009)
101
DOS CME Course 2011DOS CME Course 2011102
Every Life Deserves World Class Care
Smoking
102
DOS CME Course 2011
Smoking bull By the numbers
bull More than 400 000 Americans die from smoking-related illnesses each yearndash Thatrsquos one of every 5 deaths
bull In a study of 2963 health care encounters smoking was discussed 633 times
bull Nicotine released into the body within 10 seconds of inhalation
bull If a person smokes one pack per day and takes ten puffs of each cigarette that equates to 200 ldquohitsrdquo of nicotine daily
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
103
DOS CME Course 2011
Nicotine
bull Nicotinic receptors occur naturally
bull N1 receptors in the adrenal medulla
bull Neuromuscular junction of autonomic ganglia
bull N2 receptors in skeletal muscle
bull Number of receptor sites increases with regular stimulation
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
104
DOS CME Course 2011
Nicotinebull Addictive
bull Vasoconstrictor
bull Releases adrenaline from the adrenal cortex
ndashFeeling of increased energy
bull Releases dopamine to produce feelings of well-beingndash Actually improves memory and cognition
bull Sensitivity actually declines overnight
bull Release of insulinndash Slightly hyperglycemic
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
105
DOS CME Course 2011
Genetic componentbull About 10 of smokers lack the gene for nicotine
dependence
ndashldquosocial or occasionalrdquo smokers
ndashThey really can quit anytime they want to
ndashNo withdrawal symptoms
ndashStill poses a health risk
bull The other 90 will demonstrate physical and psychological symptoms of withdrawal
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
106
DOS CME Course 2011
Smoking
bull Identify tobacco users ndash Ask every patient every visit
ndash Have you used tobacco in the last 12 months
ndash Clinic-wide program
bull Advise every tobacco user to quitndash Personalize the message
ndash Be clear
ndash Be firm
If at first you donrsquot succeed try tryagain Bring it up at every encounter
107
DOS CME Course 2011
Smoking cessationbull Some more good reasons to quit
ndashSmoking costs over $2000 a year in current US dollars
ndashThere is no accepted safe level of cigarette smoke
ndashSecondhand smoke carries the same hazards
ndashIncreased risk of SIDS and asthma exacerbations in children
httpwwwlungusaorgstop-smokingabout-smokingfacts-figuresgeneral-smoking-factshtml
108
DOS CME Course 2011
Smoking cessation
bull Nicotine is a powerful drug addiction
bull Treat as a chronic illness
bull All healthcare providers encouraged to participate
bull Assess willingness to quit
bull Promote motivation
109
DOS CME Course 2011
Smoking cessation
bull Prochaskarsquos change theory
bull Precontemplation
ndashNot even thinking about quitting
ndashProvide education on the risks and costs of smoking
bull Contemplation
ndashAwareness that a problem exists
ndashContinue to find motivations to stop
NorcrossJC Krebs PM Prochaska JO(2011)
110
DOS CME Course 2011
Change is good
bull Determination
ndashExpressing willingness to act
ndashSelf-efficacy
bull Action ndash Currently not smoking
ndash May relapse
bull It is not unusual for a patient to ldquoquitrdquo three or four times
bull Continue to encourage and motivate himher to stop
NorcrossJC Krebs PM Prochaska JO(2011)
111
DOS CME Course 2011
Smoking cessationbull Assist the patient
ndashCollaborate with the patient to develop a plan to quit
ndashAchievable clearly defined goals
ndashIdentify and engage social supports
ndashFamily support groups
ndashPharmacologic (more on this later)
bull Arrange follow-up
ndashAt each successive visit review progress on quitting strategy
ndashLets the patient know heshe is not alone in this effort
ndashAccountability
112
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
How often
do the following
happen
MILD INTERMITTENT(check appropriate box)
MILD PERSISTENT
MODERATE PERSISTENT
SEVERE PERSISTENT
Daytime wheezingshortness of breath
0-2 times per week
Greater than 2 times per week
Daily Continually
Night-time wheezing shortness of breath
0-2 times per month
Greater than 2 times per month
Greater than 1 time per week
Frequent
How often are your physical activities limited by asthma
0-2 times per week
0-2 times per week
Greater than 2 times per week
Frequent
Daily use of albuterol or ldquorescue drugsrdquo
Less than 1 time per week or less than 3 times per month
2 time per week or more
Daily Use Frequent
DOS Wheezing protocol61
DOS CME Course 2011
Plan of carebull Step 1mdashmild intermittent
ndash no daily medication
ndash should have prn short acting rescue Beta 2 inhaler on hand
bull Step 2mdashmild persistentndash low dose inhaled corticosteroids
bull Step 3mdashmoderate persistentndash low to med inhaled corticosteroids and long acting beta 2 agonists
bull Step 4mdashsevere persistentndash high dose inhaled corticosteroids and long acting inhaled beta 2
agonists
DOS Wheezing protocol
62
DOS CME Course 2011
Ongoing carebull Plan Follow-up
ndash Evaluate 2-6 weeks after treatment initiationndash Evaluate every 1-6 months when stablendash Evaluate every 3 months interval after stepping down therapyndash Annual inactivated influenza vaccine
bull ConsultationReferralndash Life threatening or severe persistent asthmandash Goals of asthma therapy not fulfilled in 3-6 monthsndash Signs and symptoms are not typicalndash Sinusitis gastroesophageal reflux or chronic pulmonary disease
complicate the asthma
DOS Wheezing protocol
63
DOS CME Course 2011
Consults
bull Continuous oral corticosteroids or 2 bursts of oral steroids in 1 year
bull Patient under 3 years with step 3 or 4 asthma
bull If omalizumab (Xolair) is considered for treatment as there is an increase in rate of anaphylaxis with this medication
bull Exacerbation requiring hospitalization
DOS Wheezing protocol
64
DOS CME Course 2011
Patient educationbull Basic understanding of asthma and how the disease
works
bull Medications ndash Names and doses of all medications
ndash Short acting vs long acting
bull Equipment ndash Metered dose inhalers (MDI)
ndash Nebulizers
bull Emergency response
bull Activity level
bull Illness management
65
DOS CME Course 2011
Patient education
bull Know your triggers and have a strategy for avoidance
bull If mold or mites are known triggers humidifiers and evaporator coolers are not recommended in the home
bull Know the early signs of an exacerbation and what to do
bull Develop an action plan based on peak flow readings
bull What to do in case of an attack at school or work
66
DOS CME Course 2011
Patient educationbull Metered dose inhalers
ndash Remove cap and invert the device several times
ndash Exhale
ndash Place the mouthpiece between your lips with a good seal
ndash Inhale while depressing the top of the MDI
ndash Hold your breath for 10 seconds
ndash Exhale
ndash Repeat as needed
67
DOS CME Course 2011
Patient educationbull Spacers are used with MDIrsquos
used to deliver inhaled steroidsndash Ease coordination of breathing
and medication delivery
ndash Decrease the amount of medication contacting the oral mucosa
ndash Fewer side effects
bull Attach the spacer to the mouthpiece of the MDI ndash Use the MDI as described
before
ndash Some models have a whistle to indicate you are inhaling too rapidly
68
DOS CME Course 201169
DOS CME Course 2011
Characteristic Controlled
(All of the following)
Partly controlled
(Any measure noted)
Uncontrolled
Daytime symptoms
None (twice or less a week)
More than twice a week
Three or more features of partly controlled asthma
Limitation of activities
None Any
Nocturnal symptomsawakening
None Any
Need for rescue treatment
None (twice or less a week)
More than twice a week
Lung function (FEV1 or PEF)
Normal lt80 predicted or personal best
70
DOS CME Course 2011
Asthma
bull Self monitoring is essential to effective management and control
bull The following are validated tools to assess asthma control
ndashAsthmacontrolcom
ndashFree web-based
ndashQoltechcouk
ndashFree in hard copy or electronic versions
ndashRequires permission
ndashAtaqinstrumentcom
ndashFree web-based
71
DOS CME Course 2011DOS CME Course 201172
Every Life Deserves World Class Care
COPD
72
DOS CME Course 2011
Chronic obstructive pulmonary disease
bull By the numbers
bull 210 million suffer worldwide
bull 3 million fatalities
bull By 2030 COPD is expected to be the third leading cause of death worldwide
bull Most important risk factors ndash Smoking
ndash Indoor pollution
ndash Outdoor pollution
ndash Occupational irritants
WHO Retrieved January 2011
73
DOS CME Course 2011
COPD
bull Causes ndash Cigarette smoking is the number one cause worldwide
ndash Environmental irritants
ndash Genetic alpha-one antitrypsin deficiency
bull Birth defects ndash Low birth weight
ndash Respiratory infections
ndash Any factor which impairs lung development during gestation
bull Other ndash HIV
ndash Connective tissue disorders
ndash Vasculitis
74
DOS CME Course 2011
COPD
bull Sometimes referred to as umbrella term for a family of diseases which cause limited airflow
ndashChronic bronchitis
ndashEmphysema
bull Inflammation of the airways
bull Increased mucous productionndash Especially in bronchitis
bull Decreased ciliary function
bull Loss of elastic recoil ndash Especially in emphysema
75
DOS CME Course 2011
COPD
bull How inflammation ruins a lung
bull Cell mediated ndash Neutrophils
ndash Macrophages
ndash Lymphocytes
bull Release cytokines which attract more cells
bull Oxidants released by cells and found in cigarette smoke
bull Proteases
bull Cause remodeling and long term structural changes
76
DOS CME Course 2011
COPDbull Alveoli lose elasticity and become distended
ndashSaggy sacs
ndashCarbon dioxide retention
ndashChronic respiratory acidosis
bull Walls of the alveoli are degraded
ndashLoss of surface area necessary for gas exchange
77
DOS CME Course 2011
What the patient looks like
bull Productive Cough
ndashEspecially in chronic bronchitis
bull Progressive dyspnea
ndashUncomfortable awareness of breathing
bull Wheezing and chest tightness
bull Increase in AP chest diameter
ndashldquoBarrel chestrdquo especially in emphysema
ndashIncreased inspiratory effort loosens costochondral cartilage
78
DOS CME Course 2011
Alpha one antitrypsin deficiency
bull Enzyme normally produced which protects the lungs
bull Deactivates neutrophil elastase
ndashReleased during inflammation
bull Estimated over 100000 in US have AATD
bull Time to diagnosis gt8 years
bull Related to increased mortality (Krowka 2010)
ndashIncreased incidence of emphysema
79
DOS CME Course 2011
Chronic bronchitis
bull Presence of cough and sputum production over three months for two consecutive years
ndashNote the months need not be consecutive
bull The patient may feel as though they are constantly sick
bull Multiple courses of antibiotics with no improvement
bull No relationship to acute bronchitis caused by bacteria or virus
80
DOS CME Course 2011
COPD
bull Break out the testing ndash CXR
ndash ECG
ndash Sputum culture
ndash CBC and electrolytes
bull ABGrsquos ndash Respiratory failure indicated by
ndash PaO2lt 60 and SaO2 lt 90
ndash with or without PaCO2 gt 50
ndash On room air
ndash Severe acidosis pHlt 736 in addition to the above is an indication for mechanical ventilation
(GOLD 2009 p 22)
81
DOS CME Course 2011
Chronic bronchitis
bull Airway of a child afflicted with chronic bronchitis compared to normal
82
DOS CME Course 2011
Chronic bronchitisbull Related to mucociliary dysfunction
ndashIncreased mucous production and thickening
ndashLoss of cilia
ndashLoss of ciliary function
ndashMobility required to sweep out particles
83
DOS CME Course 2011
Emphysemabull Permanent enlargement of the airspaces terminal to the
distal bronchioles ndashLoss of surface area for gas exchangendashDestruction of supporting structure of alveoli
ndashAirway narrowing
bull Three distinct patterns ndashCentracinar begins centrally and spreads to terminal
bronchioles and is most closely associated with cigarette smoking
ndashPanacinar destroys alveoli uniformly predominant in lower half of lungs most closely associated with AATD
ndashParaseptal destroys the distal airway structures alveolar ducts and sacs
Demirjian BG 2010
84
DOS CME Course 2011
Bullaebull Outpouchingsballooning of lung tissue due to trapped air
ndashAir is released from damaged alveoli
ndashAsymptomatic
ndashRupture can cause pneumothorax
85
DOS CME Course 2011
Diagnosis
bull History of smoking or exposure to inhaled irritants
ndashRemember to consider work and living environment
ndashCooking indoors with fossil fuels
ndashAge over 40
bull Signs and symptoms
ndashChronic cough with sputum production
ndashDyspnea which persists daily worsens with exercise and progresses over time
bull Spirometry is strongly recommended
86
DOS CME Course 2011
Diagnosis
bull Chest x-ray
ndashRule out pneumonia cardiomyopathy
ndashNot diagnostic for COPD but may reveal other causes for symptoms
bull Arterial blood gases
ndashRecommended for patients with FEVlt 50
ndashPaO2lt 60 mmHg suggests respiratory failure
bull Sputum culture
ndashRule out infectious process
87
DOS CME Course 2011
Disease stages
bull Stage Indash FEVFVC lt 70
ndash FEV gt 80
ndash Few symptoms if any patient may be unaware
bull Stage II moderate ndash FEVFVC lt 70
ndash FEV lt 80
ndash Along with shortness of breath
88
DOS CME Course 2011
Disease stages
bull Stage IV very severe ndash FEVFVC lt 70
ndash FEV lt 30
ndash At this stage exacerbations are life-threatening
ndash Quality of life is impaired further
bull Stage III severe ndash FEVFVC lt 70
ndash FEV lt 50
ndash Worsening symptoms increasing frequency of exacerbations
89
DOS CME Course 2011
COPD vs Asthma
bull COPD
ndashOnset later in life
ndashProgressive worsening symptoms
ndashSmoking history
ndashDyspnea with exercise
ndashLargely irreversible airflow limitation
bull Asthma
ndashOnset of symptoms usually earlier in life
ndashWorsening at night
ndashLargely reversible airflow limitation
ndashSymptoms vary from day to day
90
DOS CME Course 2011
COPD Treatmentbull Now that we have diagnosis what do I do about it
bull Assess and monitor diseasendash Assess for risk factors ie smoking family history
ndash Co-morbidities such as heart failure
ndash Pattern of symptoms
ndash Impact on quality of life
bull Reduce risk factors ndash Identify environmentaloccupational factors which can be modified
ndash Smoking cessation is essential
ndash Manage exacerbations
91
DOS CME Course 2011
COPDbull Manage stable COPD
ndash Determine disease severity based on frequency and severity of symptoms
ndash Educate the patient about risk factors and disease management regimen
ndash Collaborate with the patient to develop a personalized regimen
ndashFits their lifestyle
ndashAccounts for cultural preferences family involvement
ndashAvailability of testing and medications
92
DOS CME Course 2011
Pharmacologybull Goals
ndash Improve exercise tolerance
ndash Control symptoms
ndash Reduce frequency and severity of exacerbations
ndash Improve health status
bull Bronchodilators ndash Include long-acting therapy with short-acting for better control
bull Combine medications from different classes rather than increasing dosage of just onendash Minimizes side effects
93
DOS CME Course 2011
Pharmacologybull Glucocorticosteroids
ndashCan reduce the number of exacerbations
ndashIncreased risk of pneumonia
ndashNo noted reduction in mortality
bull Vaccines
ndashInfluenza vaccines decrease serious illness and death by 50
ndashRecommended annually
ndashPneumococcal vaccines recommended for all COPD sufferers even under age 65
GOLD 2009
94
DOS CME Course 2011
Antibiotics
bull Antibiotics are not a treatment for COPD nor do they manage symptoms of an exacerbation
bull Should be given only if the following are metndash Presence of three cardinal symptoms increased dyspnea
increased sputum volume increased sputum purulence
ndash Increased sputum purulence plus one other cardinal symptom
ndash Mechanically ventilated
bull May be difficult for patients to understand why antibiotics will not ldquofixrdquo what is wrong
bull Good opportunity for learning needs assessment
GOLD 2009
95
DOS CME Course 2011
COPD
bull Pulmonary rehabilitation
bull Encourage the patient to continue activities as tolerated ndash Move as much as you can before you canrsquot move
bull Uses low impact exercise to maintain physical function
bull Exercise can be done while seatedndash Monitor pulse oximetry respiratory rate and effort before during
and after activity
bull Set goals which are realistic for both of you
96
DOS CME Course 2011
COPD
bull Pulmonary rehab includes education nutrition and exercise
bull Can be a good source of social support for someone who has seen function decline
ndashTalk with others in the same situation
ndashFind out how they cope
ndashSocialize
bull Regular influenza and pneumonia vaccines
97
DOS CME Course 2011
COPD
bull Oxygen therapy
bull Recommended for stage IV disease ndash PaO2 lt or = 55 mmHg
ndash SaO2 lt or = 88
bull Increases survival improves hemodynamicsbenefits mental state
bull Surgical options reviewed on a case-by-case basisndash Bullectomy
ndash Lung volume reduction ndashNo evidence to support this as a widespread therapy
98
DOS CME Course 2011
COPD
bull Managing exacerbations
bull An event in the natural course of the disease characterized by a change in baseline dyspnea cough or sputum beyond day to day variance is acute in onset and may warrant a change in medication
bull Air pollution and tracheobronchial infections are the most common causes
bull 30 of exacerbations no cause identified
(GOLD 2009 p 22)
99
DOS CME Course 2011
COPD
bull Hospitalization is recommended for patients exhibiting the following
ndash Failure of exacerbation to respond to medical treatment
ndash Development of new symptoms ie peripheral edema cyanosis
ndash Significant co-morbidities
ndash History of frequent exacerbations
ndash Newly occurring arrhythmias
ndash Advanced age
ndash Insufficient home support
ndash Unclear diagnosis
(GOLD 2009 p 23)
100
DOS CME Course 2011
COPD
bull Mechanical ventilation is not recognized as an effective management strategy for stable COPD
bull May be required as supportive therapy during an exacerbation
bull Associated with mortality
bull Carries risks of its ownndash Ventilator acquired pneumonia
ndash Ventilator induced lung injury
ndash Failure to wean
(GOLD 2009)
101
DOS CME Course 2011DOS CME Course 2011102
Every Life Deserves World Class Care
Smoking
102
DOS CME Course 2011
Smoking bull By the numbers
bull More than 400 000 Americans die from smoking-related illnesses each yearndash Thatrsquos one of every 5 deaths
bull In a study of 2963 health care encounters smoking was discussed 633 times
bull Nicotine released into the body within 10 seconds of inhalation
bull If a person smokes one pack per day and takes ten puffs of each cigarette that equates to 200 ldquohitsrdquo of nicotine daily
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
103
DOS CME Course 2011
Nicotine
bull Nicotinic receptors occur naturally
bull N1 receptors in the adrenal medulla
bull Neuromuscular junction of autonomic ganglia
bull N2 receptors in skeletal muscle
bull Number of receptor sites increases with regular stimulation
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
104
DOS CME Course 2011
Nicotinebull Addictive
bull Vasoconstrictor
bull Releases adrenaline from the adrenal cortex
ndashFeeling of increased energy
bull Releases dopamine to produce feelings of well-beingndash Actually improves memory and cognition
bull Sensitivity actually declines overnight
bull Release of insulinndash Slightly hyperglycemic
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
105
DOS CME Course 2011
Genetic componentbull About 10 of smokers lack the gene for nicotine
dependence
ndashldquosocial or occasionalrdquo smokers
ndashThey really can quit anytime they want to
ndashNo withdrawal symptoms
ndashStill poses a health risk
bull The other 90 will demonstrate physical and psychological symptoms of withdrawal
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
106
DOS CME Course 2011
Smoking
bull Identify tobacco users ndash Ask every patient every visit
ndash Have you used tobacco in the last 12 months
ndash Clinic-wide program
bull Advise every tobacco user to quitndash Personalize the message
ndash Be clear
ndash Be firm
If at first you donrsquot succeed try tryagain Bring it up at every encounter
107
DOS CME Course 2011
Smoking cessationbull Some more good reasons to quit
ndashSmoking costs over $2000 a year in current US dollars
ndashThere is no accepted safe level of cigarette smoke
ndashSecondhand smoke carries the same hazards
ndashIncreased risk of SIDS and asthma exacerbations in children
httpwwwlungusaorgstop-smokingabout-smokingfacts-figuresgeneral-smoking-factshtml
108
DOS CME Course 2011
Smoking cessation
bull Nicotine is a powerful drug addiction
bull Treat as a chronic illness
bull All healthcare providers encouraged to participate
bull Assess willingness to quit
bull Promote motivation
109
DOS CME Course 2011
Smoking cessation
bull Prochaskarsquos change theory
bull Precontemplation
ndashNot even thinking about quitting
ndashProvide education on the risks and costs of smoking
bull Contemplation
ndashAwareness that a problem exists
ndashContinue to find motivations to stop
NorcrossJC Krebs PM Prochaska JO(2011)
110
DOS CME Course 2011
Change is good
bull Determination
ndashExpressing willingness to act
ndashSelf-efficacy
bull Action ndash Currently not smoking
ndash May relapse
bull It is not unusual for a patient to ldquoquitrdquo three or four times
bull Continue to encourage and motivate himher to stop
NorcrossJC Krebs PM Prochaska JO(2011)
111
DOS CME Course 2011
Smoking cessationbull Assist the patient
ndashCollaborate with the patient to develop a plan to quit
ndashAchievable clearly defined goals
ndashIdentify and engage social supports
ndashFamily support groups
ndashPharmacologic (more on this later)
bull Arrange follow-up
ndashAt each successive visit review progress on quitting strategy
ndashLets the patient know heshe is not alone in this effort
ndashAccountability
112
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
Ongoing carebull Plan Follow-up
ndash Evaluate 2-6 weeks after treatment initiationndash Evaluate every 1-6 months when stablendash Evaluate every 3 months interval after stepping down therapyndash Annual inactivated influenza vaccine
bull ConsultationReferralndash Life threatening or severe persistent asthmandash Goals of asthma therapy not fulfilled in 3-6 monthsndash Signs and symptoms are not typicalndash Sinusitis gastroesophageal reflux or chronic pulmonary disease
complicate the asthma
DOS Wheezing protocol
63
DOS CME Course 2011
Consults
bull Continuous oral corticosteroids or 2 bursts of oral steroids in 1 year
bull Patient under 3 years with step 3 or 4 asthma
bull If omalizumab (Xolair) is considered for treatment as there is an increase in rate of anaphylaxis with this medication
bull Exacerbation requiring hospitalization
DOS Wheezing protocol
64
DOS CME Course 2011
Patient educationbull Basic understanding of asthma and how the disease
works
bull Medications ndash Names and doses of all medications
ndash Short acting vs long acting
bull Equipment ndash Metered dose inhalers (MDI)
ndash Nebulizers
bull Emergency response
bull Activity level
bull Illness management
65
DOS CME Course 2011
Patient education
bull Know your triggers and have a strategy for avoidance
bull If mold or mites are known triggers humidifiers and evaporator coolers are not recommended in the home
bull Know the early signs of an exacerbation and what to do
bull Develop an action plan based on peak flow readings
bull What to do in case of an attack at school or work
66
DOS CME Course 2011
Patient educationbull Metered dose inhalers
ndash Remove cap and invert the device several times
ndash Exhale
ndash Place the mouthpiece between your lips with a good seal
ndash Inhale while depressing the top of the MDI
ndash Hold your breath for 10 seconds
ndash Exhale
ndash Repeat as needed
67
DOS CME Course 2011
Patient educationbull Spacers are used with MDIrsquos
used to deliver inhaled steroidsndash Ease coordination of breathing
and medication delivery
ndash Decrease the amount of medication contacting the oral mucosa
ndash Fewer side effects
bull Attach the spacer to the mouthpiece of the MDI ndash Use the MDI as described
before
ndash Some models have a whistle to indicate you are inhaling too rapidly
68
DOS CME Course 201169
DOS CME Course 2011
Characteristic Controlled
(All of the following)
Partly controlled
(Any measure noted)
Uncontrolled
Daytime symptoms
None (twice or less a week)
More than twice a week
Three or more features of partly controlled asthma
Limitation of activities
None Any
Nocturnal symptomsawakening
None Any
Need for rescue treatment
None (twice or less a week)
More than twice a week
Lung function (FEV1 or PEF)
Normal lt80 predicted or personal best
70
DOS CME Course 2011
Asthma
bull Self monitoring is essential to effective management and control
bull The following are validated tools to assess asthma control
ndashAsthmacontrolcom
ndashFree web-based
ndashQoltechcouk
ndashFree in hard copy or electronic versions
ndashRequires permission
ndashAtaqinstrumentcom
ndashFree web-based
71
DOS CME Course 2011DOS CME Course 201172
Every Life Deserves World Class Care
COPD
72
DOS CME Course 2011
Chronic obstructive pulmonary disease
bull By the numbers
bull 210 million suffer worldwide
bull 3 million fatalities
bull By 2030 COPD is expected to be the third leading cause of death worldwide
bull Most important risk factors ndash Smoking
ndash Indoor pollution
ndash Outdoor pollution
ndash Occupational irritants
WHO Retrieved January 2011
73
DOS CME Course 2011
COPD
bull Causes ndash Cigarette smoking is the number one cause worldwide
ndash Environmental irritants
ndash Genetic alpha-one antitrypsin deficiency
bull Birth defects ndash Low birth weight
ndash Respiratory infections
ndash Any factor which impairs lung development during gestation
bull Other ndash HIV
ndash Connective tissue disorders
ndash Vasculitis
74
DOS CME Course 2011
COPD
bull Sometimes referred to as umbrella term for a family of diseases which cause limited airflow
ndashChronic bronchitis
ndashEmphysema
bull Inflammation of the airways
bull Increased mucous productionndash Especially in bronchitis
bull Decreased ciliary function
bull Loss of elastic recoil ndash Especially in emphysema
75
DOS CME Course 2011
COPD
bull How inflammation ruins a lung
bull Cell mediated ndash Neutrophils
ndash Macrophages
ndash Lymphocytes
bull Release cytokines which attract more cells
bull Oxidants released by cells and found in cigarette smoke
bull Proteases
bull Cause remodeling and long term structural changes
76
DOS CME Course 2011
COPDbull Alveoli lose elasticity and become distended
ndashSaggy sacs
ndashCarbon dioxide retention
ndashChronic respiratory acidosis
bull Walls of the alveoli are degraded
ndashLoss of surface area necessary for gas exchange
77
DOS CME Course 2011
What the patient looks like
bull Productive Cough
ndashEspecially in chronic bronchitis
bull Progressive dyspnea
ndashUncomfortable awareness of breathing
bull Wheezing and chest tightness
bull Increase in AP chest diameter
ndashldquoBarrel chestrdquo especially in emphysema
ndashIncreased inspiratory effort loosens costochondral cartilage
78
DOS CME Course 2011
Alpha one antitrypsin deficiency
bull Enzyme normally produced which protects the lungs
bull Deactivates neutrophil elastase
ndashReleased during inflammation
bull Estimated over 100000 in US have AATD
bull Time to diagnosis gt8 years
bull Related to increased mortality (Krowka 2010)
ndashIncreased incidence of emphysema
79
DOS CME Course 2011
Chronic bronchitis
bull Presence of cough and sputum production over three months for two consecutive years
ndashNote the months need not be consecutive
bull The patient may feel as though they are constantly sick
bull Multiple courses of antibiotics with no improvement
bull No relationship to acute bronchitis caused by bacteria or virus
80
DOS CME Course 2011
COPD
bull Break out the testing ndash CXR
ndash ECG
ndash Sputum culture
ndash CBC and electrolytes
bull ABGrsquos ndash Respiratory failure indicated by
ndash PaO2lt 60 and SaO2 lt 90
ndash with or without PaCO2 gt 50
ndash On room air
ndash Severe acidosis pHlt 736 in addition to the above is an indication for mechanical ventilation
(GOLD 2009 p 22)
81
DOS CME Course 2011
Chronic bronchitis
bull Airway of a child afflicted with chronic bronchitis compared to normal
82
DOS CME Course 2011
Chronic bronchitisbull Related to mucociliary dysfunction
ndashIncreased mucous production and thickening
ndashLoss of cilia
ndashLoss of ciliary function
ndashMobility required to sweep out particles
83
DOS CME Course 2011
Emphysemabull Permanent enlargement of the airspaces terminal to the
distal bronchioles ndashLoss of surface area for gas exchangendashDestruction of supporting structure of alveoli
ndashAirway narrowing
bull Three distinct patterns ndashCentracinar begins centrally and spreads to terminal
bronchioles and is most closely associated with cigarette smoking
ndashPanacinar destroys alveoli uniformly predominant in lower half of lungs most closely associated with AATD
ndashParaseptal destroys the distal airway structures alveolar ducts and sacs
Demirjian BG 2010
84
DOS CME Course 2011
Bullaebull Outpouchingsballooning of lung tissue due to trapped air
ndashAir is released from damaged alveoli
ndashAsymptomatic
ndashRupture can cause pneumothorax
85
DOS CME Course 2011
Diagnosis
bull History of smoking or exposure to inhaled irritants
ndashRemember to consider work and living environment
ndashCooking indoors with fossil fuels
ndashAge over 40
bull Signs and symptoms
ndashChronic cough with sputum production
ndashDyspnea which persists daily worsens with exercise and progresses over time
bull Spirometry is strongly recommended
86
DOS CME Course 2011
Diagnosis
bull Chest x-ray
ndashRule out pneumonia cardiomyopathy
ndashNot diagnostic for COPD but may reveal other causes for symptoms
bull Arterial blood gases
ndashRecommended for patients with FEVlt 50
ndashPaO2lt 60 mmHg suggests respiratory failure
bull Sputum culture
ndashRule out infectious process
87
DOS CME Course 2011
Disease stages
bull Stage Indash FEVFVC lt 70
ndash FEV gt 80
ndash Few symptoms if any patient may be unaware
bull Stage II moderate ndash FEVFVC lt 70
ndash FEV lt 80
ndash Along with shortness of breath
88
DOS CME Course 2011
Disease stages
bull Stage IV very severe ndash FEVFVC lt 70
ndash FEV lt 30
ndash At this stage exacerbations are life-threatening
ndash Quality of life is impaired further
bull Stage III severe ndash FEVFVC lt 70
ndash FEV lt 50
ndash Worsening symptoms increasing frequency of exacerbations
89
DOS CME Course 2011
COPD vs Asthma
bull COPD
ndashOnset later in life
ndashProgressive worsening symptoms
ndashSmoking history
ndashDyspnea with exercise
ndashLargely irreversible airflow limitation
bull Asthma
ndashOnset of symptoms usually earlier in life
ndashWorsening at night
ndashLargely reversible airflow limitation
ndashSymptoms vary from day to day
90
DOS CME Course 2011
COPD Treatmentbull Now that we have diagnosis what do I do about it
bull Assess and monitor diseasendash Assess for risk factors ie smoking family history
ndash Co-morbidities such as heart failure
ndash Pattern of symptoms
ndash Impact on quality of life
bull Reduce risk factors ndash Identify environmentaloccupational factors which can be modified
ndash Smoking cessation is essential
ndash Manage exacerbations
91
DOS CME Course 2011
COPDbull Manage stable COPD
ndash Determine disease severity based on frequency and severity of symptoms
ndash Educate the patient about risk factors and disease management regimen
ndash Collaborate with the patient to develop a personalized regimen
ndashFits their lifestyle
ndashAccounts for cultural preferences family involvement
ndashAvailability of testing and medications
92
DOS CME Course 2011
Pharmacologybull Goals
ndash Improve exercise tolerance
ndash Control symptoms
ndash Reduce frequency and severity of exacerbations
ndash Improve health status
bull Bronchodilators ndash Include long-acting therapy with short-acting for better control
bull Combine medications from different classes rather than increasing dosage of just onendash Minimizes side effects
93
DOS CME Course 2011
Pharmacologybull Glucocorticosteroids
ndashCan reduce the number of exacerbations
ndashIncreased risk of pneumonia
ndashNo noted reduction in mortality
bull Vaccines
ndashInfluenza vaccines decrease serious illness and death by 50
ndashRecommended annually
ndashPneumococcal vaccines recommended for all COPD sufferers even under age 65
GOLD 2009
94
DOS CME Course 2011
Antibiotics
bull Antibiotics are not a treatment for COPD nor do they manage symptoms of an exacerbation
bull Should be given only if the following are metndash Presence of three cardinal symptoms increased dyspnea
increased sputum volume increased sputum purulence
ndash Increased sputum purulence plus one other cardinal symptom
ndash Mechanically ventilated
bull May be difficult for patients to understand why antibiotics will not ldquofixrdquo what is wrong
bull Good opportunity for learning needs assessment
GOLD 2009
95
DOS CME Course 2011
COPD
bull Pulmonary rehabilitation
bull Encourage the patient to continue activities as tolerated ndash Move as much as you can before you canrsquot move
bull Uses low impact exercise to maintain physical function
bull Exercise can be done while seatedndash Monitor pulse oximetry respiratory rate and effort before during
and after activity
bull Set goals which are realistic for both of you
96
DOS CME Course 2011
COPD
bull Pulmonary rehab includes education nutrition and exercise
bull Can be a good source of social support for someone who has seen function decline
ndashTalk with others in the same situation
ndashFind out how they cope
ndashSocialize
bull Regular influenza and pneumonia vaccines
97
DOS CME Course 2011
COPD
bull Oxygen therapy
bull Recommended for stage IV disease ndash PaO2 lt or = 55 mmHg
ndash SaO2 lt or = 88
bull Increases survival improves hemodynamicsbenefits mental state
bull Surgical options reviewed on a case-by-case basisndash Bullectomy
ndash Lung volume reduction ndashNo evidence to support this as a widespread therapy
98
DOS CME Course 2011
COPD
bull Managing exacerbations
bull An event in the natural course of the disease characterized by a change in baseline dyspnea cough or sputum beyond day to day variance is acute in onset and may warrant a change in medication
bull Air pollution and tracheobronchial infections are the most common causes
bull 30 of exacerbations no cause identified
(GOLD 2009 p 22)
99
DOS CME Course 2011
COPD
bull Hospitalization is recommended for patients exhibiting the following
ndash Failure of exacerbation to respond to medical treatment
ndash Development of new symptoms ie peripheral edema cyanosis
ndash Significant co-morbidities
ndash History of frequent exacerbations
ndash Newly occurring arrhythmias
ndash Advanced age
ndash Insufficient home support
ndash Unclear diagnosis
(GOLD 2009 p 23)
100
DOS CME Course 2011
COPD
bull Mechanical ventilation is not recognized as an effective management strategy for stable COPD
bull May be required as supportive therapy during an exacerbation
bull Associated with mortality
bull Carries risks of its ownndash Ventilator acquired pneumonia
ndash Ventilator induced lung injury
ndash Failure to wean
(GOLD 2009)
101
DOS CME Course 2011DOS CME Course 2011102
Every Life Deserves World Class Care
Smoking
102
DOS CME Course 2011
Smoking bull By the numbers
bull More than 400 000 Americans die from smoking-related illnesses each yearndash Thatrsquos one of every 5 deaths
bull In a study of 2963 health care encounters smoking was discussed 633 times
bull Nicotine released into the body within 10 seconds of inhalation
bull If a person smokes one pack per day and takes ten puffs of each cigarette that equates to 200 ldquohitsrdquo of nicotine daily
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
103
DOS CME Course 2011
Nicotine
bull Nicotinic receptors occur naturally
bull N1 receptors in the adrenal medulla
bull Neuromuscular junction of autonomic ganglia
bull N2 receptors in skeletal muscle
bull Number of receptor sites increases with regular stimulation
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
104
DOS CME Course 2011
Nicotinebull Addictive
bull Vasoconstrictor
bull Releases adrenaline from the adrenal cortex
ndashFeeling of increased energy
bull Releases dopamine to produce feelings of well-beingndash Actually improves memory and cognition
bull Sensitivity actually declines overnight
bull Release of insulinndash Slightly hyperglycemic
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
105
DOS CME Course 2011
Genetic componentbull About 10 of smokers lack the gene for nicotine
dependence
ndashldquosocial or occasionalrdquo smokers
ndashThey really can quit anytime they want to
ndashNo withdrawal symptoms
ndashStill poses a health risk
bull The other 90 will demonstrate physical and psychological symptoms of withdrawal
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
106
DOS CME Course 2011
Smoking
bull Identify tobacco users ndash Ask every patient every visit
ndash Have you used tobacco in the last 12 months
ndash Clinic-wide program
bull Advise every tobacco user to quitndash Personalize the message
ndash Be clear
ndash Be firm
If at first you donrsquot succeed try tryagain Bring it up at every encounter
107
DOS CME Course 2011
Smoking cessationbull Some more good reasons to quit
ndashSmoking costs over $2000 a year in current US dollars
ndashThere is no accepted safe level of cigarette smoke
ndashSecondhand smoke carries the same hazards
ndashIncreased risk of SIDS and asthma exacerbations in children
httpwwwlungusaorgstop-smokingabout-smokingfacts-figuresgeneral-smoking-factshtml
108
DOS CME Course 2011
Smoking cessation
bull Nicotine is a powerful drug addiction
bull Treat as a chronic illness
bull All healthcare providers encouraged to participate
bull Assess willingness to quit
bull Promote motivation
109
DOS CME Course 2011
Smoking cessation
bull Prochaskarsquos change theory
bull Precontemplation
ndashNot even thinking about quitting
ndashProvide education on the risks and costs of smoking
bull Contemplation
ndashAwareness that a problem exists
ndashContinue to find motivations to stop
NorcrossJC Krebs PM Prochaska JO(2011)
110
DOS CME Course 2011
Change is good
bull Determination
ndashExpressing willingness to act
ndashSelf-efficacy
bull Action ndash Currently not smoking
ndash May relapse
bull It is not unusual for a patient to ldquoquitrdquo three or four times
bull Continue to encourage and motivate himher to stop
NorcrossJC Krebs PM Prochaska JO(2011)
111
DOS CME Course 2011
Smoking cessationbull Assist the patient
ndashCollaborate with the patient to develop a plan to quit
ndashAchievable clearly defined goals
ndashIdentify and engage social supports
ndashFamily support groups
ndashPharmacologic (more on this later)
bull Arrange follow-up
ndashAt each successive visit review progress on quitting strategy
ndashLets the patient know heshe is not alone in this effort
ndashAccountability
112
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
Patient educationbull Basic understanding of asthma and how the disease
works
bull Medications ndash Names and doses of all medications
ndash Short acting vs long acting
bull Equipment ndash Metered dose inhalers (MDI)
ndash Nebulizers
bull Emergency response
bull Activity level
bull Illness management
65
DOS CME Course 2011
Patient education
bull Know your triggers and have a strategy for avoidance
bull If mold or mites are known triggers humidifiers and evaporator coolers are not recommended in the home
bull Know the early signs of an exacerbation and what to do
bull Develop an action plan based on peak flow readings
bull What to do in case of an attack at school or work
66
DOS CME Course 2011
Patient educationbull Metered dose inhalers
ndash Remove cap and invert the device several times
ndash Exhale
ndash Place the mouthpiece between your lips with a good seal
ndash Inhale while depressing the top of the MDI
ndash Hold your breath for 10 seconds
ndash Exhale
ndash Repeat as needed
67
DOS CME Course 2011
Patient educationbull Spacers are used with MDIrsquos
used to deliver inhaled steroidsndash Ease coordination of breathing
and medication delivery
ndash Decrease the amount of medication contacting the oral mucosa
ndash Fewer side effects
bull Attach the spacer to the mouthpiece of the MDI ndash Use the MDI as described
before
ndash Some models have a whistle to indicate you are inhaling too rapidly
68
DOS CME Course 201169
DOS CME Course 2011
Characteristic Controlled
(All of the following)
Partly controlled
(Any measure noted)
Uncontrolled
Daytime symptoms
None (twice or less a week)
More than twice a week
Three or more features of partly controlled asthma
Limitation of activities
None Any
Nocturnal symptomsawakening
None Any
Need for rescue treatment
None (twice or less a week)
More than twice a week
Lung function (FEV1 or PEF)
Normal lt80 predicted or personal best
70
DOS CME Course 2011
Asthma
bull Self monitoring is essential to effective management and control
bull The following are validated tools to assess asthma control
ndashAsthmacontrolcom
ndashFree web-based
ndashQoltechcouk
ndashFree in hard copy or electronic versions
ndashRequires permission
ndashAtaqinstrumentcom
ndashFree web-based
71
DOS CME Course 2011DOS CME Course 201172
Every Life Deserves World Class Care
COPD
72
DOS CME Course 2011
Chronic obstructive pulmonary disease
bull By the numbers
bull 210 million suffer worldwide
bull 3 million fatalities
bull By 2030 COPD is expected to be the third leading cause of death worldwide
bull Most important risk factors ndash Smoking
ndash Indoor pollution
ndash Outdoor pollution
ndash Occupational irritants
WHO Retrieved January 2011
73
DOS CME Course 2011
COPD
bull Causes ndash Cigarette smoking is the number one cause worldwide
ndash Environmental irritants
ndash Genetic alpha-one antitrypsin deficiency
bull Birth defects ndash Low birth weight
ndash Respiratory infections
ndash Any factor which impairs lung development during gestation
bull Other ndash HIV
ndash Connective tissue disorders
ndash Vasculitis
74
DOS CME Course 2011
COPD
bull Sometimes referred to as umbrella term for a family of diseases which cause limited airflow
ndashChronic bronchitis
ndashEmphysema
bull Inflammation of the airways
bull Increased mucous productionndash Especially in bronchitis
bull Decreased ciliary function
bull Loss of elastic recoil ndash Especially in emphysema
75
DOS CME Course 2011
COPD
bull How inflammation ruins a lung
bull Cell mediated ndash Neutrophils
ndash Macrophages
ndash Lymphocytes
bull Release cytokines which attract more cells
bull Oxidants released by cells and found in cigarette smoke
bull Proteases
bull Cause remodeling and long term structural changes
76
DOS CME Course 2011
COPDbull Alveoli lose elasticity and become distended
ndashSaggy sacs
ndashCarbon dioxide retention
ndashChronic respiratory acidosis
bull Walls of the alveoli are degraded
ndashLoss of surface area necessary for gas exchange
77
DOS CME Course 2011
What the patient looks like
bull Productive Cough
ndashEspecially in chronic bronchitis
bull Progressive dyspnea
ndashUncomfortable awareness of breathing
bull Wheezing and chest tightness
bull Increase in AP chest diameter
ndashldquoBarrel chestrdquo especially in emphysema
ndashIncreased inspiratory effort loosens costochondral cartilage
78
DOS CME Course 2011
Alpha one antitrypsin deficiency
bull Enzyme normally produced which protects the lungs
bull Deactivates neutrophil elastase
ndashReleased during inflammation
bull Estimated over 100000 in US have AATD
bull Time to diagnosis gt8 years
bull Related to increased mortality (Krowka 2010)
ndashIncreased incidence of emphysema
79
DOS CME Course 2011
Chronic bronchitis
bull Presence of cough and sputum production over three months for two consecutive years
ndashNote the months need not be consecutive
bull The patient may feel as though they are constantly sick
bull Multiple courses of antibiotics with no improvement
bull No relationship to acute bronchitis caused by bacteria or virus
80
DOS CME Course 2011
COPD
bull Break out the testing ndash CXR
ndash ECG
ndash Sputum culture
ndash CBC and electrolytes
bull ABGrsquos ndash Respiratory failure indicated by
ndash PaO2lt 60 and SaO2 lt 90
ndash with or without PaCO2 gt 50
ndash On room air
ndash Severe acidosis pHlt 736 in addition to the above is an indication for mechanical ventilation
(GOLD 2009 p 22)
81
DOS CME Course 2011
Chronic bronchitis
bull Airway of a child afflicted with chronic bronchitis compared to normal
82
DOS CME Course 2011
Chronic bronchitisbull Related to mucociliary dysfunction
ndashIncreased mucous production and thickening
ndashLoss of cilia
ndashLoss of ciliary function
ndashMobility required to sweep out particles
83
DOS CME Course 2011
Emphysemabull Permanent enlargement of the airspaces terminal to the
distal bronchioles ndashLoss of surface area for gas exchangendashDestruction of supporting structure of alveoli
ndashAirway narrowing
bull Three distinct patterns ndashCentracinar begins centrally and spreads to terminal
bronchioles and is most closely associated with cigarette smoking
ndashPanacinar destroys alveoli uniformly predominant in lower half of lungs most closely associated with AATD
ndashParaseptal destroys the distal airway structures alveolar ducts and sacs
Demirjian BG 2010
84
DOS CME Course 2011
Bullaebull Outpouchingsballooning of lung tissue due to trapped air
ndashAir is released from damaged alveoli
ndashAsymptomatic
ndashRupture can cause pneumothorax
85
DOS CME Course 2011
Diagnosis
bull History of smoking or exposure to inhaled irritants
ndashRemember to consider work and living environment
ndashCooking indoors with fossil fuels
ndashAge over 40
bull Signs and symptoms
ndashChronic cough with sputum production
ndashDyspnea which persists daily worsens with exercise and progresses over time
bull Spirometry is strongly recommended
86
DOS CME Course 2011
Diagnosis
bull Chest x-ray
ndashRule out pneumonia cardiomyopathy
ndashNot diagnostic for COPD but may reveal other causes for symptoms
bull Arterial blood gases
ndashRecommended for patients with FEVlt 50
ndashPaO2lt 60 mmHg suggests respiratory failure
bull Sputum culture
ndashRule out infectious process
87
DOS CME Course 2011
Disease stages
bull Stage Indash FEVFVC lt 70
ndash FEV gt 80
ndash Few symptoms if any patient may be unaware
bull Stage II moderate ndash FEVFVC lt 70
ndash FEV lt 80
ndash Along with shortness of breath
88
DOS CME Course 2011
Disease stages
bull Stage IV very severe ndash FEVFVC lt 70
ndash FEV lt 30
ndash At this stage exacerbations are life-threatening
ndash Quality of life is impaired further
bull Stage III severe ndash FEVFVC lt 70
ndash FEV lt 50
ndash Worsening symptoms increasing frequency of exacerbations
89
DOS CME Course 2011
COPD vs Asthma
bull COPD
ndashOnset later in life
ndashProgressive worsening symptoms
ndashSmoking history
ndashDyspnea with exercise
ndashLargely irreversible airflow limitation
bull Asthma
ndashOnset of symptoms usually earlier in life
ndashWorsening at night
ndashLargely reversible airflow limitation
ndashSymptoms vary from day to day
90
DOS CME Course 2011
COPD Treatmentbull Now that we have diagnosis what do I do about it
bull Assess and monitor diseasendash Assess for risk factors ie smoking family history
ndash Co-morbidities such as heart failure
ndash Pattern of symptoms
ndash Impact on quality of life
bull Reduce risk factors ndash Identify environmentaloccupational factors which can be modified
ndash Smoking cessation is essential
ndash Manage exacerbations
91
DOS CME Course 2011
COPDbull Manage stable COPD
ndash Determine disease severity based on frequency and severity of symptoms
ndash Educate the patient about risk factors and disease management regimen
ndash Collaborate with the patient to develop a personalized regimen
ndashFits their lifestyle
ndashAccounts for cultural preferences family involvement
ndashAvailability of testing and medications
92
DOS CME Course 2011
Pharmacologybull Goals
ndash Improve exercise tolerance
ndash Control symptoms
ndash Reduce frequency and severity of exacerbations
ndash Improve health status
bull Bronchodilators ndash Include long-acting therapy with short-acting for better control
bull Combine medications from different classes rather than increasing dosage of just onendash Minimizes side effects
93
DOS CME Course 2011
Pharmacologybull Glucocorticosteroids
ndashCan reduce the number of exacerbations
ndashIncreased risk of pneumonia
ndashNo noted reduction in mortality
bull Vaccines
ndashInfluenza vaccines decrease serious illness and death by 50
ndashRecommended annually
ndashPneumococcal vaccines recommended for all COPD sufferers even under age 65
GOLD 2009
94
DOS CME Course 2011
Antibiotics
bull Antibiotics are not a treatment for COPD nor do they manage symptoms of an exacerbation
bull Should be given only if the following are metndash Presence of three cardinal symptoms increased dyspnea
increased sputum volume increased sputum purulence
ndash Increased sputum purulence plus one other cardinal symptom
ndash Mechanically ventilated
bull May be difficult for patients to understand why antibiotics will not ldquofixrdquo what is wrong
bull Good opportunity for learning needs assessment
GOLD 2009
95
DOS CME Course 2011
COPD
bull Pulmonary rehabilitation
bull Encourage the patient to continue activities as tolerated ndash Move as much as you can before you canrsquot move
bull Uses low impact exercise to maintain physical function
bull Exercise can be done while seatedndash Monitor pulse oximetry respiratory rate and effort before during
and after activity
bull Set goals which are realistic for both of you
96
DOS CME Course 2011
COPD
bull Pulmonary rehab includes education nutrition and exercise
bull Can be a good source of social support for someone who has seen function decline
ndashTalk with others in the same situation
ndashFind out how they cope
ndashSocialize
bull Regular influenza and pneumonia vaccines
97
DOS CME Course 2011
COPD
bull Oxygen therapy
bull Recommended for stage IV disease ndash PaO2 lt or = 55 mmHg
ndash SaO2 lt or = 88
bull Increases survival improves hemodynamicsbenefits mental state
bull Surgical options reviewed on a case-by-case basisndash Bullectomy
ndash Lung volume reduction ndashNo evidence to support this as a widespread therapy
98
DOS CME Course 2011
COPD
bull Managing exacerbations
bull An event in the natural course of the disease characterized by a change in baseline dyspnea cough or sputum beyond day to day variance is acute in onset and may warrant a change in medication
bull Air pollution and tracheobronchial infections are the most common causes
bull 30 of exacerbations no cause identified
(GOLD 2009 p 22)
99
DOS CME Course 2011
COPD
bull Hospitalization is recommended for patients exhibiting the following
ndash Failure of exacerbation to respond to medical treatment
ndash Development of new symptoms ie peripheral edema cyanosis
ndash Significant co-morbidities
ndash History of frequent exacerbations
ndash Newly occurring arrhythmias
ndash Advanced age
ndash Insufficient home support
ndash Unclear diagnosis
(GOLD 2009 p 23)
100
DOS CME Course 2011
COPD
bull Mechanical ventilation is not recognized as an effective management strategy for stable COPD
bull May be required as supportive therapy during an exacerbation
bull Associated with mortality
bull Carries risks of its ownndash Ventilator acquired pneumonia
ndash Ventilator induced lung injury
ndash Failure to wean
(GOLD 2009)
101
DOS CME Course 2011DOS CME Course 2011102
Every Life Deserves World Class Care
Smoking
102
DOS CME Course 2011
Smoking bull By the numbers
bull More than 400 000 Americans die from smoking-related illnesses each yearndash Thatrsquos one of every 5 deaths
bull In a study of 2963 health care encounters smoking was discussed 633 times
bull Nicotine released into the body within 10 seconds of inhalation
bull If a person smokes one pack per day and takes ten puffs of each cigarette that equates to 200 ldquohitsrdquo of nicotine daily
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
103
DOS CME Course 2011
Nicotine
bull Nicotinic receptors occur naturally
bull N1 receptors in the adrenal medulla
bull Neuromuscular junction of autonomic ganglia
bull N2 receptors in skeletal muscle
bull Number of receptor sites increases with regular stimulation
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
104
DOS CME Course 2011
Nicotinebull Addictive
bull Vasoconstrictor
bull Releases adrenaline from the adrenal cortex
ndashFeeling of increased energy
bull Releases dopamine to produce feelings of well-beingndash Actually improves memory and cognition
bull Sensitivity actually declines overnight
bull Release of insulinndash Slightly hyperglycemic
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
105
DOS CME Course 2011
Genetic componentbull About 10 of smokers lack the gene for nicotine
dependence
ndashldquosocial or occasionalrdquo smokers
ndashThey really can quit anytime they want to
ndashNo withdrawal symptoms
ndashStill poses a health risk
bull The other 90 will demonstrate physical and psychological symptoms of withdrawal
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
106
DOS CME Course 2011
Smoking
bull Identify tobacco users ndash Ask every patient every visit
ndash Have you used tobacco in the last 12 months
ndash Clinic-wide program
bull Advise every tobacco user to quitndash Personalize the message
ndash Be clear
ndash Be firm
If at first you donrsquot succeed try tryagain Bring it up at every encounter
107
DOS CME Course 2011
Smoking cessationbull Some more good reasons to quit
ndashSmoking costs over $2000 a year in current US dollars
ndashThere is no accepted safe level of cigarette smoke
ndashSecondhand smoke carries the same hazards
ndashIncreased risk of SIDS and asthma exacerbations in children
httpwwwlungusaorgstop-smokingabout-smokingfacts-figuresgeneral-smoking-factshtml
108
DOS CME Course 2011
Smoking cessation
bull Nicotine is a powerful drug addiction
bull Treat as a chronic illness
bull All healthcare providers encouraged to participate
bull Assess willingness to quit
bull Promote motivation
109
DOS CME Course 2011
Smoking cessation
bull Prochaskarsquos change theory
bull Precontemplation
ndashNot even thinking about quitting
ndashProvide education on the risks and costs of smoking
bull Contemplation
ndashAwareness that a problem exists
ndashContinue to find motivations to stop
NorcrossJC Krebs PM Prochaska JO(2011)
110
DOS CME Course 2011
Change is good
bull Determination
ndashExpressing willingness to act
ndashSelf-efficacy
bull Action ndash Currently not smoking
ndash May relapse
bull It is not unusual for a patient to ldquoquitrdquo three or four times
bull Continue to encourage and motivate himher to stop
NorcrossJC Krebs PM Prochaska JO(2011)
111
DOS CME Course 2011
Smoking cessationbull Assist the patient
ndashCollaborate with the patient to develop a plan to quit
ndashAchievable clearly defined goals
ndashIdentify and engage social supports
ndashFamily support groups
ndashPharmacologic (more on this later)
bull Arrange follow-up
ndashAt each successive visit review progress on quitting strategy
ndashLets the patient know heshe is not alone in this effort
ndashAccountability
112
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
Patient educationbull Metered dose inhalers
ndash Remove cap and invert the device several times
ndash Exhale
ndash Place the mouthpiece between your lips with a good seal
ndash Inhale while depressing the top of the MDI
ndash Hold your breath for 10 seconds
ndash Exhale
ndash Repeat as needed
67
DOS CME Course 2011
Patient educationbull Spacers are used with MDIrsquos
used to deliver inhaled steroidsndash Ease coordination of breathing
and medication delivery
ndash Decrease the amount of medication contacting the oral mucosa
ndash Fewer side effects
bull Attach the spacer to the mouthpiece of the MDI ndash Use the MDI as described
before
ndash Some models have a whistle to indicate you are inhaling too rapidly
68
DOS CME Course 201169
DOS CME Course 2011
Characteristic Controlled
(All of the following)
Partly controlled
(Any measure noted)
Uncontrolled
Daytime symptoms
None (twice or less a week)
More than twice a week
Three or more features of partly controlled asthma
Limitation of activities
None Any
Nocturnal symptomsawakening
None Any
Need for rescue treatment
None (twice or less a week)
More than twice a week
Lung function (FEV1 or PEF)
Normal lt80 predicted or personal best
70
DOS CME Course 2011
Asthma
bull Self monitoring is essential to effective management and control
bull The following are validated tools to assess asthma control
ndashAsthmacontrolcom
ndashFree web-based
ndashQoltechcouk
ndashFree in hard copy or electronic versions
ndashRequires permission
ndashAtaqinstrumentcom
ndashFree web-based
71
DOS CME Course 2011DOS CME Course 201172
Every Life Deserves World Class Care
COPD
72
DOS CME Course 2011
Chronic obstructive pulmonary disease
bull By the numbers
bull 210 million suffer worldwide
bull 3 million fatalities
bull By 2030 COPD is expected to be the third leading cause of death worldwide
bull Most important risk factors ndash Smoking
ndash Indoor pollution
ndash Outdoor pollution
ndash Occupational irritants
WHO Retrieved January 2011
73
DOS CME Course 2011
COPD
bull Causes ndash Cigarette smoking is the number one cause worldwide
ndash Environmental irritants
ndash Genetic alpha-one antitrypsin deficiency
bull Birth defects ndash Low birth weight
ndash Respiratory infections
ndash Any factor which impairs lung development during gestation
bull Other ndash HIV
ndash Connective tissue disorders
ndash Vasculitis
74
DOS CME Course 2011
COPD
bull Sometimes referred to as umbrella term for a family of diseases which cause limited airflow
ndashChronic bronchitis
ndashEmphysema
bull Inflammation of the airways
bull Increased mucous productionndash Especially in bronchitis
bull Decreased ciliary function
bull Loss of elastic recoil ndash Especially in emphysema
75
DOS CME Course 2011
COPD
bull How inflammation ruins a lung
bull Cell mediated ndash Neutrophils
ndash Macrophages
ndash Lymphocytes
bull Release cytokines which attract more cells
bull Oxidants released by cells and found in cigarette smoke
bull Proteases
bull Cause remodeling and long term structural changes
76
DOS CME Course 2011
COPDbull Alveoli lose elasticity and become distended
ndashSaggy sacs
ndashCarbon dioxide retention
ndashChronic respiratory acidosis
bull Walls of the alveoli are degraded
ndashLoss of surface area necessary for gas exchange
77
DOS CME Course 2011
What the patient looks like
bull Productive Cough
ndashEspecially in chronic bronchitis
bull Progressive dyspnea
ndashUncomfortable awareness of breathing
bull Wheezing and chest tightness
bull Increase in AP chest diameter
ndashldquoBarrel chestrdquo especially in emphysema
ndashIncreased inspiratory effort loosens costochondral cartilage
78
DOS CME Course 2011
Alpha one antitrypsin deficiency
bull Enzyme normally produced which protects the lungs
bull Deactivates neutrophil elastase
ndashReleased during inflammation
bull Estimated over 100000 in US have AATD
bull Time to diagnosis gt8 years
bull Related to increased mortality (Krowka 2010)
ndashIncreased incidence of emphysema
79
DOS CME Course 2011
Chronic bronchitis
bull Presence of cough and sputum production over three months for two consecutive years
ndashNote the months need not be consecutive
bull The patient may feel as though they are constantly sick
bull Multiple courses of antibiotics with no improvement
bull No relationship to acute bronchitis caused by bacteria or virus
80
DOS CME Course 2011
COPD
bull Break out the testing ndash CXR
ndash ECG
ndash Sputum culture
ndash CBC and electrolytes
bull ABGrsquos ndash Respiratory failure indicated by
ndash PaO2lt 60 and SaO2 lt 90
ndash with or without PaCO2 gt 50
ndash On room air
ndash Severe acidosis pHlt 736 in addition to the above is an indication for mechanical ventilation
(GOLD 2009 p 22)
81
DOS CME Course 2011
Chronic bronchitis
bull Airway of a child afflicted with chronic bronchitis compared to normal
82
DOS CME Course 2011
Chronic bronchitisbull Related to mucociliary dysfunction
ndashIncreased mucous production and thickening
ndashLoss of cilia
ndashLoss of ciliary function
ndashMobility required to sweep out particles
83
DOS CME Course 2011
Emphysemabull Permanent enlargement of the airspaces terminal to the
distal bronchioles ndashLoss of surface area for gas exchangendashDestruction of supporting structure of alveoli
ndashAirway narrowing
bull Three distinct patterns ndashCentracinar begins centrally and spreads to terminal
bronchioles and is most closely associated with cigarette smoking
ndashPanacinar destroys alveoli uniformly predominant in lower half of lungs most closely associated with AATD
ndashParaseptal destroys the distal airway structures alveolar ducts and sacs
Demirjian BG 2010
84
DOS CME Course 2011
Bullaebull Outpouchingsballooning of lung tissue due to trapped air
ndashAir is released from damaged alveoli
ndashAsymptomatic
ndashRupture can cause pneumothorax
85
DOS CME Course 2011
Diagnosis
bull History of smoking or exposure to inhaled irritants
ndashRemember to consider work and living environment
ndashCooking indoors with fossil fuels
ndashAge over 40
bull Signs and symptoms
ndashChronic cough with sputum production
ndashDyspnea which persists daily worsens with exercise and progresses over time
bull Spirometry is strongly recommended
86
DOS CME Course 2011
Diagnosis
bull Chest x-ray
ndashRule out pneumonia cardiomyopathy
ndashNot diagnostic for COPD but may reveal other causes for symptoms
bull Arterial blood gases
ndashRecommended for patients with FEVlt 50
ndashPaO2lt 60 mmHg suggests respiratory failure
bull Sputum culture
ndashRule out infectious process
87
DOS CME Course 2011
Disease stages
bull Stage Indash FEVFVC lt 70
ndash FEV gt 80
ndash Few symptoms if any patient may be unaware
bull Stage II moderate ndash FEVFVC lt 70
ndash FEV lt 80
ndash Along with shortness of breath
88
DOS CME Course 2011
Disease stages
bull Stage IV very severe ndash FEVFVC lt 70
ndash FEV lt 30
ndash At this stage exacerbations are life-threatening
ndash Quality of life is impaired further
bull Stage III severe ndash FEVFVC lt 70
ndash FEV lt 50
ndash Worsening symptoms increasing frequency of exacerbations
89
DOS CME Course 2011
COPD vs Asthma
bull COPD
ndashOnset later in life
ndashProgressive worsening symptoms
ndashSmoking history
ndashDyspnea with exercise
ndashLargely irreversible airflow limitation
bull Asthma
ndashOnset of symptoms usually earlier in life
ndashWorsening at night
ndashLargely reversible airflow limitation
ndashSymptoms vary from day to day
90
DOS CME Course 2011
COPD Treatmentbull Now that we have diagnosis what do I do about it
bull Assess and monitor diseasendash Assess for risk factors ie smoking family history
ndash Co-morbidities such as heart failure
ndash Pattern of symptoms
ndash Impact on quality of life
bull Reduce risk factors ndash Identify environmentaloccupational factors which can be modified
ndash Smoking cessation is essential
ndash Manage exacerbations
91
DOS CME Course 2011
COPDbull Manage stable COPD
ndash Determine disease severity based on frequency and severity of symptoms
ndash Educate the patient about risk factors and disease management regimen
ndash Collaborate with the patient to develop a personalized regimen
ndashFits their lifestyle
ndashAccounts for cultural preferences family involvement
ndashAvailability of testing and medications
92
DOS CME Course 2011
Pharmacologybull Goals
ndash Improve exercise tolerance
ndash Control symptoms
ndash Reduce frequency and severity of exacerbations
ndash Improve health status
bull Bronchodilators ndash Include long-acting therapy with short-acting for better control
bull Combine medications from different classes rather than increasing dosage of just onendash Minimizes side effects
93
DOS CME Course 2011
Pharmacologybull Glucocorticosteroids
ndashCan reduce the number of exacerbations
ndashIncreased risk of pneumonia
ndashNo noted reduction in mortality
bull Vaccines
ndashInfluenza vaccines decrease serious illness and death by 50
ndashRecommended annually
ndashPneumococcal vaccines recommended for all COPD sufferers even under age 65
GOLD 2009
94
DOS CME Course 2011
Antibiotics
bull Antibiotics are not a treatment for COPD nor do they manage symptoms of an exacerbation
bull Should be given only if the following are metndash Presence of three cardinal symptoms increased dyspnea
increased sputum volume increased sputum purulence
ndash Increased sputum purulence plus one other cardinal symptom
ndash Mechanically ventilated
bull May be difficult for patients to understand why antibiotics will not ldquofixrdquo what is wrong
bull Good opportunity for learning needs assessment
GOLD 2009
95
DOS CME Course 2011
COPD
bull Pulmonary rehabilitation
bull Encourage the patient to continue activities as tolerated ndash Move as much as you can before you canrsquot move
bull Uses low impact exercise to maintain physical function
bull Exercise can be done while seatedndash Monitor pulse oximetry respiratory rate and effort before during
and after activity
bull Set goals which are realistic for both of you
96
DOS CME Course 2011
COPD
bull Pulmonary rehab includes education nutrition and exercise
bull Can be a good source of social support for someone who has seen function decline
ndashTalk with others in the same situation
ndashFind out how they cope
ndashSocialize
bull Regular influenza and pneumonia vaccines
97
DOS CME Course 2011
COPD
bull Oxygen therapy
bull Recommended for stage IV disease ndash PaO2 lt or = 55 mmHg
ndash SaO2 lt or = 88
bull Increases survival improves hemodynamicsbenefits mental state
bull Surgical options reviewed on a case-by-case basisndash Bullectomy
ndash Lung volume reduction ndashNo evidence to support this as a widespread therapy
98
DOS CME Course 2011
COPD
bull Managing exacerbations
bull An event in the natural course of the disease characterized by a change in baseline dyspnea cough or sputum beyond day to day variance is acute in onset and may warrant a change in medication
bull Air pollution and tracheobronchial infections are the most common causes
bull 30 of exacerbations no cause identified
(GOLD 2009 p 22)
99
DOS CME Course 2011
COPD
bull Hospitalization is recommended for patients exhibiting the following
ndash Failure of exacerbation to respond to medical treatment
ndash Development of new symptoms ie peripheral edema cyanosis
ndash Significant co-morbidities
ndash History of frequent exacerbations
ndash Newly occurring arrhythmias
ndash Advanced age
ndash Insufficient home support
ndash Unclear diagnosis
(GOLD 2009 p 23)
100
DOS CME Course 2011
COPD
bull Mechanical ventilation is not recognized as an effective management strategy for stable COPD
bull May be required as supportive therapy during an exacerbation
bull Associated with mortality
bull Carries risks of its ownndash Ventilator acquired pneumonia
ndash Ventilator induced lung injury
ndash Failure to wean
(GOLD 2009)
101
DOS CME Course 2011DOS CME Course 2011102
Every Life Deserves World Class Care
Smoking
102
DOS CME Course 2011
Smoking bull By the numbers
bull More than 400 000 Americans die from smoking-related illnesses each yearndash Thatrsquos one of every 5 deaths
bull In a study of 2963 health care encounters smoking was discussed 633 times
bull Nicotine released into the body within 10 seconds of inhalation
bull If a person smokes one pack per day and takes ten puffs of each cigarette that equates to 200 ldquohitsrdquo of nicotine daily
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
103
DOS CME Course 2011
Nicotine
bull Nicotinic receptors occur naturally
bull N1 receptors in the adrenal medulla
bull Neuromuscular junction of autonomic ganglia
bull N2 receptors in skeletal muscle
bull Number of receptor sites increases with regular stimulation
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
104
DOS CME Course 2011
Nicotinebull Addictive
bull Vasoconstrictor
bull Releases adrenaline from the adrenal cortex
ndashFeeling of increased energy
bull Releases dopamine to produce feelings of well-beingndash Actually improves memory and cognition
bull Sensitivity actually declines overnight
bull Release of insulinndash Slightly hyperglycemic
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
105
DOS CME Course 2011
Genetic componentbull About 10 of smokers lack the gene for nicotine
dependence
ndashldquosocial or occasionalrdquo smokers
ndashThey really can quit anytime they want to
ndashNo withdrawal symptoms
ndashStill poses a health risk
bull The other 90 will demonstrate physical and psychological symptoms of withdrawal
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
106
DOS CME Course 2011
Smoking
bull Identify tobacco users ndash Ask every patient every visit
ndash Have you used tobacco in the last 12 months
ndash Clinic-wide program
bull Advise every tobacco user to quitndash Personalize the message
ndash Be clear
ndash Be firm
If at first you donrsquot succeed try tryagain Bring it up at every encounter
107
DOS CME Course 2011
Smoking cessationbull Some more good reasons to quit
ndashSmoking costs over $2000 a year in current US dollars
ndashThere is no accepted safe level of cigarette smoke
ndashSecondhand smoke carries the same hazards
ndashIncreased risk of SIDS and asthma exacerbations in children
httpwwwlungusaorgstop-smokingabout-smokingfacts-figuresgeneral-smoking-factshtml
108
DOS CME Course 2011
Smoking cessation
bull Nicotine is a powerful drug addiction
bull Treat as a chronic illness
bull All healthcare providers encouraged to participate
bull Assess willingness to quit
bull Promote motivation
109
DOS CME Course 2011
Smoking cessation
bull Prochaskarsquos change theory
bull Precontemplation
ndashNot even thinking about quitting
ndashProvide education on the risks and costs of smoking
bull Contemplation
ndashAwareness that a problem exists
ndashContinue to find motivations to stop
NorcrossJC Krebs PM Prochaska JO(2011)
110
DOS CME Course 2011
Change is good
bull Determination
ndashExpressing willingness to act
ndashSelf-efficacy
bull Action ndash Currently not smoking
ndash May relapse
bull It is not unusual for a patient to ldquoquitrdquo three or four times
bull Continue to encourage and motivate himher to stop
NorcrossJC Krebs PM Prochaska JO(2011)
111
DOS CME Course 2011
Smoking cessationbull Assist the patient
ndashCollaborate with the patient to develop a plan to quit
ndashAchievable clearly defined goals
ndashIdentify and engage social supports
ndashFamily support groups
ndashPharmacologic (more on this later)
bull Arrange follow-up
ndashAt each successive visit review progress on quitting strategy
ndashLets the patient know heshe is not alone in this effort
ndashAccountability
112
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 201169
DOS CME Course 2011
Characteristic Controlled
(All of the following)
Partly controlled
(Any measure noted)
Uncontrolled
Daytime symptoms
None (twice or less a week)
More than twice a week
Three or more features of partly controlled asthma
Limitation of activities
None Any
Nocturnal symptomsawakening
None Any
Need for rescue treatment
None (twice or less a week)
More than twice a week
Lung function (FEV1 or PEF)
Normal lt80 predicted or personal best
70
DOS CME Course 2011
Asthma
bull Self monitoring is essential to effective management and control
bull The following are validated tools to assess asthma control
ndashAsthmacontrolcom
ndashFree web-based
ndashQoltechcouk
ndashFree in hard copy or electronic versions
ndashRequires permission
ndashAtaqinstrumentcom
ndashFree web-based
71
DOS CME Course 2011DOS CME Course 201172
Every Life Deserves World Class Care
COPD
72
DOS CME Course 2011
Chronic obstructive pulmonary disease
bull By the numbers
bull 210 million suffer worldwide
bull 3 million fatalities
bull By 2030 COPD is expected to be the third leading cause of death worldwide
bull Most important risk factors ndash Smoking
ndash Indoor pollution
ndash Outdoor pollution
ndash Occupational irritants
WHO Retrieved January 2011
73
DOS CME Course 2011
COPD
bull Causes ndash Cigarette smoking is the number one cause worldwide
ndash Environmental irritants
ndash Genetic alpha-one antitrypsin deficiency
bull Birth defects ndash Low birth weight
ndash Respiratory infections
ndash Any factor which impairs lung development during gestation
bull Other ndash HIV
ndash Connective tissue disorders
ndash Vasculitis
74
DOS CME Course 2011
COPD
bull Sometimes referred to as umbrella term for a family of diseases which cause limited airflow
ndashChronic bronchitis
ndashEmphysema
bull Inflammation of the airways
bull Increased mucous productionndash Especially in bronchitis
bull Decreased ciliary function
bull Loss of elastic recoil ndash Especially in emphysema
75
DOS CME Course 2011
COPD
bull How inflammation ruins a lung
bull Cell mediated ndash Neutrophils
ndash Macrophages
ndash Lymphocytes
bull Release cytokines which attract more cells
bull Oxidants released by cells and found in cigarette smoke
bull Proteases
bull Cause remodeling and long term structural changes
76
DOS CME Course 2011
COPDbull Alveoli lose elasticity and become distended
ndashSaggy sacs
ndashCarbon dioxide retention
ndashChronic respiratory acidosis
bull Walls of the alveoli are degraded
ndashLoss of surface area necessary for gas exchange
77
DOS CME Course 2011
What the patient looks like
bull Productive Cough
ndashEspecially in chronic bronchitis
bull Progressive dyspnea
ndashUncomfortable awareness of breathing
bull Wheezing and chest tightness
bull Increase in AP chest diameter
ndashldquoBarrel chestrdquo especially in emphysema
ndashIncreased inspiratory effort loosens costochondral cartilage
78
DOS CME Course 2011
Alpha one antitrypsin deficiency
bull Enzyme normally produced which protects the lungs
bull Deactivates neutrophil elastase
ndashReleased during inflammation
bull Estimated over 100000 in US have AATD
bull Time to diagnosis gt8 years
bull Related to increased mortality (Krowka 2010)
ndashIncreased incidence of emphysema
79
DOS CME Course 2011
Chronic bronchitis
bull Presence of cough and sputum production over three months for two consecutive years
ndashNote the months need not be consecutive
bull The patient may feel as though they are constantly sick
bull Multiple courses of antibiotics with no improvement
bull No relationship to acute bronchitis caused by bacteria or virus
80
DOS CME Course 2011
COPD
bull Break out the testing ndash CXR
ndash ECG
ndash Sputum culture
ndash CBC and electrolytes
bull ABGrsquos ndash Respiratory failure indicated by
ndash PaO2lt 60 and SaO2 lt 90
ndash with or without PaCO2 gt 50
ndash On room air
ndash Severe acidosis pHlt 736 in addition to the above is an indication for mechanical ventilation
(GOLD 2009 p 22)
81
DOS CME Course 2011
Chronic bronchitis
bull Airway of a child afflicted with chronic bronchitis compared to normal
82
DOS CME Course 2011
Chronic bronchitisbull Related to mucociliary dysfunction
ndashIncreased mucous production and thickening
ndashLoss of cilia
ndashLoss of ciliary function
ndashMobility required to sweep out particles
83
DOS CME Course 2011
Emphysemabull Permanent enlargement of the airspaces terminal to the
distal bronchioles ndashLoss of surface area for gas exchangendashDestruction of supporting structure of alveoli
ndashAirway narrowing
bull Three distinct patterns ndashCentracinar begins centrally and spreads to terminal
bronchioles and is most closely associated with cigarette smoking
ndashPanacinar destroys alveoli uniformly predominant in lower half of lungs most closely associated with AATD
ndashParaseptal destroys the distal airway structures alveolar ducts and sacs
Demirjian BG 2010
84
DOS CME Course 2011
Bullaebull Outpouchingsballooning of lung tissue due to trapped air
ndashAir is released from damaged alveoli
ndashAsymptomatic
ndashRupture can cause pneumothorax
85
DOS CME Course 2011
Diagnosis
bull History of smoking or exposure to inhaled irritants
ndashRemember to consider work and living environment
ndashCooking indoors with fossil fuels
ndashAge over 40
bull Signs and symptoms
ndashChronic cough with sputum production
ndashDyspnea which persists daily worsens with exercise and progresses over time
bull Spirometry is strongly recommended
86
DOS CME Course 2011
Diagnosis
bull Chest x-ray
ndashRule out pneumonia cardiomyopathy
ndashNot diagnostic for COPD but may reveal other causes for symptoms
bull Arterial blood gases
ndashRecommended for patients with FEVlt 50
ndashPaO2lt 60 mmHg suggests respiratory failure
bull Sputum culture
ndashRule out infectious process
87
DOS CME Course 2011
Disease stages
bull Stage Indash FEVFVC lt 70
ndash FEV gt 80
ndash Few symptoms if any patient may be unaware
bull Stage II moderate ndash FEVFVC lt 70
ndash FEV lt 80
ndash Along with shortness of breath
88
DOS CME Course 2011
Disease stages
bull Stage IV very severe ndash FEVFVC lt 70
ndash FEV lt 30
ndash At this stage exacerbations are life-threatening
ndash Quality of life is impaired further
bull Stage III severe ndash FEVFVC lt 70
ndash FEV lt 50
ndash Worsening symptoms increasing frequency of exacerbations
89
DOS CME Course 2011
COPD vs Asthma
bull COPD
ndashOnset later in life
ndashProgressive worsening symptoms
ndashSmoking history
ndashDyspnea with exercise
ndashLargely irreversible airflow limitation
bull Asthma
ndashOnset of symptoms usually earlier in life
ndashWorsening at night
ndashLargely reversible airflow limitation
ndashSymptoms vary from day to day
90
DOS CME Course 2011
COPD Treatmentbull Now that we have diagnosis what do I do about it
bull Assess and monitor diseasendash Assess for risk factors ie smoking family history
ndash Co-morbidities such as heart failure
ndash Pattern of symptoms
ndash Impact on quality of life
bull Reduce risk factors ndash Identify environmentaloccupational factors which can be modified
ndash Smoking cessation is essential
ndash Manage exacerbations
91
DOS CME Course 2011
COPDbull Manage stable COPD
ndash Determine disease severity based on frequency and severity of symptoms
ndash Educate the patient about risk factors and disease management regimen
ndash Collaborate with the patient to develop a personalized regimen
ndashFits their lifestyle
ndashAccounts for cultural preferences family involvement
ndashAvailability of testing and medications
92
DOS CME Course 2011
Pharmacologybull Goals
ndash Improve exercise tolerance
ndash Control symptoms
ndash Reduce frequency and severity of exacerbations
ndash Improve health status
bull Bronchodilators ndash Include long-acting therapy with short-acting for better control
bull Combine medications from different classes rather than increasing dosage of just onendash Minimizes side effects
93
DOS CME Course 2011
Pharmacologybull Glucocorticosteroids
ndashCan reduce the number of exacerbations
ndashIncreased risk of pneumonia
ndashNo noted reduction in mortality
bull Vaccines
ndashInfluenza vaccines decrease serious illness and death by 50
ndashRecommended annually
ndashPneumococcal vaccines recommended for all COPD sufferers even under age 65
GOLD 2009
94
DOS CME Course 2011
Antibiotics
bull Antibiotics are not a treatment for COPD nor do they manage symptoms of an exacerbation
bull Should be given only if the following are metndash Presence of three cardinal symptoms increased dyspnea
increased sputum volume increased sputum purulence
ndash Increased sputum purulence plus one other cardinal symptom
ndash Mechanically ventilated
bull May be difficult for patients to understand why antibiotics will not ldquofixrdquo what is wrong
bull Good opportunity for learning needs assessment
GOLD 2009
95
DOS CME Course 2011
COPD
bull Pulmonary rehabilitation
bull Encourage the patient to continue activities as tolerated ndash Move as much as you can before you canrsquot move
bull Uses low impact exercise to maintain physical function
bull Exercise can be done while seatedndash Monitor pulse oximetry respiratory rate and effort before during
and after activity
bull Set goals which are realistic for both of you
96
DOS CME Course 2011
COPD
bull Pulmonary rehab includes education nutrition and exercise
bull Can be a good source of social support for someone who has seen function decline
ndashTalk with others in the same situation
ndashFind out how they cope
ndashSocialize
bull Regular influenza and pneumonia vaccines
97
DOS CME Course 2011
COPD
bull Oxygen therapy
bull Recommended for stage IV disease ndash PaO2 lt or = 55 mmHg
ndash SaO2 lt or = 88
bull Increases survival improves hemodynamicsbenefits mental state
bull Surgical options reviewed on a case-by-case basisndash Bullectomy
ndash Lung volume reduction ndashNo evidence to support this as a widespread therapy
98
DOS CME Course 2011
COPD
bull Managing exacerbations
bull An event in the natural course of the disease characterized by a change in baseline dyspnea cough or sputum beyond day to day variance is acute in onset and may warrant a change in medication
bull Air pollution and tracheobronchial infections are the most common causes
bull 30 of exacerbations no cause identified
(GOLD 2009 p 22)
99
DOS CME Course 2011
COPD
bull Hospitalization is recommended for patients exhibiting the following
ndash Failure of exacerbation to respond to medical treatment
ndash Development of new symptoms ie peripheral edema cyanosis
ndash Significant co-morbidities
ndash History of frequent exacerbations
ndash Newly occurring arrhythmias
ndash Advanced age
ndash Insufficient home support
ndash Unclear diagnosis
(GOLD 2009 p 23)
100
DOS CME Course 2011
COPD
bull Mechanical ventilation is not recognized as an effective management strategy for stable COPD
bull May be required as supportive therapy during an exacerbation
bull Associated with mortality
bull Carries risks of its ownndash Ventilator acquired pneumonia
ndash Ventilator induced lung injury
ndash Failure to wean
(GOLD 2009)
101
DOS CME Course 2011DOS CME Course 2011102
Every Life Deserves World Class Care
Smoking
102
DOS CME Course 2011
Smoking bull By the numbers
bull More than 400 000 Americans die from smoking-related illnesses each yearndash Thatrsquos one of every 5 deaths
bull In a study of 2963 health care encounters smoking was discussed 633 times
bull Nicotine released into the body within 10 seconds of inhalation
bull If a person smokes one pack per day and takes ten puffs of each cigarette that equates to 200 ldquohitsrdquo of nicotine daily
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
103
DOS CME Course 2011
Nicotine
bull Nicotinic receptors occur naturally
bull N1 receptors in the adrenal medulla
bull Neuromuscular junction of autonomic ganglia
bull N2 receptors in skeletal muscle
bull Number of receptor sites increases with regular stimulation
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
104
DOS CME Course 2011
Nicotinebull Addictive
bull Vasoconstrictor
bull Releases adrenaline from the adrenal cortex
ndashFeeling of increased energy
bull Releases dopamine to produce feelings of well-beingndash Actually improves memory and cognition
bull Sensitivity actually declines overnight
bull Release of insulinndash Slightly hyperglycemic
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
105
DOS CME Course 2011
Genetic componentbull About 10 of smokers lack the gene for nicotine
dependence
ndashldquosocial or occasionalrdquo smokers
ndashThey really can quit anytime they want to
ndashNo withdrawal symptoms
ndashStill poses a health risk
bull The other 90 will demonstrate physical and psychological symptoms of withdrawal
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
106
DOS CME Course 2011
Smoking
bull Identify tobacco users ndash Ask every patient every visit
ndash Have you used tobacco in the last 12 months
ndash Clinic-wide program
bull Advise every tobacco user to quitndash Personalize the message
ndash Be clear
ndash Be firm
If at first you donrsquot succeed try tryagain Bring it up at every encounter
107
DOS CME Course 2011
Smoking cessationbull Some more good reasons to quit
ndashSmoking costs over $2000 a year in current US dollars
ndashThere is no accepted safe level of cigarette smoke
ndashSecondhand smoke carries the same hazards
ndashIncreased risk of SIDS and asthma exacerbations in children
httpwwwlungusaorgstop-smokingabout-smokingfacts-figuresgeneral-smoking-factshtml
108
DOS CME Course 2011
Smoking cessation
bull Nicotine is a powerful drug addiction
bull Treat as a chronic illness
bull All healthcare providers encouraged to participate
bull Assess willingness to quit
bull Promote motivation
109
DOS CME Course 2011
Smoking cessation
bull Prochaskarsquos change theory
bull Precontemplation
ndashNot even thinking about quitting
ndashProvide education on the risks and costs of smoking
bull Contemplation
ndashAwareness that a problem exists
ndashContinue to find motivations to stop
NorcrossJC Krebs PM Prochaska JO(2011)
110
DOS CME Course 2011
Change is good
bull Determination
ndashExpressing willingness to act
ndashSelf-efficacy
bull Action ndash Currently not smoking
ndash May relapse
bull It is not unusual for a patient to ldquoquitrdquo three or four times
bull Continue to encourage and motivate himher to stop
NorcrossJC Krebs PM Prochaska JO(2011)
111
DOS CME Course 2011
Smoking cessationbull Assist the patient
ndashCollaborate with the patient to develop a plan to quit
ndashAchievable clearly defined goals
ndashIdentify and engage social supports
ndashFamily support groups
ndashPharmacologic (more on this later)
bull Arrange follow-up
ndashAt each successive visit review progress on quitting strategy
ndashLets the patient know heshe is not alone in this effort
ndashAccountability
112
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
Asthma
bull Self monitoring is essential to effective management and control
bull The following are validated tools to assess asthma control
ndashAsthmacontrolcom
ndashFree web-based
ndashQoltechcouk
ndashFree in hard copy or electronic versions
ndashRequires permission
ndashAtaqinstrumentcom
ndashFree web-based
71
DOS CME Course 2011DOS CME Course 201172
Every Life Deserves World Class Care
COPD
72
DOS CME Course 2011
Chronic obstructive pulmonary disease
bull By the numbers
bull 210 million suffer worldwide
bull 3 million fatalities
bull By 2030 COPD is expected to be the third leading cause of death worldwide
bull Most important risk factors ndash Smoking
ndash Indoor pollution
ndash Outdoor pollution
ndash Occupational irritants
WHO Retrieved January 2011
73
DOS CME Course 2011
COPD
bull Causes ndash Cigarette smoking is the number one cause worldwide
ndash Environmental irritants
ndash Genetic alpha-one antitrypsin deficiency
bull Birth defects ndash Low birth weight
ndash Respiratory infections
ndash Any factor which impairs lung development during gestation
bull Other ndash HIV
ndash Connective tissue disorders
ndash Vasculitis
74
DOS CME Course 2011
COPD
bull Sometimes referred to as umbrella term for a family of diseases which cause limited airflow
ndashChronic bronchitis
ndashEmphysema
bull Inflammation of the airways
bull Increased mucous productionndash Especially in bronchitis
bull Decreased ciliary function
bull Loss of elastic recoil ndash Especially in emphysema
75
DOS CME Course 2011
COPD
bull How inflammation ruins a lung
bull Cell mediated ndash Neutrophils
ndash Macrophages
ndash Lymphocytes
bull Release cytokines which attract more cells
bull Oxidants released by cells and found in cigarette smoke
bull Proteases
bull Cause remodeling and long term structural changes
76
DOS CME Course 2011
COPDbull Alveoli lose elasticity and become distended
ndashSaggy sacs
ndashCarbon dioxide retention
ndashChronic respiratory acidosis
bull Walls of the alveoli are degraded
ndashLoss of surface area necessary for gas exchange
77
DOS CME Course 2011
What the patient looks like
bull Productive Cough
ndashEspecially in chronic bronchitis
bull Progressive dyspnea
ndashUncomfortable awareness of breathing
bull Wheezing and chest tightness
bull Increase in AP chest diameter
ndashldquoBarrel chestrdquo especially in emphysema
ndashIncreased inspiratory effort loosens costochondral cartilage
78
DOS CME Course 2011
Alpha one antitrypsin deficiency
bull Enzyme normally produced which protects the lungs
bull Deactivates neutrophil elastase
ndashReleased during inflammation
bull Estimated over 100000 in US have AATD
bull Time to diagnosis gt8 years
bull Related to increased mortality (Krowka 2010)
ndashIncreased incidence of emphysema
79
DOS CME Course 2011
Chronic bronchitis
bull Presence of cough and sputum production over three months for two consecutive years
ndashNote the months need not be consecutive
bull The patient may feel as though they are constantly sick
bull Multiple courses of antibiotics with no improvement
bull No relationship to acute bronchitis caused by bacteria or virus
80
DOS CME Course 2011
COPD
bull Break out the testing ndash CXR
ndash ECG
ndash Sputum culture
ndash CBC and electrolytes
bull ABGrsquos ndash Respiratory failure indicated by
ndash PaO2lt 60 and SaO2 lt 90
ndash with or without PaCO2 gt 50
ndash On room air
ndash Severe acidosis pHlt 736 in addition to the above is an indication for mechanical ventilation
(GOLD 2009 p 22)
81
DOS CME Course 2011
Chronic bronchitis
bull Airway of a child afflicted with chronic bronchitis compared to normal
82
DOS CME Course 2011
Chronic bronchitisbull Related to mucociliary dysfunction
ndashIncreased mucous production and thickening
ndashLoss of cilia
ndashLoss of ciliary function
ndashMobility required to sweep out particles
83
DOS CME Course 2011
Emphysemabull Permanent enlargement of the airspaces terminal to the
distal bronchioles ndashLoss of surface area for gas exchangendashDestruction of supporting structure of alveoli
ndashAirway narrowing
bull Three distinct patterns ndashCentracinar begins centrally and spreads to terminal
bronchioles and is most closely associated with cigarette smoking
ndashPanacinar destroys alveoli uniformly predominant in lower half of lungs most closely associated with AATD
ndashParaseptal destroys the distal airway structures alveolar ducts and sacs
Demirjian BG 2010
84
DOS CME Course 2011
Bullaebull Outpouchingsballooning of lung tissue due to trapped air
ndashAir is released from damaged alveoli
ndashAsymptomatic
ndashRupture can cause pneumothorax
85
DOS CME Course 2011
Diagnosis
bull History of smoking or exposure to inhaled irritants
ndashRemember to consider work and living environment
ndashCooking indoors with fossil fuels
ndashAge over 40
bull Signs and symptoms
ndashChronic cough with sputum production
ndashDyspnea which persists daily worsens with exercise and progresses over time
bull Spirometry is strongly recommended
86
DOS CME Course 2011
Diagnosis
bull Chest x-ray
ndashRule out pneumonia cardiomyopathy
ndashNot diagnostic for COPD but may reveal other causes for symptoms
bull Arterial blood gases
ndashRecommended for patients with FEVlt 50
ndashPaO2lt 60 mmHg suggests respiratory failure
bull Sputum culture
ndashRule out infectious process
87
DOS CME Course 2011
Disease stages
bull Stage Indash FEVFVC lt 70
ndash FEV gt 80
ndash Few symptoms if any patient may be unaware
bull Stage II moderate ndash FEVFVC lt 70
ndash FEV lt 80
ndash Along with shortness of breath
88
DOS CME Course 2011
Disease stages
bull Stage IV very severe ndash FEVFVC lt 70
ndash FEV lt 30
ndash At this stage exacerbations are life-threatening
ndash Quality of life is impaired further
bull Stage III severe ndash FEVFVC lt 70
ndash FEV lt 50
ndash Worsening symptoms increasing frequency of exacerbations
89
DOS CME Course 2011
COPD vs Asthma
bull COPD
ndashOnset later in life
ndashProgressive worsening symptoms
ndashSmoking history
ndashDyspnea with exercise
ndashLargely irreversible airflow limitation
bull Asthma
ndashOnset of symptoms usually earlier in life
ndashWorsening at night
ndashLargely reversible airflow limitation
ndashSymptoms vary from day to day
90
DOS CME Course 2011
COPD Treatmentbull Now that we have diagnosis what do I do about it
bull Assess and monitor diseasendash Assess for risk factors ie smoking family history
ndash Co-morbidities such as heart failure
ndash Pattern of symptoms
ndash Impact on quality of life
bull Reduce risk factors ndash Identify environmentaloccupational factors which can be modified
ndash Smoking cessation is essential
ndash Manage exacerbations
91
DOS CME Course 2011
COPDbull Manage stable COPD
ndash Determine disease severity based on frequency and severity of symptoms
ndash Educate the patient about risk factors and disease management regimen
ndash Collaborate with the patient to develop a personalized regimen
ndashFits their lifestyle
ndashAccounts for cultural preferences family involvement
ndashAvailability of testing and medications
92
DOS CME Course 2011
Pharmacologybull Goals
ndash Improve exercise tolerance
ndash Control symptoms
ndash Reduce frequency and severity of exacerbations
ndash Improve health status
bull Bronchodilators ndash Include long-acting therapy with short-acting for better control
bull Combine medications from different classes rather than increasing dosage of just onendash Minimizes side effects
93
DOS CME Course 2011
Pharmacologybull Glucocorticosteroids
ndashCan reduce the number of exacerbations
ndashIncreased risk of pneumonia
ndashNo noted reduction in mortality
bull Vaccines
ndashInfluenza vaccines decrease serious illness and death by 50
ndashRecommended annually
ndashPneumococcal vaccines recommended for all COPD sufferers even under age 65
GOLD 2009
94
DOS CME Course 2011
Antibiotics
bull Antibiotics are not a treatment for COPD nor do they manage symptoms of an exacerbation
bull Should be given only if the following are metndash Presence of three cardinal symptoms increased dyspnea
increased sputum volume increased sputum purulence
ndash Increased sputum purulence plus one other cardinal symptom
ndash Mechanically ventilated
bull May be difficult for patients to understand why antibiotics will not ldquofixrdquo what is wrong
bull Good opportunity for learning needs assessment
GOLD 2009
95
DOS CME Course 2011
COPD
bull Pulmonary rehabilitation
bull Encourage the patient to continue activities as tolerated ndash Move as much as you can before you canrsquot move
bull Uses low impact exercise to maintain physical function
bull Exercise can be done while seatedndash Monitor pulse oximetry respiratory rate and effort before during
and after activity
bull Set goals which are realistic for both of you
96
DOS CME Course 2011
COPD
bull Pulmonary rehab includes education nutrition and exercise
bull Can be a good source of social support for someone who has seen function decline
ndashTalk with others in the same situation
ndashFind out how they cope
ndashSocialize
bull Regular influenza and pneumonia vaccines
97
DOS CME Course 2011
COPD
bull Oxygen therapy
bull Recommended for stage IV disease ndash PaO2 lt or = 55 mmHg
ndash SaO2 lt or = 88
bull Increases survival improves hemodynamicsbenefits mental state
bull Surgical options reviewed on a case-by-case basisndash Bullectomy
ndash Lung volume reduction ndashNo evidence to support this as a widespread therapy
98
DOS CME Course 2011
COPD
bull Managing exacerbations
bull An event in the natural course of the disease characterized by a change in baseline dyspnea cough or sputum beyond day to day variance is acute in onset and may warrant a change in medication
bull Air pollution and tracheobronchial infections are the most common causes
bull 30 of exacerbations no cause identified
(GOLD 2009 p 22)
99
DOS CME Course 2011
COPD
bull Hospitalization is recommended for patients exhibiting the following
ndash Failure of exacerbation to respond to medical treatment
ndash Development of new symptoms ie peripheral edema cyanosis
ndash Significant co-morbidities
ndash History of frequent exacerbations
ndash Newly occurring arrhythmias
ndash Advanced age
ndash Insufficient home support
ndash Unclear diagnosis
(GOLD 2009 p 23)
100
DOS CME Course 2011
COPD
bull Mechanical ventilation is not recognized as an effective management strategy for stable COPD
bull May be required as supportive therapy during an exacerbation
bull Associated with mortality
bull Carries risks of its ownndash Ventilator acquired pneumonia
ndash Ventilator induced lung injury
ndash Failure to wean
(GOLD 2009)
101
DOS CME Course 2011DOS CME Course 2011102
Every Life Deserves World Class Care
Smoking
102
DOS CME Course 2011
Smoking bull By the numbers
bull More than 400 000 Americans die from smoking-related illnesses each yearndash Thatrsquos one of every 5 deaths
bull In a study of 2963 health care encounters smoking was discussed 633 times
bull Nicotine released into the body within 10 seconds of inhalation
bull If a person smokes one pack per day and takes ten puffs of each cigarette that equates to 200 ldquohitsrdquo of nicotine daily
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
103
DOS CME Course 2011
Nicotine
bull Nicotinic receptors occur naturally
bull N1 receptors in the adrenal medulla
bull Neuromuscular junction of autonomic ganglia
bull N2 receptors in skeletal muscle
bull Number of receptor sites increases with regular stimulation
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
104
DOS CME Course 2011
Nicotinebull Addictive
bull Vasoconstrictor
bull Releases adrenaline from the adrenal cortex
ndashFeeling of increased energy
bull Releases dopamine to produce feelings of well-beingndash Actually improves memory and cognition
bull Sensitivity actually declines overnight
bull Release of insulinndash Slightly hyperglycemic
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
105
DOS CME Course 2011
Genetic componentbull About 10 of smokers lack the gene for nicotine
dependence
ndashldquosocial or occasionalrdquo smokers
ndashThey really can quit anytime they want to
ndashNo withdrawal symptoms
ndashStill poses a health risk
bull The other 90 will demonstrate physical and psychological symptoms of withdrawal
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
106
DOS CME Course 2011
Smoking
bull Identify tobacco users ndash Ask every patient every visit
ndash Have you used tobacco in the last 12 months
ndash Clinic-wide program
bull Advise every tobacco user to quitndash Personalize the message
ndash Be clear
ndash Be firm
If at first you donrsquot succeed try tryagain Bring it up at every encounter
107
DOS CME Course 2011
Smoking cessationbull Some more good reasons to quit
ndashSmoking costs over $2000 a year in current US dollars
ndashThere is no accepted safe level of cigarette smoke
ndashSecondhand smoke carries the same hazards
ndashIncreased risk of SIDS and asthma exacerbations in children
httpwwwlungusaorgstop-smokingabout-smokingfacts-figuresgeneral-smoking-factshtml
108
DOS CME Course 2011
Smoking cessation
bull Nicotine is a powerful drug addiction
bull Treat as a chronic illness
bull All healthcare providers encouraged to participate
bull Assess willingness to quit
bull Promote motivation
109
DOS CME Course 2011
Smoking cessation
bull Prochaskarsquos change theory
bull Precontemplation
ndashNot even thinking about quitting
ndashProvide education on the risks and costs of smoking
bull Contemplation
ndashAwareness that a problem exists
ndashContinue to find motivations to stop
NorcrossJC Krebs PM Prochaska JO(2011)
110
DOS CME Course 2011
Change is good
bull Determination
ndashExpressing willingness to act
ndashSelf-efficacy
bull Action ndash Currently not smoking
ndash May relapse
bull It is not unusual for a patient to ldquoquitrdquo three or four times
bull Continue to encourage and motivate himher to stop
NorcrossJC Krebs PM Prochaska JO(2011)
111
DOS CME Course 2011
Smoking cessationbull Assist the patient
ndashCollaborate with the patient to develop a plan to quit
ndashAchievable clearly defined goals
ndashIdentify and engage social supports
ndashFamily support groups
ndashPharmacologic (more on this later)
bull Arrange follow-up
ndashAt each successive visit review progress on quitting strategy
ndashLets the patient know heshe is not alone in this effort
ndashAccountability
112
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
Chronic obstructive pulmonary disease
bull By the numbers
bull 210 million suffer worldwide
bull 3 million fatalities
bull By 2030 COPD is expected to be the third leading cause of death worldwide
bull Most important risk factors ndash Smoking
ndash Indoor pollution
ndash Outdoor pollution
ndash Occupational irritants
WHO Retrieved January 2011
73
DOS CME Course 2011
COPD
bull Causes ndash Cigarette smoking is the number one cause worldwide
ndash Environmental irritants
ndash Genetic alpha-one antitrypsin deficiency
bull Birth defects ndash Low birth weight
ndash Respiratory infections
ndash Any factor which impairs lung development during gestation
bull Other ndash HIV
ndash Connective tissue disorders
ndash Vasculitis
74
DOS CME Course 2011
COPD
bull Sometimes referred to as umbrella term for a family of diseases which cause limited airflow
ndashChronic bronchitis
ndashEmphysema
bull Inflammation of the airways
bull Increased mucous productionndash Especially in bronchitis
bull Decreased ciliary function
bull Loss of elastic recoil ndash Especially in emphysema
75
DOS CME Course 2011
COPD
bull How inflammation ruins a lung
bull Cell mediated ndash Neutrophils
ndash Macrophages
ndash Lymphocytes
bull Release cytokines which attract more cells
bull Oxidants released by cells and found in cigarette smoke
bull Proteases
bull Cause remodeling and long term structural changes
76
DOS CME Course 2011
COPDbull Alveoli lose elasticity and become distended
ndashSaggy sacs
ndashCarbon dioxide retention
ndashChronic respiratory acidosis
bull Walls of the alveoli are degraded
ndashLoss of surface area necessary for gas exchange
77
DOS CME Course 2011
What the patient looks like
bull Productive Cough
ndashEspecially in chronic bronchitis
bull Progressive dyspnea
ndashUncomfortable awareness of breathing
bull Wheezing and chest tightness
bull Increase in AP chest diameter
ndashldquoBarrel chestrdquo especially in emphysema
ndashIncreased inspiratory effort loosens costochondral cartilage
78
DOS CME Course 2011
Alpha one antitrypsin deficiency
bull Enzyme normally produced which protects the lungs
bull Deactivates neutrophil elastase
ndashReleased during inflammation
bull Estimated over 100000 in US have AATD
bull Time to diagnosis gt8 years
bull Related to increased mortality (Krowka 2010)
ndashIncreased incidence of emphysema
79
DOS CME Course 2011
Chronic bronchitis
bull Presence of cough and sputum production over three months for two consecutive years
ndashNote the months need not be consecutive
bull The patient may feel as though they are constantly sick
bull Multiple courses of antibiotics with no improvement
bull No relationship to acute bronchitis caused by bacteria or virus
80
DOS CME Course 2011
COPD
bull Break out the testing ndash CXR
ndash ECG
ndash Sputum culture
ndash CBC and electrolytes
bull ABGrsquos ndash Respiratory failure indicated by
ndash PaO2lt 60 and SaO2 lt 90
ndash with or without PaCO2 gt 50
ndash On room air
ndash Severe acidosis pHlt 736 in addition to the above is an indication for mechanical ventilation
(GOLD 2009 p 22)
81
DOS CME Course 2011
Chronic bronchitis
bull Airway of a child afflicted with chronic bronchitis compared to normal
82
DOS CME Course 2011
Chronic bronchitisbull Related to mucociliary dysfunction
ndashIncreased mucous production and thickening
ndashLoss of cilia
ndashLoss of ciliary function
ndashMobility required to sweep out particles
83
DOS CME Course 2011
Emphysemabull Permanent enlargement of the airspaces terminal to the
distal bronchioles ndashLoss of surface area for gas exchangendashDestruction of supporting structure of alveoli
ndashAirway narrowing
bull Three distinct patterns ndashCentracinar begins centrally and spreads to terminal
bronchioles and is most closely associated with cigarette smoking
ndashPanacinar destroys alveoli uniformly predominant in lower half of lungs most closely associated with AATD
ndashParaseptal destroys the distal airway structures alveolar ducts and sacs
Demirjian BG 2010
84
DOS CME Course 2011
Bullaebull Outpouchingsballooning of lung tissue due to trapped air
ndashAir is released from damaged alveoli
ndashAsymptomatic
ndashRupture can cause pneumothorax
85
DOS CME Course 2011
Diagnosis
bull History of smoking or exposure to inhaled irritants
ndashRemember to consider work and living environment
ndashCooking indoors with fossil fuels
ndashAge over 40
bull Signs and symptoms
ndashChronic cough with sputum production
ndashDyspnea which persists daily worsens with exercise and progresses over time
bull Spirometry is strongly recommended
86
DOS CME Course 2011
Diagnosis
bull Chest x-ray
ndashRule out pneumonia cardiomyopathy
ndashNot diagnostic for COPD but may reveal other causes for symptoms
bull Arterial blood gases
ndashRecommended for patients with FEVlt 50
ndashPaO2lt 60 mmHg suggests respiratory failure
bull Sputum culture
ndashRule out infectious process
87
DOS CME Course 2011
Disease stages
bull Stage Indash FEVFVC lt 70
ndash FEV gt 80
ndash Few symptoms if any patient may be unaware
bull Stage II moderate ndash FEVFVC lt 70
ndash FEV lt 80
ndash Along with shortness of breath
88
DOS CME Course 2011
Disease stages
bull Stage IV very severe ndash FEVFVC lt 70
ndash FEV lt 30
ndash At this stage exacerbations are life-threatening
ndash Quality of life is impaired further
bull Stage III severe ndash FEVFVC lt 70
ndash FEV lt 50
ndash Worsening symptoms increasing frequency of exacerbations
89
DOS CME Course 2011
COPD vs Asthma
bull COPD
ndashOnset later in life
ndashProgressive worsening symptoms
ndashSmoking history
ndashDyspnea with exercise
ndashLargely irreversible airflow limitation
bull Asthma
ndashOnset of symptoms usually earlier in life
ndashWorsening at night
ndashLargely reversible airflow limitation
ndashSymptoms vary from day to day
90
DOS CME Course 2011
COPD Treatmentbull Now that we have diagnosis what do I do about it
bull Assess and monitor diseasendash Assess for risk factors ie smoking family history
ndash Co-morbidities such as heart failure
ndash Pattern of symptoms
ndash Impact on quality of life
bull Reduce risk factors ndash Identify environmentaloccupational factors which can be modified
ndash Smoking cessation is essential
ndash Manage exacerbations
91
DOS CME Course 2011
COPDbull Manage stable COPD
ndash Determine disease severity based on frequency and severity of symptoms
ndash Educate the patient about risk factors and disease management regimen
ndash Collaborate with the patient to develop a personalized regimen
ndashFits their lifestyle
ndashAccounts for cultural preferences family involvement
ndashAvailability of testing and medications
92
DOS CME Course 2011
Pharmacologybull Goals
ndash Improve exercise tolerance
ndash Control symptoms
ndash Reduce frequency and severity of exacerbations
ndash Improve health status
bull Bronchodilators ndash Include long-acting therapy with short-acting for better control
bull Combine medications from different classes rather than increasing dosage of just onendash Minimizes side effects
93
DOS CME Course 2011
Pharmacologybull Glucocorticosteroids
ndashCan reduce the number of exacerbations
ndashIncreased risk of pneumonia
ndashNo noted reduction in mortality
bull Vaccines
ndashInfluenza vaccines decrease serious illness and death by 50
ndashRecommended annually
ndashPneumococcal vaccines recommended for all COPD sufferers even under age 65
GOLD 2009
94
DOS CME Course 2011
Antibiotics
bull Antibiotics are not a treatment for COPD nor do they manage symptoms of an exacerbation
bull Should be given only if the following are metndash Presence of three cardinal symptoms increased dyspnea
increased sputum volume increased sputum purulence
ndash Increased sputum purulence plus one other cardinal symptom
ndash Mechanically ventilated
bull May be difficult for patients to understand why antibiotics will not ldquofixrdquo what is wrong
bull Good opportunity for learning needs assessment
GOLD 2009
95
DOS CME Course 2011
COPD
bull Pulmonary rehabilitation
bull Encourage the patient to continue activities as tolerated ndash Move as much as you can before you canrsquot move
bull Uses low impact exercise to maintain physical function
bull Exercise can be done while seatedndash Monitor pulse oximetry respiratory rate and effort before during
and after activity
bull Set goals which are realistic for both of you
96
DOS CME Course 2011
COPD
bull Pulmonary rehab includes education nutrition and exercise
bull Can be a good source of social support for someone who has seen function decline
ndashTalk with others in the same situation
ndashFind out how they cope
ndashSocialize
bull Regular influenza and pneumonia vaccines
97
DOS CME Course 2011
COPD
bull Oxygen therapy
bull Recommended for stage IV disease ndash PaO2 lt or = 55 mmHg
ndash SaO2 lt or = 88
bull Increases survival improves hemodynamicsbenefits mental state
bull Surgical options reviewed on a case-by-case basisndash Bullectomy
ndash Lung volume reduction ndashNo evidence to support this as a widespread therapy
98
DOS CME Course 2011
COPD
bull Managing exacerbations
bull An event in the natural course of the disease characterized by a change in baseline dyspnea cough or sputum beyond day to day variance is acute in onset and may warrant a change in medication
bull Air pollution and tracheobronchial infections are the most common causes
bull 30 of exacerbations no cause identified
(GOLD 2009 p 22)
99
DOS CME Course 2011
COPD
bull Hospitalization is recommended for patients exhibiting the following
ndash Failure of exacerbation to respond to medical treatment
ndash Development of new symptoms ie peripheral edema cyanosis
ndash Significant co-morbidities
ndash History of frequent exacerbations
ndash Newly occurring arrhythmias
ndash Advanced age
ndash Insufficient home support
ndash Unclear diagnosis
(GOLD 2009 p 23)
100
DOS CME Course 2011
COPD
bull Mechanical ventilation is not recognized as an effective management strategy for stable COPD
bull May be required as supportive therapy during an exacerbation
bull Associated with mortality
bull Carries risks of its ownndash Ventilator acquired pneumonia
ndash Ventilator induced lung injury
ndash Failure to wean
(GOLD 2009)
101
DOS CME Course 2011DOS CME Course 2011102
Every Life Deserves World Class Care
Smoking
102
DOS CME Course 2011
Smoking bull By the numbers
bull More than 400 000 Americans die from smoking-related illnesses each yearndash Thatrsquos one of every 5 deaths
bull In a study of 2963 health care encounters smoking was discussed 633 times
bull Nicotine released into the body within 10 seconds of inhalation
bull If a person smokes one pack per day and takes ten puffs of each cigarette that equates to 200 ldquohitsrdquo of nicotine daily
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
103
DOS CME Course 2011
Nicotine
bull Nicotinic receptors occur naturally
bull N1 receptors in the adrenal medulla
bull Neuromuscular junction of autonomic ganglia
bull N2 receptors in skeletal muscle
bull Number of receptor sites increases with regular stimulation
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
104
DOS CME Course 2011
Nicotinebull Addictive
bull Vasoconstrictor
bull Releases adrenaline from the adrenal cortex
ndashFeeling of increased energy
bull Releases dopamine to produce feelings of well-beingndash Actually improves memory and cognition
bull Sensitivity actually declines overnight
bull Release of insulinndash Slightly hyperglycemic
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
105
DOS CME Course 2011
Genetic componentbull About 10 of smokers lack the gene for nicotine
dependence
ndashldquosocial or occasionalrdquo smokers
ndashThey really can quit anytime they want to
ndashNo withdrawal symptoms
ndashStill poses a health risk
bull The other 90 will demonstrate physical and psychological symptoms of withdrawal
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
106
DOS CME Course 2011
Smoking
bull Identify tobacco users ndash Ask every patient every visit
ndash Have you used tobacco in the last 12 months
ndash Clinic-wide program
bull Advise every tobacco user to quitndash Personalize the message
ndash Be clear
ndash Be firm
If at first you donrsquot succeed try tryagain Bring it up at every encounter
107
DOS CME Course 2011
Smoking cessationbull Some more good reasons to quit
ndashSmoking costs over $2000 a year in current US dollars
ndashThere is no accepted safe level of cigarette smoke
ndashSecondhand smoke carries the same hazards
ndashIncreased risk of SIDS and asthma exacerbations in children
httpwwwlungusaorgstop-smokingabout-smokingfacts-figuresgeneral-smoking-factshtml
108
DOS CME Course 2011
Smoking cessation
bull Nicotine is a powerful drug addiction
bull Treat as a chronic illness
bull All healthcare providers encouraged to participate
bull Assess willingness to quit
bull Promote motivation
109
DOS CME Course 2011
Smoking cessation
bull Prochaskarsquos change theory
bull Precontemplation
ndashNot even thinking about quitting
ndashProvide education on the risks and costs of smoking
bull Contemplation
ndashAwareness that a problem exists
ndashContinue to find motivations to stop
NorcrossJC Krebs PM Prochaska JO(2011)
110
DOS CME Course 2011
Change is good
bull Determination
ndashExpressing willingness to act
ndashSelf-efficacy
bull Action ndash Currently not smoking
ndash May relapse
bull It is not unusual for a patient to ldquoquitrdquo three or four times
bull Continue to encourage and motivate himher to stop
NorcrossJC Krebs PM Prochaska JO(2011)
111
DOS CME Course 2011
Smoking cessationbull Assist the patient
ndashCollaborate with the patient to develop a plan to quit
ndashAchievable clearly defined goals
ndashIdentify and engage social supports
ndashFamily support groups
ndashPharmacologic (more on this later)
bull Arrange follow-up
ndashAt each successive visit review progress on quitting strategy
ndashLets the patient know heshe is not alone in this effort
ndashAccountability
112
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
COPD
bull Sometimes referred to as umbrella term for a family of diseases which cause limited airflow
ndashChronic bronchitis
ndashEmphysema
bull Inflammation of the airways
bull Increased mucous productionndash Especially in bronchitis
bull Decreased ciliary function
bull Loss of elastic recoil ndash Especially in emphysema
75
DOS CME Course 2011
COPD
bull How inflammation ruins a lung
bull Cell mediated ndash Neutrophils
ndash Macrophages
ndash Lymphocytes
bull Release cytokines which attract more cells
bull Oxidants released by cells and found in cigarette smoke
bull Proteases
bull Cause remodeling and long term structural changes
76
DOS CME Course 2011
COPDbull Alveoli lose elasticity and become distended
ndashSaggy sacs
ndashCarbon dioxide retention
ndashChronic respiratory acidosis
bull Walls of the alveoli are degraded
ndashLoss of surface area necessary for gas exchange
77
DOS CME Course 2011
What the patient looks like
bull Productive Cough
ndashEspecially in chronic bronchitis
bull Progressive dyspnea
ndashUncomfortable awareness of breathing
bull Wheezing and chest tightness
bull Increase in AP chest diameter
ndashldquoBarrel chestrdquo especially in emphysema
ndashIncreased inspiratory effort loosens costochondral cartilage
78
DOS CME Course 2011
Alpha one antitrypsin deficiency
bull Enzyme normally produced which protects the lungs
bull Deactivates neutrophil elastase
ndashReleased during inflammation
bull Estimated over 100000 in US have AATD
bull Time to diagnosis gt8 years
bull Related to increased mortality (Krowka 2010)
ndashIncreased incidence of emphysema
79
DOS CME Course 2011
Chronic bronchitis
bull Presence of cough and sputum production over three months for two consecutive years
ndashNote the months need not be consecutive
bull The patient may feel as though they are constantly sick
bull Multiple courses of antibiotics with no improvement
bull No relationship to acute bronchitis caused by bacteria or virus
80
DOS CME Course 2011
COPD
bull Break out the testing ndash CXR
ndash ECG
ndash Sputum culture
ndash CBC and electrolytes
bull ABGrsquos ndash Respiratory failure indicated by
ndash PaO2lt 60 and SaO2 lt 90
ndash with or without PaCO2 gt 50
ndash On room air
ndash Severe acidosis pHlt 736 in addition to the above is an indication for mechanical ventilation
(GOLD 2009 p 22)
81
DOS CME Course 2011
Chronic bronchitis
bull Airway of a child afflicted with chronic bronchitis compared to normal
82
DOS CME Course 2011
Chronic bronchitisbull Related to mucociliary dysfunction
ndashIncreased mucous production and thickening
ndashLoss of cilia
ndashLoss of ciliary function
ndashMobility required to sweep out particles
83
DOS CME Course 2011
Emphysemabull Permanent enlargement of the airspaces terminal to the
distal bronchioles ndashLoss of surface area for gas exchangendashDestruction of supporting structure of alveoli
ndashAirway narrowing
bull Three distinct patterns ndashCentracinar begins centrally and spreads to terminal
bronchioles and is most closely associated with cigarette smoking
ndashPanacinar destroys alveoli uniformly predominant in lower half of lungs most closely associated with AATD
ndashParaseptal destroys the distal airway structures alveolar ducts and sacs
Demirjian BG 2010
84
DOS CME Course 2011
Bullaebull Outpouchingsballooning of lung tissue due to trapped air
ndashAir is released from damaged alveoli
ndashAsymptomatic
ndashRupture can cause pneumothorax
85
DOS CME Course 2011
Diagnosis
bull History of smoking or exposure to inhaled irritants
ndashRemember to consider work and living environment
ndashCooking indoors with fossil fuels
ndashAge over 40
bull Signs and symptoms
ndashChronic cough with sputum production
ndashDyspnea which persists daily worsens with exercise and progresses over time
bull Spirometry is strongly recommended
86
DOS CME Course 2011
Diagnosis
bull Chest x-ray
ndashRule out pneumonia cardiomyopathy
ndashNot diagnostic for COPD but may reveal other causes for symptoms
bull Arterial blood gases
ndashRecommended for patients with FEVlt 50
ndashPaO2lt 60 mmHg suggests respiratory failure
bull Sputum culture
ndashRule out infectious process
87
DOS CME Course 2011
Disease stages
bull Stage Indash FEVFVC lt 70
ndash FEV gt 80
ndash Few symptoms if any patient may be unaware
bull Stage II moderate ndash FEVFVC lt 70
ndash FEV lt 80
ndash Along with shortness of breath
88
DOS CME Course 2011
Disease stages
bull Stage IV very severe ndash FEVFVC lt 70
ndash FEV lt 30
ndash At this stage exacerbations are life-threatening
ndash Quality of life is impaired further
bull Stage III severe ndash FEVFVC lt 70
ndash FEV lt 50
ndash Worsening symptoms increasing frequency of exacerbations
89
DOS CME Course 2011
COPD vs Asthma
bull COPD
ndashOnset later in life
ndashProgressive worsening symptoms
ndashSmoking history
ndashDyspnea with exercise
ndashLargely irreversible airflow limitation
bull Asthma
ndashOnset of symptoms usually earlier in life
ndashWorsening at night
ndashLargely reversible airflow limitation
ndashSymptoms vary from day to day
90
DOS CME Course 2011
COPD Treatmentbull Now that we have diagnosis what do I do about it
bull Assess and monitor diseasendash Assess for risk factors ie smoking family history
ndash Co-morbidities such as heart failure
ndash Pattern of symptoms
ndash Impact on quality of life
bull Reduce risk factors ndash Identify environmentaloccupational factors which can be modified
ndash Smoking cessation is essential
ndash Manage exacerbations
91
DOS CME Course 2011
COPDbull Manage stable COPD
ndash Determine disease severity based on frequency and severity of symptoms
ndash Educate the patient about risk factors and disease management regimen
ndash Collaborate with the patient to develop a personalized regimen
ndashFits their lifestyle
ndashAccounts for cultural preferences family involvement
ndashAvailability of testing and medications
92
DOS CME Course 2011
Pharmacologybull Goals
ndash Improve exercise tolerance
ndash Control symptoms
ndash Reduce frequency and severity of exacerbations
ndash Improve health status
bull Bronchodilators ndash Include long-acting therapy with short-acting for better control
bull Combine medications from different classes rather than increasing dosage of just onendash Minimizes side effects
93
DOS CME Course 2011
Pharmacologybull Glucocorticosteroids
ndashCan reduce the number of exacerbations
ndashIncreased risk of pneumonia
ndashNo noted reduction in mortality
bull Vaccines
ndashInfluenza vaccines decrease serious illness and death by 50
ndashRecommended annually
ndashPneumococcal vaccines recommended for all COPD sufferers even under age 65
GOLD 2009
94
DOS CME Course 2011
Antibiotics
bull Antibiotics are not a treatment for COPD nor do they manage symptoms of an exacerbation
bull Should be given only if the following are metndash Presence of three cardinal symptoms increased dyspnea
increased sputum volume increased sputum purulence
ndash Increased sputum purulence plus one other cardinal symptom
ndash Mechanically ventilated
bull May be difficult for patients to understand why antibiotics will not ldquofixrdquo what is wrong
bull Good opportunity for learning needs assessment
GOLD 2009
95
DOS CME Course 2011
COPD
bull Pulmonary rehabilitation
bull Encourage the patient to continue activities as tolerated ndash Move as much as you can before you canrsquot move
bull Uses low impact exercise to maintain physical function
bull Exercise can be done while seatedndash Monitor pulse oximetry respiratory rate and effort before during
and after activity
bull Set goals which are realistic for both of you
96
DOS CME Course 2011
COPD
bull Pulmonary rehab includes education nutrition and exercise
bull Can be a good source of social support for someone who has seen function decline
ndashTalk with others in the same situation
ndashFind out how they cope
ndashSocialize
bull Regular influenza and pneumonia vaccines
97
DOS CME Course 2011
COPD
bull Oxygen therapy
bull Recommended for stage IV disease ndash PaO2 lt or = 55 mmHg
ndash SaO2 lt or = 88
bull Increases survival improves hemodynamicsbenefits mental state
bull Surgical options reviewed on a case-by-case basisndash Bullectomy
ndash Lung volume reduction ndashNo evidence to support this as a widespread therapy
98
DOS CME Course 2011
COPD
bull Managing exacerbations
bull An event in the natural course of the disease characterized by a change in baseline dyspnea cough or sputum beyond day to day variance is acute in onset and may warrant a change in medication
bull Air pollution and tracheobronchial infections are the most common causes
bull 30 of exacerbations no cause identified
(GOLD 2009 p 22)
99
DOS CME Course 2011
COPD
bull Hospitalization is recommended for patients exhibiting the following
ndash Failure of exacerbation to respond to medical treatment
ndash Development of new symptoms ie peripheral edema cyanosis
ndash Significant co-morbidities
ndash History of frequent exacerbations
ndash Newly occurring arrhythmias
ndash Advanced age
ndash Insufficient home support
ndash Unclear diagnosis
(GOLD 2009 p 23)
100
DOS CME Course 2011
COPD
bull Mechanical ventilation is not recognized as an effective management strategy for stable COPD
bull May be required as supportive therapy during an exacerbation
bull Associated with mortality
bull Carries risks of its ownndash Ventilator acquired pneumonia
ndash Ventilator induced lung injury
ndash Failure to wean
(GOLD 2009)
101
DOS CME Course 2011DOS CME Course 2011102
Every Life Deserves World Class Care
Smoking
102
DOS CME Course 2011
Smoking bull By the numbers
bull More than 400 000 Americans die from smoking-related illnesses each yearndash Thatrsquos one of every 5 deaths
bull In a study of 2963 health care encounters smoking was discussed 633 times
bull Nicotine released into the body within 10 seconds of inhalation
bull If a person smokes one pack per day and takes ten puffs of each cigarette that equates to 200 ldquohitsrdquo of nicotine daily
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
103
DOS CME Course 2011
Nicotine
bull Nicotinic receptors occur naturally
bull N1 receptors in the adrenal medulla
bull Neuromuscular junction of autonomic ganglia
bull N2 receptors in skeletal muscle
bull Number of receptor sites increases with regular stimulation
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
104
DOS CME Course 2011
Nicotinebull Addictive
bull Vasoconstrictor
bull Releases adrenaline from the adrenal cortex
ndashFeeling of increased energy
bull Releases dopamine to produce feelings of well-beingndash Actually improves memory and cognition
bull Sensitivity actually declines overnight
bull Release of insulinndash Slightly hyperglycemic
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
105
DOS CME Course 2011
Genetic componentbull About 10 of smokers lack the gene for nicotine
dependence
ndashldquosocial or occasionalrdquo smokers
ndashThey really can quit anytime they want to
ndashNo withdrawal symptoms
ndashStill poses a health risk
bull The other 90 will demonstrate physical and psychological symptoms of withdrawal
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
106
DOS CME Course 2011
Smoking
bull Identify tobacco users ndash Ask every patient every visit
ndash Have you used tobacco in the last 12 months
ndash Clinic-wide program
bull Advise every tobacco user to quitndash Personalize the message
ndash Be clear
ndash Be firm
If at first you donrsquot succeed try tryagain Bring it up at every encounter
107
DOS CME Course 2011
Smoking cessationbull Some more good reasons to quit
ndashSmoking costs over $2000 a year in current US dollars
ndashThere is no accepted safe level of cigarette smoke
ndashSecondhand smoke carries the same hazards
ndashIncreased risk of SIDS and asthma exacerbations in children
httpwwwlungusaorgstop-smokingabout-smokingfacts-figuresgeneral-smoking-factshtml
108
DOS CME Course 2011
Smoking cessation
bull Nicotine is a powerful drug addiction
bull Treat as a chronic illness
bull All healthcare providers encouraged to participate
bull Assess willingness to quit
bull Promote motivation
109
DOS CME Course 2011
Smoking cessation
bull Prochaskarsquos change theory
bull Precontemplation
ndashNot even thinking about quitting
ndashProvide education on the risks and costs of smoking
bull Contemplation
ndashAwareness that a problem exists
ndashContinue to find motivations to stop
NorcrossJC Krebs PM Prochaska JO(2011)
110
DOS CME Course 2011
Change is good
bull Determination
ndashExpressing willingness to act
ndashSelf-efficacy
bull Action ndash Currently not smoking
ndash May relapse
bull It is not unusual for a patient to ldquoquitrdquo three or four times
bull Continue to encourage and motivate himher to stop
NorcrossJC Krebs PM Prochaska JO(2011)
111
DOS CME Course 2011
Smoking cessationbull Assist the patient
ndashCollaborate with the patient to develop a plan to quit
ndashAchievable clearly defined goals
ndashIdentify and engage social supports
ndashFamily support groups
ndashPharmacologic (more on this later)
bull Arrange follow-up
ndashAt each successive visit review progress on quitting strategy
ndashLets the patient know heshe is not alone in this effort
ndashAccountability
112
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
COPDbull Alveoli lose elasticity and become distended
ndashSaggy sacs
ndashCarbon dioxide retention
ndashChronic respiratory acidosis
bull Walls of the alveoli are degraded
ndashLoss of surface area necessary for gas exchange
77
DOS CME Course 2011
What the patient looks like
bull Productive Cough
ndashEspecially in chronic bronchitis
bull Progressive dyspnea
ndashUncomfortable awareness of breathing
bull Wheezing and chest tightness
bull Increase in AP chest diameter
ndashldquoBarrel chestrdquo especially in emphysema
ndashIncreased inspiratory effort loosens costochondral cartilage
78
DOS CME Course 2011
Alpha one antitrypsin deficiency
bull Enzyme normally produced which protects the lungs
bull Deactivates neutrophil elastase
ndashReleased during inflammation
bull Estimated over 100000 in US have AATD
bull Time to diagnosis gt8 years
bull Related to increased mortality (Krowka 2010)
ndashIncreased incidence of emphysema
79
DOS CME Course 2011
Chronic bronchitis
bull Presence of cough and sputum production over three months for two consecutive years
ndashNote the months need not be consecutive
bull The patient may feel as though they are constantly sick
bull Multiple courses of antibiotics with no improvement
bull No relationship to acute bronchitis caused by bacteria or virus
80
DOS CME Course 2011
COPD
bull Break out the testing ndash CXR
ndash ECG
ndash Sputum culture
ndash CBC and electrolytes
bull ABGrsquos ndash Respiratory failure indicated by
ndash PaO2lt 60 and SaO2 lt 90
ndash with or without PaCO2 gt 50
ndash On room air
ndash Severe acidosis pHlt 736 in addition to the above is an indication for mechanical ventilation
(GOLD 2009 p 22)
81
DOS CME Course 2011
Chronic bronchitis
bull Airway of a child afflicted with chronic bronchitis compared to normal
82
DOS CME Course 2011
Chronic bronchitisbull Related to mucociliary dysfunction
ndashIncreased mucous production and thickening
ndashLoss of cilia
ndashLoss of ciliary function
ndashMobility required to sweep out particles
83
DOS CME Course 2011
Emphysemabull Permanent enlargement of the airspaces terminal to the
distal bronchioles ndashLoss of surface area for gas exchangendashDestruction of supporting structure of alveoli
ndashAirway narrowing
bull Three distinct patterns ndashCentracinar begins centrally and spreads to terminal
bronchioles and is most closely associated with cigarette smoking
ndashPanacinar destroys alveoli uniformly predominant in lower half of lungs most closely associated with AATD
ndashParaseptal destroys the distal airway structures alveolar ducts and sacs
Demirjian BG 2010
84
DOS CME Course 2011
Bullaebull Outpouchingsballooning of lung tissue due to trapped air
ndashAir is released from damaged alveoli
ndashAsymptomatic
ndashRupture can cause pneumothorax
85
DOS CME Course 2011
Diagnosis
bull History of smoking or exposure to inhaled irritants
ndashRemember to consider work and living environment
ndashCooking indoors with fossil fuels
ndashAge over 40
bull Signs and symptoms
ndashChronic cough with sputum production
ndashDyspnea which persists daily worsens with exercise and progresses over time
bull Spirometry is strongly recommended
86
DOS CME Course 2011
Diagnosis
bull Chest x-ray
ndashRule out pneumonia cardiomyopathy
ndashNot diagnostic for COPD but may reveal other causes for symptoms
bull Arterial blood gases
ndashRecommended for patients with FEVlt 50
ndashPaO2lt 60 mmHg suggests respiratory failure
bull Sputum culture
ndashRule out infectious process
87
DOS CME Course 2011
Disease stages
bull Stage Indash FEVFVC lt 70
ndash FEV gt 80
ndash Few symptoms if any patient may be unaware
bull Stage II moderate ndash FEVFVC lt 70
ndash FEV lt 80
ndash Along with shortness of breath
88
DOS CME Course 2011
Disease stages
bull Stage IV very severe ndash FEVFVC lt 70
ndash FEV lt 30
ndash At this stage exacerbations are life-threatening
ndash Quality of life is impaired further
bull Stage III severe ndash FEVFVC lt 70
ndash FEV lt 50
ndash Worsening symptoms increasing frequency of exacerbations
89
DOS CME Course 2011
COPD vs Asthma
bull COPD
ndashOnset later in life
ndashProgressive worsening symptoms
ndashSmoking history
ndashDyspnea with exercise
ndashLargely irreversible airflow limitation
bull Asthma
ndashOnset of symptoms usually earlier in life
ndashWorsening at night
ndashLargely reversible airflow limitation
ndashSymptoms vary from day to day
90
DOS CME Course 2011
COPD Treatmentbull Now that we have diagnosis what do I do about it
bull Assess and monitor diseasendash Assess for risk factors ie smoking family history
ndash Co-morbidities such as heart failure
ndash Pattern of symptoms
ndash Impact on quality of life
bull Reduce risk factors ndash Identify environmentaloccupational factors which can be modified
ndash Smoking cessation is essential
ndash Manage exacerbations
91
DOS CME Course 2011
COPDbull Manage stable COPD
ndash Determine disease severity based on frequency and severity of symptoms
ndash Educate the patient about risk factors and disease management regimen
ndash Collaborate with the patient to develop a personalized regimen
ndashFits their lifestyle
ndashAccounts for cultural preferences family involvement
ndashAvailability of testing and medications
92
DOS CME Course 2011
Pharmacologybull Goals
ndash Improve exercise tolerance
ndash Control symptoms
ndash Reduce frequency and severity of exacerbations
ndash Improve health status
bull Bronchodilators ndash Include long-acting therapy with short-acting for better control
bull Combine medications from different classes rather than increasing dosage of just onendash Minimizes side effects
93
DOS CME Course 2011
Pharmacologybull Glucocorticosteroids
ndashCan reduce the number of exacerbations
ndashIncreased risk of pneumonia
ndashNo noted reduction in mortality
bull Vaccines
ndashInfluenza vaccines decrease serious illness and death by 50
ndashRecommended annually
ndashPneumococcal vaccines recommended for all COPD sufferers even under age 65
GOLD 2009
94
DOS CME Course 2011
Antibiotics
bull Antibiotics are not a treatment for COPD nor do they manage symptoms of an exacerbation
bull Should be given only if the following are metndash Presence of three cardinal symptoms increased dyspnea
increased sputum volume increased sputum purulence
ndash Increased sputum purulence plus one other cardinal symptom
ndash Mechanically ventilated
bull May be difficult for patients to understand why antibiotics will not ldquofixrdquo what is wrong
bull Good opportunity for learning needs assessment
GOLD 2009
95
DOS CME Course 2011
COPD
bull Pulmonary rehabilitation
bull Encourage the patient to continue activities as tolerated ndash Move as much as you can before you canrsquot move
bull Uses low impact exercise to maintain physical function
bull Exercise can be done while seatedndash Monitor pulse oximetry respiratory rate and effort before during
and after activity
bull Set goals which are realistic for both of you
96
DOS CME Course 2011
COPD
bull Pulmonary rehab includes education nutrition and exercise
bull Can be a good source of social support for someone who has seen function decline
ndashTalk with others in the same situation
ndashFind out how they cope
ndashSocialize
bull Regular influenza and pneumonia vaccines
97
DOS CME Course 2011
COPD
bull Oxygen therapy
bull Recommended for stage IV disease ndash PaO2 lt or = 55 mmHg
ndash SaO2 lt or = 88
bull Increases survival improves hemodynamicsbenefits mental state
bull Surgical options reviewed on a case-by-case basisndash Bullectomy
ndash Lung volume reduction ndashNo evidence to support this as a widespread therapy
98
DOS CME Course 2011
COPD
bull Managing exacerbations
bull An event in the natural course of the disease characterized by a change in baseline dyspnea cough or sputum beyond day to day variance is acute in onset and may warrant a change in medication
bull Air pollution and tracheobronchial infections are the most common causes
bull 30 of exacerbations no cause identified
(GOLD 2009 p 22)
99
DOS CME Course 2011
COPD
bull Hospitalization is recommended for patients exhibiting the following
ndash Failure of exacerbation to respond to medical treatment
ndash Development of new symptoms ie peripheral edema cyanosis
ndash Significant co-morbidities
ndash History of frequent exacerbations
ndash Newly occurring arrhythmias
ndash Advanced age
ndash Insufficient home support
ndash Unclear diagnosis
(GOLD 2009 p 23)
100
DOS CME Course 2011
COPD
bull Mechanical ventilation is not recognized as an effective management strategy for stable COPD
bull May be required as supportive therapy during an exacerbation
bull Associated with mortality
bull Carries risks of its ownndash Ventilator acquired pneumonia
ndash Ventilator induced lung injury
ndash Failure to wean
(GOLD 2009)
101
DOS CME Course 2011DOS CME Course 2011102
Every Life Deserves World Class Care
Smoking
102
DOS CME Course 2011
Smoking bull By the numbers
bull More than 400 000 Americans die from smoking-related illnesses each yearndash Thatrsquos one of every 5 deaths
bull In a study of 2963 health care encounters smoking was discussed 633 times
bull Nicotine released into the body within 10 seconds of inhalation
bull If a person smokes one pack per day and takes ten puffs of each cigarette that equates to 200 ldquohitsrdquo of nicotine daily
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
103
DOS CME Course 2011
Nicotine
bull Nicotinic receptors occur naturally
bull N1 receptors in the adrenal medulla
bull Neuromuscular junction of autonomic ganglia
bull N2 receptors in skeletal muscle
bull Number of receptor sites increases with regular stimulation
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
104
DOS CME Course 2011
Nicotinebull Addictive
bull Vasoconstrictor
bull Releases adrenaline from the adrenal cortex
ndashFeeling of increased energy
bull Releases dopamine to produce feelings of well-beingndash Actually improves memory and cognition
bull Sensitivity actually declines overnight
bull Release of insulinndash Slightly hyperglycemic
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
105
DOS CME Course 2011
Genetic componentbull About 10 of smokers lack the gene for nicotine
dependence
ndashldquosocial or occasionalrdquo smokers
ndashThey really can quit anytime they want to
ndashNo withdrawal symptoms
ndashStill poses a health risk
bull The other 90 will demonstrate physical and psychological symptoms of withdrawal
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
106
DOS CME Course 2011
Smoking
bull Identify tobacco users ndash Ask every patient every visit
ndash Have you used tobacco in the last 12 months
ndash Clinic-wide program
bull Advise every tobacco user to quitndash Personalize the message
ndash Be clear
ndash Be firm
If at first you donrsquot succeed try tryagain Bring it up at every encounter
107
DOS CME Course 2011
Smoking cessationbull Some more good reasons to quit
ndashSmoking costs over $2000 a year in current US dollars
ndashThere is no accepted safe level of cigarette smoke
ndashSecondhand smoke carries the same hazards
ndashIncreased risk of SIDS and asthma exacerbations in children
httpwwwlungusaorgstop-smokingabout-smokingfacts-figuresgeneral-smoking-factshtml
108
DOS CME Course 2011
Smoking cessation
bull Nicotine is a powerful drug addiction
bull Treat as a chronic illness
bull All healthcare providers encouraged to participate
bull Assess willingness to quit
bull Promote motivation
109
DOS CME Course 2011
Smoking cessation
bull Prochaskarsquos change theory
bull Precontemplation
ndashNot even thinking about quitting
ndashProvide education on the risks and costs of smoking
bull Contemplation
ndashAwareness that a problem exists
ndashContinue to find motivations to stop
NorcrossJC Krebs PM Prochaska JO(2011)
110
DOS CME Course 2011
Change is good
bull Determination
ndashExpressing willingness to act
ndashSelf-efficacy
bull Action ndash Currently not smoking
ndash May relapse
bull It is not unusual for a patient to ldquoquitrdquo three or four times
bull Continue to encourage and motivate himher to stop
NorcrossJC Krebs PM Prochaska JO(2011)
111
DOS CME Course 2011
Smoking cessationbull Assist the patient
ndashCollaborate with the patient to develop a plan to quit
ndashAchievable clearly defined goals
ndashIdentify and engage social supports
ndashFamily support groups
ndashPharmacologic (more on this later)
bull Arrange follow-up
ndashAt each successive visit review progress on quitting strategy
ndashLets the patient know heshe is not alone in this effort
ndashAccountability
112
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
Alpha one antitrypsin deficiency
bull Enzyme normally produced which protects the lungs
bull Deactivates neutrophil elastase
ndashReleased during inflammation
bull Estimated over 100000 in US have AATD
bull Time to diagnosis gt8 years
bull Related to increased mortality (Krowka 2010)
ndashIncreased incidence of emphysema
79
DOS CME Course 2011
Chronic bronchitis
bull Presence of cough and sputum production over three months for two consecutive years
ndashNote the months need not be consecutive
bull The patient may feel as though they are constantly sick
bull Multiple courses of antibiotics with no improvement
bull No relationship to acute bronchitis caused by bacteria or virus
80
DOS CME Course 2011
COPD
bull Break out the testing ndash CXR
ndash ECG
ndash Sputum culture
ndash CBC and electrolytes
bull ABGrsquos ndash Respiratory failure indicated by
ndash PaO2lt 60 and SaO2 lt 90
ndash with or without PaCO2 gt 50
ndash On room air
ndash Severe acidosis pHlt 736 in addition to the above is an indication for mechanical ventilation
(GOLD 2009 p 22)
81
DOS CME Course 2011
Chronic bronchitis
bull Airway of a child afflicted with chronic bronchitis compared to normal
82
DOS CME Course 2011
Chronic bronchitisbull Related to mucociliary dysfunction
ndashIncreased mucous production and thickening
ndashLoss of cilia
ndashLoss of ciliary function
ndashMobility required to sweep out particles
83
DOS CME Course 2011
Emphysemabull Permanent enlargement of the airspaces terminal to the
distal bronchioles ndashLoss of surface area for gas exchangendashDestruction of supporting structure of alveoli
ndashAirway narrowing
bull Three distinct patterns ndashCentracinar begins centrally and spreads to terminal
bronchioles and is most closely associated with cigarette smoking
ndashPanacinar destroys alveoli uniformly predominant in lower half of lungs most closely associated with AATD
ndashParaseptal destroys the distal airway structures alveolar ducts and sacs
Demirjian BG 2010
84
DOS CME Course 2011
Bullaebull Outpouchingsballooning of lung tissue due to trapped air
ndashAir is released from damaged alveoli
ndashAsymptomatic
ndashRupture can cause pneumothorax
85
DOS CME Course 2011
Diagnosis
bull History of smoking or exposure to inhaled irritants
ndashRemember to consider work and living environment
ndashCooking indoors with fossil fuels
ndashAge over 40
bull Signs and symptoms
ndashChronic cough with sputum production
ndashDyspnea which persists daily worsens with exercise and progresses over time
bull Spirometry is strongly recommended
86
DOS CME Course 2011
Diagnosis
bull Chest x-ray
ndashRule out pneumonia cardiomyopathy
ndashNot diagnostic for COPD but may reveal other causes for symptoms
bull Arterial blood gases
ndashRecommended for patients with FEVlt 50
ndashPaO2lt 60 mmHg suggests respiratory failure
bull Sputum culture
ndashRule out infectious process
87
DOS CME Course 2011
Disease stages
bull Stage Indash FEVFVC lt 70
ndash FEV gt 80
ndash Few symptoms if any patient may be unaware
bull Stage II moderate ndash FEVFVC lt 70
ndash FEV lt 80
ndash Along with shortness of breath
88
DOS CME Course 2011
Disease stages
bull Stage IV very severe ndash FEVFVC lt 70
ndash FEV lt 30
ndash At this stage exacerbations are life-threatening
ndash Quality of life is impaired further
bull Stage III severe ndash FEVFVC lt 70
ndash FEV lt 50
ndash Worsening symptoms increasing frequency of exacerbations
89
DOS CME Course 2011
COPD vs Asthma
bull COPD
ndashOnset later in life
ndashProgressive worsening symptoms
ndashSmoking history
ndashDyspnea with exercise
ndashLargely irreversible airflow limitation
bull Asthma
ndashOnset of symptoms usually earlier in life
ndashWorsening at night
ndashLargely reversible airflow limitation
ndashSymptoms vary from day to day
90
DOS CME Course 2011
COPD Treatmentbull Now that we have diagnosis what do I do about it
bull Assess and monitor diseasendash Assess for risk factors ie smoking family history
ndash Co-morbidities such as heart failure
ndash Pattern of symptoms
ndash Impact on quality of life
bull Reduce risk factors ndash Identify environmentaloccupational factors which can be modified
ndash Smoking cessation is essential
ndash Manage exacerbations
91
DOS CME Course 2011
COPDbull Manage stable COPD
ndash Determine disease severity based on frequency and severity of symptoms
ndash Educate the patient about risk factors and disease management regimen
ndash Collaborate with the patient to develop a personalized regimen
ndashFits their lifestyle
ndashAccounts for cultural preferences family involvement
ndashAvailability of testing and medications
92
DOS CME Course 2011
Pharmacologybull Goals
ndash Improve exercise tolerance
ndash Control symptoms
ndash Reduce frequency and severity of exacerbations
ndash Improve health status
bull Bronchodilators ndash Include long-acting therapy with short-acting for better control
bull Combine medications from different classes rather than increasing dosage of just onendash Minimizes side effects
93
DOS CME Course 2011
Pharmacologybull Glucocorticosteroids
ndashCan reduce the number of exacerbations
ndashIncreased risk of pneumonia
ndashNo noted reduction in mortality
bull Vaccines
ndashInfluenza vaccines decrease serious illness and death by 50
ndashRecommended annually
ndashPneumococcal vaccines recommended for all COPD sufferers even under age 65
GOLD 2009
94
DOS CME Course 2011
Antibiotics
bull Antibiotics are not a treatment for COPD nor do they manage symptoms of an exacerbation
bull Should be given only if the following are metndash Presence of three cardinal symptoms increased dyspnea
increased sputum volume increased sputum purulence
ndash Increased sputum purulence plus one other cardinal symptom
ndash Mechanically ventilated
bull May be difficult for patients to understand why antibiotics will not ldquofixrdquo what is wrong
bull Good opportunity for learning needs assessment
GOLD 2009
95
DOS CME Course 2011
COPD
bull Pulmonary rehabilitation
bull Encourage the patient to continue activities as tolerated ndash Move as much as you can before you canrsquot move
bull Uses low impact exercise to maintain physical function
bull Exercise can be done while seatedndash Monitor pulse oximetry respiratory rate and effort before during
and after activity
bull Set goals which are realistic for both of you
96
DOS CME Course 2011
COPD
bull Pulmonary rehab includes education nutrition and exercise
bull Can be a good source of social support for someone who has seen function decline
ndashTalk with others in the same situation
ndashFind out how they cope
ndashSocialize
bull Regular influenza and pneumonia vaccines
97
DOS CME Course 2011
COPD
bull Oxygen therapy
bull Recommended for stage IV disease ndash PaO2 lt or = 55 mmHg
ndash SaO2 lt or = 88
bull Increases survival improves hemodynamicsbenefits mental state
bull Surgical options reviewed on a case-by-case basisndash Bullectomy
ndash Lung volume reduction ndashNo evidence to support this as a widespread therapy
98
DOS CME Course 2011
COPD
bull Managing exacerbations
bull An event in the natural course of the disease characterized by a change in baseline dyspnea cough or sputum beyond day to day variance is acute in onset and may warrant a change in medication
bull Air pollution and tracheobronchial infections are the most common causes
bull 30 of exacerbations no cause identified
(GOLD 2009 p 22)
99
DOS CME Course 2011
COPD
bull Hospitalization is recommended for patients exhibiting the following
ndash Failure of exacerbation to respond to medical treatment
ndash Development of new symptoms ie peripheral edema cyanosis
ndash Significant co-morbidities
ndash History of frequent exacerbations
ndash Newly occurring arrhythmias
ndash Advanced age
ndash Insufficient home support
ndash Unclear diagnosis
(GOLD 2009 p 23)
100
DOS CME Course 2011
COPD
bull Mechanical ventilation is not recognized as an effective management strategy for stable COPD
bull May be required as supportive therapy during an exacerbation
bull Associated with mortality
bull Carries risks of its ownndash Ventilator acquired pneumonia
ndash Ventilator induced lung injury
ndash Failure to wean
(GOLD 2009)
101
DOS CME Course 2011DOS CME Course 2011102
Every Life Deserves World Class Care
Smoking
102
DOS CME Course 2011
Smoking bull By the numbers
bull More than 400 000 Americans die from smoking-related illnesses each yearndash Thatrsquos one of every 5 deaths
bull In a study of 2963 health care encounters smoking was discussed 633 times
bull Nicotine released into the body within 10 seconds of inhalation
bull If a person smokes one pack per day and takes ten puffs of each cigarette that equates to 200 ldquohitsrdquo of nicotine daily
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
103
DOS CME Course 2011
Nicotine
bull Nicotinic receptors occur naturally
bull N1 receptors in the adrenal medulla
bull Neuromuscular junction of autonomic ganglia
bull N2 receptors in skeletal muscle
bull Number of receptor sites increases with regular stimulation
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
104
DOS CME Course 2011
Nicotinebull Addictive
bull Vasoconstrictor
bull Releases adrenaline from the adrenal cortex
ndashFeeling of increased energy
bull Releases dopamine to produce feelings of well-beingndash Actually improves memory and cognition
bull Sensitivity actually declines overnight
bull Release of insulinndash Slightly hyperglycemic
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
105
DOS CME Course 2011
Genetic componentbull About 10 of smokers lack the gene for nicotine
dependence
ndashldquosocial or occasionalrdquo smokers
ndashThey really can quit anytime they want to
ndashNo withdrawal symptoms
ndashStill poses a health risk
bull The other 90 will demonstrate physical and psychological symptoms of withdrawal
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
106
DOS CME Course 2011
Smoking
bull Identify tobacco users ndash Ask every patient every visit
ndash Have you used tobacco in the last 12 months
ndash Clinic-wide program
bull Advise every tobacco user to quitndash Personalize the message
ndash Be clear
ndash Be firm
If at first you donrsquot succeed try tryagain Bring it up at every encounter
107
DOS CME Course 2011
Smoking cessationbull Some more good reasons to quit
ndashSmoking costs over $2000 a year in current US dollars
ndashThere is no accepted safe level of cigarette smoke
ndashSecondhand smoke carries the same hazards
ndashIncreased risk of SIDS and asthma exacerbations in children
httpwwwlungusaorgstop-smokingabout-smokingfacts-figuresgeneral-smoking-factshtml
108
DOS CME Course 2011
Smoking cessation
bull Nicotine is a powerful drug addiction
bull Treat as a chronic illness
bull All healthcare providers encouraged to participate
bull Assess willingness to quit
bull Promote motivation
109
DOS CME Course 2011
Smoking cessation
bull Prochaskarsquos change theory
bull Precontemplation
ndashNot even thinking about quitting
ndashProvide education on the risks and costs of smoking
bull Contemplation
ndashAwareness that a problem exists
ndashContinue to find motivations to stop
NorcrossJC Krebs PM Prochaska JO(2011)
110
DOS CME Course 2011
Change is good
bull Determination
ndashExpressing willingness to act
ndashSelf-efficacy
bull Action ndash Currently not smoking
ndash May relapse
bull It is not unusual for a patient to ldquoquitrdquo three or four times
bull Continue to encourage and motivate himher to stop
NorcrossJC Krebs PM Prochaska JO(2011)
111
DOS CME Course 2011
Smoking cessationbull Assist the patient
ndashCollaborate with the patient to develop a plan to quit
ndashAchievable clearly defined goals
ndashIdentify and engage social supports
ndashFamily support groups
ndashPharmacologic (more on this later)
bull Arrange follow-up
ndashAt each successive visit review progress on quitting strategy
ndashLets the patient know heshe is not alone in this effort
ndashAccountability
112
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
COPD
bull Break out the testing ndash CXR
ndash ECG
ndash Sputum culture
ndash CBC and electrolytes
bull ABGrsquos ndash Respiratory failure indicated by
ndash PaO2lt 60 and SaO2 lt 90
ndash with or without PaCO2 gt 50
ndash On room air
ndash Severe acidosis pHlt 736 in addition to the above is an indication for mechanical ventilation
(GOLD 2009 p 22)
81
DOS CME Course 2011
Chronic bronchitis
bull Airway of a child afflicted with chronic bronchitis compared to normal
82
DOS CME Course 2011
Chronic bronchitisbull Related to mucociliary dysfunction
ndashIncreased mucous production and thickening
ndashLoss of cilia
ndashLoss of ciliary function
ndashMobility required to sweep out particles
83
DOS CME Course 2011
Emphysemabull Permanent enlargement of the airspaces terminal to the
distal bronchioles ndashLoss of surface area for gas exchangendashDestruction of supporting structure of alveoli
ndashAirway narrowing
bull Three distinct patterns ndashCentracinar begins centrally and spreads to terminal
bronchioles and is most closely associated with cigarette smoking
ndashPanacinar destroys alveoli uniformly predominant in lower half of lungs most closely associated with AATD
ndashParaseptal destroys the distal airway structures alveolar ducts and sacs
Demirjian BG 2010
84
DOS CME Course 2011
Bullaebull Outpouchingsballooning of lung tissue due to trapped air
ndashAir is released from damaged alveoli
ndashAsymptomatic
ndashRupture can cause pneumothorax
85
DOS CME Course 2011
Diagnosis
bull History of smoking or exposure to inhaled irritants
ndashRemember to consider work and living environment
ndashCooking indoors with fossil fuels
ndashAge over 40
bull Signs and symptoms
ndashChronic cough with sputum production
ndashDyspnea which persists daily worsens with exercise and progresses over time
bull Spirometry is strongly recommended
86
DOS CME Course 2011
Diagnosis
bull Chest x-ray
ndashRule out pneumonia cardiomyopathy
ndashNot diagnostic for COPD but may reveal other causes for symptoms
bull Arterial blood gases
ndashRecommended for patients with FEVlt 50
ndashPaO2lt 60 mmHg suggests respiratory failure
bull Sputum culture
ndashRule out infectious process
87
DOS CME Course 2011
Disease stages
bull Stage Indash FEVFVC lt 70
ndash FEV gt 80
ndash Few symptoms if any patient may be unaware
bull Stage II moderate ndash FEVFVC lt 70
ndash FEV lt 80
ndash Along with shortness of breath
88
DOS CME Course 2011
Disease stages
bull Stage IV very severe ndash FEVFVC lt 70
ndash FEV lt 30
ndash At this stage exacerbations are life-threatening
ndash Quality of life is impaired further
bull Stage III severe ndash FEVFVC lt 70
ndash FEV lt 50
ndash Worsening symptoms increasing frequency of exacerbations
89
DOS CME Course 2011
COPD vs Asthma
bull COPD
ndashOnset later in life
ndashProgressive worsening symptoms
ndashSmoking history
ndashDyspnea with exercise
ndashLargely irreversible airflow limitation
bull Asthma
ndashOnset of symptoms usually earlier in life
ndashWorsening at night
ndashLargely reversible airflow limitation
ndashSymptoms vary from day to day
90
DOS CME Course 2011
COPD Treatmentbull Now that we have diagnosis what do I do about it
bull Assess and monitor diseasendash Assess for risk factors ie smoking family history
ndash Co-morbidities such as heart failure
ndash Pattern of symptoms
ndash Impact on quality of life
bull Reduce risk factors ndash Identify environmentaloccupational factors which can be modified
ndash Smoking cessation is essential
ndash Manage exacerbations
91
DOS CME Course 2011
COPDbull Manage stable COPD
ndash Determine disease severity based on frequency and severity of symptoms
ndash Educate the patient about risk factors and disease management regimen
ndash Collaborate with the patient to develop a personalized regimen
ndashFits their lifestyle
ndashAccounts for cultural preferences family involvement
ndashAvailability of testing and medications
92
DOS CME Course 2011
Pharmacologybull Goals
ndash Improve exercise tolerance
ndash Control symptoms
ndash Reduce frequency and severity of exacerbations
ndash Improve health status
bull Bronchodilators ndash Include long-acting therapy with short-acting for better control
bull Combine medications from different classes rather than increasing dosage of just onendash Minimizes side effects
93
DOS CME Course 2011
Pharmacologybull Glucocorticosteroids
ndashCan reduce the number of exacerbations
ndashIncreased risk of pneumonia
ndashNo noted reduction in mortality
bull Vaccines
ndashInfluenza vaccines decrease serious illness and death by 50
ndashRecommended annually
ndashPneumococcal vaccines recommended for all COPD sufferers even under age 65
GOLD 2009
94
DOS CME Course 2011
Antibiotics
bull Antibiotics are not a treatment for COPD nor do they manage symptoms of an exacerbation
bull Should be given only if the following are metndash Presence of three cardinal symptoms increased dyspnea
increased sputum volume increased sputum purulence
ndash Increased sputum purulence plus one other cardinal symptom
ndash Mechanically ventilated
bull May be difficult for patients to understand why antibiotics will not ldquofixrdquo what is wrong
bull Good opportunity for learning needs assessment
GOLD 2009
95
DOS CME Course 2011
COPD
bull Pulmonary rehabilitation
bull Encourage the patient to continue activities as tolerated ndash Move as much as you can before you canrsquot move
bull Uses low impact exercise to maintain physical function
bull Exercise can be done while seatedndash Monitor pulse oximetry respiratory rate and effort before during
and after activity
bull Set goals which are realistic for both of you
96
DOS CME Course 2011
COPD
bull Pulmonary rehab includes education nutrition and exercise
bull Can be a good source of social support for someone who has seen function decline
ndashTalk with others in the same situation
ndashFind out how they cope
ndashSocialize
bull Regular influenza and pneumonia vaccines
97
DOS CME Course 2011
COPD
bull Oxygen therapy
bull Recommended for stage IV disease ndash PaO2 lt or = 55 mmHg
ndash SaO2 lt or = 88
bull Increases survival improves hemodynamicsbenefits mental state
bull Surgical options reviewed on a case-by-case basisndash Bullectomy
ndash Lung volume reduction ndashNo evidence to support this as a widespread therapy
98
DOS CME Course 2011
COPD
bull Managing exacerbations
bull An event in the natural course of the disease characterized by a change in baseline dyspnea cough or sputum beyond day to day variance is acute in onset and may warrant a change in medication
bull Air pollution and tracheobronchial infections are the most common causes
bull 30 of exacerbations no cause identified
(GOLD 2009 p 22)
99
DOS CME Course 2011
COPD
bull Hospitalization is recommended for patients exhibiting the following
ndash Failure of exacerbation to respond to medical treatment
ndash Development of new symptoms ie peripheral edema cyanosis
ndash Significant co-morbidities
ndash History of frequent exacerbations
ndash Newly occurring arrhythmias
ndash Advanced age
ndash Insufficient home support
ndash Unclear diagnosis
(GOLD 2009 p 23)
100
DOS CME Course 2011
COPD
bull Mechanical ventilation is not recognized as an effective management strategy for stable COPD
bull May be required as supportive therapy during an exacerbation
bull Associated with mortality
bull Carries risks of its ownndash Ventilator acquired pneumonia
ndash Ventilator induced lung injury
ndash Failure to wean
(GOLD 2009)
101
DOS CME Course 2011DOS CME Course 2011102
Every Life Deserves World Class Care
Smoking
102
DOS CME Course 2011
Smoking bull By the numbers
bull More than 400 000 Americans die from smoking-related illnesses each yearndash Thatrsquos one of every 5 deaths
bull In a study of 2963 health care encounters smoking was discussed 633 times
bull Nicotine released into the body within 10 seconds of inhalation
bull If a person smokes one pack per day and takes ten puffs of each cigarette that equates to 200 ldquohitsrdquo of nicotine daily
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
103
DOS CME Course 2011
Nicotine
bull Nicotinic receptors occur naturally
bull N1 receptors in the adrenal medulla
bull Neuromuscular junction of autonomic ganglia
bull N2 receptors in skeletal muscle
bull Number of receptor sites increases with regular stimulation
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
104
DOS CME Course 2011
Nicotinebull Addictive
bull Vasoconstrictor
bull Releases adrenaline from the adrenal cortex
ndashFeeling of increased energy
bull Releases dopamine to produce feelings of well-beingndash Actually improves memory and cognition
bull Sensitivity actually declines overnight
bull Release of insulinndash Slightly hyperglycemic
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
105
DOS CME Course 2011
Genetic componentbull About 10 of smokers lack the gene for nicotine
dependence
ndashldquosocial or occasionalrdquo smokers
ndashThey really can quit anytime they want to
ndashNo withdrawal symptoms
ndashStill poses a health risk
bull The other 90 will demonstrate physical and psychological symptoms of withdrawal
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
106
DOS CME Course 2011
Smoking
bull Identify tobacco users ndash Ask every patient every visit
ndash Have you used tobacco in the last 12 months
ndash Clinic-wide program
bull Advise every tobacco user to quitndash Personalize the message
ndash Be clear
ndash Be firm
If at first you donrsquot succeed try tryagain Bring it up at every encounter
107
DOS CME Course 2011
Smoking cessationbull Some more good reasons to quit
ndashSmoking costs over $2000 a year in current US dollars
ndashThere is no accepted safe level of cigarette smoke
ndashSecondhand smoke carries the same hazards
ndashIncreased risk of SIDS and asthma exacerbations in children
httpwwwlungusaorgstop-smokingabout-smokingfacts-figuresgeneral-smoking-factshtml
108
DOS CME Course 2011
Smoking cessation
bull Nicotine is a powerful drug addiction
bull Treat as a chronic illness
bull All healthcare providers encouraged to participate
bull Assess willingness to quit
bull Promote motivation
109
DOS CME Course 2011
Smoking cessation
bull Prochaskarsquos change theory
bull Precontemplation
ndashNot even thinking about quitting
ndashProvide education on the risks and costs of smoking
bull Contemplation
ndashAwareness that a problem exists
ndashContinue to find motivations to stop
NorcrossJC Krebs PM Prochaska JO(2011)
110
DOS CME Course 2011
Change is good
bull Determination
ndashExpressing willingness to act
ndashSelf-efficacy
bull Action ndash Currently not smoking
ndash May relapse
bull It is not unusual for a patient to ldquoquitrdquo three or four times
bull Continue to encourage and motivate himher to stop
NorcrossJC Krebs PM Prochaska JO(2011)
111
DOS CME Course 2011
Smoking cessationbull Assist the patient
ndashCollaborate with the patient to develop a plan to quit
ndashAchievable clearly defined goals
ndashIdentify and engage social supports
ndashFamily support groups
ndashPharmacologic (more on this later)
bull Arrange follow-up
ndashAt each successive visit review progress on quitting strategy
ndashLets the patient know heshe is not alone in this effort
ndashAccountability
112
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
Chronic bronchitisbull Related to mucociliary dysfunction
ndashIncreased mucous production and thickening
ndashLoss of cilia
ndashLoss of ciliary function
ndashMobility required to sweep out particles
83
DOS CME Course 2011
Emphysemabull Permanent enlargement of the airspaces terminal to the
distal bronchioles ndashLoss of surface area for gas exchangendashDestruction of supporting structure of alveoli
ndashAirway narrowing
bull Three distinct patterns ndashCentracinar begins centrally and spreads to terminal
bronchioles and is most closely associated with cigarette smoking
ndashPanacinar destroys alveoli uniformly predominant in lower half of lungs most closely associated with AATD
ndashParaseptal destroys the distal airway structures alveolar ducts and sacs
Demirjian BG 2010
84
DOS CME Course 2011
Bullaebull Outpouchingsballooning of lung tissue due to trapped air
ndashAir is released from damaged alveoli
ndashAsymptomatic
ndashRupture can cause pneumothorax
85
DOS CME Course 2011
Diagnosis
bull History of smoking or exposure to inhaled irritants
ndashRemember to consider work and living environment
ndashCooking indoors with fossil fuels
ndashAge over 40
bull Signs and symptoms
ndashChronic cough with sputum production
ndashDyspnea which persists daily worsens with exercise and progresses over time
bull Spirometry is strongly recommended
86
DOS CME Course 2011
Diagnosis
bull Chest x-ray
ndashRule out pneumonia cardiomyopathy
ndashNot diagnostic for COPD but may reveal other causes for symptoms
bull Arterial blood gases
ndashRecommended for patients with FEVlt 50
ndashPaO2lt 60 mmHg suggests respiratory failure
bull Sputum culture
ndashRule out infectious process
87
DOS CME Course 2011
Disease stages
bull Stage Indash FEVFVC lt 70
ndash FEV gt 80
ndash Few symptoms if any patient may be unaware
bull Stage II moderate ndash FEVFVC lt 70
ndash FEV lt 80
ndash Along with shortness of breath
88
DOS CME Course 2011
Disease stages
bull Stage IV very severe ndash FEVFVC lt 70
ndash FEV lt 30
ndash At this stage exacerbations are life-threatening
ndash Quality of life is impaired further
bull Stage III severe ndash FEVFVC lt 70
ndash FEV lt 50
ndash Worsening symptoms increasing frequency of exacerbations
89
DOS CME Course 2011
COPD vs Asthma
bull COPD
ndashOnset later in life
ndashProgressive worsening symptoms
ndashSmoking history
ndashDyspnea with exercise
ndashLargely irreversible airflow limitation
bull Asthma
ndashOnset of symptoms usually earlier in life
ndashWorsening at night
ndashLargely reversible airflow limitation
ndashSymptoms vary from day to day
90
DOS CME Course 2011
COPD Treatmentbull Now that we have diagnosis what do I do about it
bull Assess and monitor diseasendash Assess for risk factors ie smoking family history
ndash Co-morbidities such as heart failure
ndash Pattern of symptoms
ndash Impact on quality of life
bull Reduce risk factors ndash Identify environmentaloccupational factors which can be modified
ndash Smoking cessation is essential
ndash Manage exacerbations
91
DOS CME Course 2011
COPDbull Manage stable COPD
ndash Determine disease severity based on frequency and severity of symptoms
ndash Educate the patient about risk factors and disease management regimen
ndash Collaborate with the patient to develop a personalized regimen
ndashFits their lifestyle
ndashAccounts for cultural preferences family involvement
ndashAvailability of testing and medications
92
DOS CME Course 2011
Pharmacologybull Goals
ndash Improve exercise tolerance
ndash Control symptoms
ndash Reduce frequency and severity of exacerbations
ndash Improve health status
bull Bronchodilators ndash Include long-acting therapy with short-acting for better control
bull Combine medications from different classes rather than increasing dosage of just onendash Minimizes side effects
93
DOS CME Course 2011
Pharmacologybull Glucocorticosteroids
ndashCan reduce the number of exacerbations
ndashIncreased risk of pneumonia
ndashNo noted reduction in mortality
bull Vaccines
ndashInfluenza vaccines decrease serious illness and death by 50
ndashRecommended annually
ndashPneumococcal vaccines recommended for all COPD sufferers even under age 65
GOLD 2009
94
DOS CME Course 2011
Antibiotics
bull Antibiotics are not a treatment for COPD nor do they manage symptoms of an exacerbation
bull Should be given only if the following are metndash Presence of three cardinal symptoms increased dyspnea
increased sputum volume increased sputum purulence
ndash Increased sputum purulence plus one other cardinal symptom
ndash Mechanically ventilated
bull May be difficult for patients to understand why antibiotics will not ldquofixrdquo what is wrong
bull Good opportunity for learning needs assessment
GOLD 2009
95
DOS CME Course 2011
COPD
bull Pulmonary rehabilitation
bull Encourage the patient to continue activities as tolerated ndash Move as much as you can before you canrsquot move
bull Uses low impact exercise to maintain physical function
bull Exercise can be done while seatedndash Monitor pulse oximetry respiratory rate and effort before during
and after activity
bull Set goals which are realistic for both of you
96
DOS CME Course 2011
COPD
bull Pulmonary rehab includes education nutrition and exercise
bull Can be a good source of social support for someone who has seen function decline
ndashTalk with others in the same situation
ndashFind out how they cope
ndashSocialize
bull Regular influenza and pneumonia vaccines
97
DOS CME Course 2011
COPD
bull Oxygen therapy
bull Recommended for stage IV disease ndash PaO2 lt or = 55 mmHg
ndash SaO2 lt or = 88
bull Increases survival improves hemodynamicsbenefits mental state
bull Surgical options reviewed on a case-by-case basisndash Bullectomy
ndash Lung volume reduction ndashNo evidence to support this as a widespread therapy
98
DOS CME Course 2011
COPD
bull Managing exacerbations
bull An event in the natural course of the disease characterized by a change in baseline dyspnea cough or sputum beyond day to day variance is acute in onset and may warrant a change in medication
bull Air pollution and tracheobronchial infections are the most common causes
bull 30 of exacerbations no cause identified
(GOLD 2009 p 22)
99
DOS CME Course 2011
COPD
bull Hospitalization is recommended for patients exhibiting the following
ndash Failure of exacerbation to respond to medical treatment
ndash Development of new symptoms ie peripheral edema cyanosis
ndash Significant co-morbidities
ndash History of frequent exacerbations
ndash Newly occurring arrhythmias
ndash Advanced age
ndash Insufficient home support
ndash Unclear diagnosis
(GOLD 2009 p 23)
100
DOS CME Course 2011
COPD
bull Mechanical ventilation is not recognized as an effective management strategy for stable COPD
bull May be required as supportive therapy during an exacerbation
bull Associated with mortality
bull Carries risks of its ownndash Ventilator acquired pneumonia
ndash Ventilator induced lung injury
ndash Failure to wean
(GOLD 2009)
101
DOS CME Course 2011DOS CME Course 2011102
Every Life Deserves World Class Care
Smoking
102
DOS CME Course 2011
Smoking bull By the numbers
bull More than 400 000 Americans die from smoking-related illnesses each yearndash Thatrsquos one of every 5 deaths
bull In a study of 2963 health care encounters smoking was discussed 633 times
bull Nicotine released into the body within 10 seconds of inhalation
bull If a person smokes one pack per day and takes ten puffs of each cigarette that equates to 200 ldquohitsrdquo of nicotine daily
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
103
DOS CME Course 2011
Nicotine
bull Nicotinic receptors occur naturally
bull N1 receptors in the adrenal medulla
bull Neuromuscular junction of autonomic ganglia
bull N2 receptors in skeletal muscle
bull Number of receptor sites increases with regular stimulation
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
104
DOS CME Course 2011
Nicotinebull Addictive
bull Vasoconstrictor
bull Releases adrenaline from the adrenal cortex
ndashFeeling of increased energy
bull Releases dopamine to produce feelings of well-beingndash Actually improves memory and cognition
bull Sensitivity actually declines overnight
bull Release of insulinndash Slightly hyperglycemic
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
105
DOS CME Course 2011
Genetic componentbull About 10 of smokers lack the gene for nicotine
dependence
ndashldquosocial or occasionalrdquo smokers
ndashThey really can quit anytime they want to
ndashNo withdrawal symptoms
ndashStill poses a health risk
bull The other 90 will demonstrate physical and psychological symptoms of withdrawal
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
106
DOS CME Course 2011
Smoking
bull Identify tobacco users ndash Ask every patient every visit
ndash Have you used tobacco in the last 12 months
ndash Clinic-wide program
bull Advise every tobacco user to quitndash Personalize the message
ndash Be clear
ndash Be firm
If at first you donrsquot succeed try tryagain Bring it up at every encounter
107
DOS CME Course 2011
Smoking cessationbull Some more good reasons to quit
ndashSmoking costs over $2000 a year in current US dollars
ndashThere is no accepted safe level of cigarette smoke
ndashSecondhand smoke carries the same hazards
ndashIncreased risk of SIDS and asthma exacerbations in children
httpwwwlungusaorgstop-smokingabout-smokingfacts-figuresgeneral-smoking-factshtml
108
DOS CME Course 2011
Smoking cessation
bull Nicotine is a powerful drug addiction
bull Treat as a chronic illness
bull All healthcare providers encouraged to participate
bull Assess willingness to quit
bull Promote motivation
109
DOS CME Course 2011
Smoking cessation
bull Prochaskarsquos change theory
bull Precontemplation
ndashNot even thinking about quitting
ndashProvide education on the risks and costs of smoking
bull Contemplation
ndashAwareness that a problem exists
ndashContinue to find motivations to stop
NorcrossJC Krebs PM Prochaska JO(2011)
110
DOS CME Course 2011
Change is good
bull Determination
ndashExpressing willingness to act
ndashSelf-efficacy
bull Action ndash Currently not smoking
ndash May relapse
bull It is not unusual for a patient to ldquoquitrdquo three or four times
bull Continue to encourage and motivate himher to stop
NorcrossJC Krebs PM Prochaska JO(2011)
111
DOS CME Course 2011
Smoking cessationbull Assist the patient
ndashCollaborate with the patient to develop a plan to quit
ndashAchievable clearly defined goals
ndashIdentify and engage social supports
ndashFamily support groups
ndashPharmacologic (more on this later)
bull Arrange follow-up
ndashAt each successive visit review progress on quitting strategy
ndashLets the patient know heshe is not alone in this effort
ndashAccountability
112
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
Bullaebull Outpouchingsballooning of lung tissue due to trapped air
ndashAir is released from damaged alveoli
ndashAsymptomatic
ndashRupture can cause pneumothorax
85
DOS CME Course 2011
Diagnosis
bull History of smoking or exposure to inhaled irritants
ndashRemember to consider work and living environment
ndashCooking indoors with fossil fuels
ndashAge over 40
bull Signs and symptoms
ndashChronic cough with sputum production
ndashDyspnea which persists daily worsens with exercise and progresses over time
bull Spirometry is strongly recommended
86
DOS CME Course 2011
Diagnosis
bull Chest x-ray
ndashRule out pneumonia cardiomyopathy
ndashNot diagnostic for COPD but may reveal other causes for symptoms
bull Arterial blood gases
ndashRecommended for patients with FEVlt 50
ndashPaO2lt 60 mmHg suggests respiratory failure
bull Sputum culture
ndashRule out infectious process
87
DOS CME Course 2011
Disease stages
bull Stage Indash FEVFVC lt 70
ndash FEV gt 80
ndash Few symptoms if any patient may be unaware
bull Stage II moderate ndash FEVFVC lt 70
ndash FEV lt 80
ndash Along with shortness of breath
88
DOS CME Course 2011
Disease stages
bull Stage IV very severe ndash FEVFVC lt 70
ndash FEV lt 30
ndash At this stage exacerbations are life-threatening
ndash Quality of life is impaired further
bull Stage III severe ndash FEVFVC lt 70
ndash FEV lt 50
ndash Worsening symptoms increasing frequency of exacerbations
89
DOS CME Course 2011
COPD vs Asthma
bull COPD
ndashOnset later in life
ndashProgressive worsening symptoms
ndashSmoking history
ndashDyspnea with exercise
ndashLargely irreversible airflow limitation
bull Asthma
ndashOnset of symptoms usually earlier in life
ndashWorsening at night
ndashLargely reversible airflow limitation
ndashSymptoms vary from day to day
90
DOS CME Course 2011
COPD Treatmentbull Now that we have diagnosis what do I do about it
bull Assess and monitor diseasendash Assess for risk factors ie smoking family history
ndash Co-morbidities such as heart failure
ndash Pattern of symptoms
ndash Impact on quality of life
bull Reduce risk factors ndash Identify environmentaloccupational factors which can be modified
ndash Smoking cessation is essential
ndash Manage exacerbations
91
DOS CME Course 2011
COPDbull Manage stable COPD
ndash Determine disease severity based on frequency and severity of symptoms
ndash Educate the patient about risk factors and disease management regimen
ndash Collaborate with the patient to develop a personalized regimen
ndashFits their lifestyle
ndashAccounts for cultural preferences family involvement
ndashAvailability of testing and medications
92
DOS CME Course 2011
Pharmacologybull Goals
ndash Improve exercise tolerance
ndash Control symptoms
ndash Reduce frequency and severity of exacerbations
ndash Improve health status
bull Bronchodilators ndash Include long-acting therapy with short-acting for better control
bull Combine medications from different classes rather than increasing dosage of just onendash Minimizes side effects
93
DOS CME Course 2011
Pharmacologybull Glucocorticosteroids
ndashCan reduce the number of exacerbations
ndashIncreased risk of pneumonia
ndashNo noted reduction in mortality
bull Vaccines
ndashInfluenza vaccines decrease serious illness and death by 50
ndashRecommended annually
ndashPneumococcal vaccines recommended for all COPD sufferers even under age 65
GOLD 2009
94
DOS CME Course 2011
Antibiotics
bull Antibiotics are not a treatment for COPD nor do they manage symptoms of an exacerbation
bull Should be given only if the following are metndash Presence of three cardinal symptoms increased dyspnea
increased sputum volume increased sputum purulence
ndash Increased sputum purulence plus one other cardinal symptom
ndash Mechanically ventilated
bull May be difficult for patients to understand why antibiotics will not ldquofixrdquo what is wrong
bull Good opportunity for learning needs assessment
GOLD 2009
95
DOS CME Course 2011
COPD
bull Pulmonary rehabilitation
bull Encourage the patient to continue activities as tolerated ndash Move as much as you can before you canrsquot move
bull Uses low impact exercise to maintain physical function
bull Exercise can be done while seatedndash Monitor pulse oximetry respiratory rate and effort before during
and after activity
bull Set goals which are realistic for both of you
96
DOS CME Course 2011
COPD
bull Pulmonary rehab includes education nutrition and exercise
bull Can be a good source of social support for someone who has seen function decline
ndashTalk with others in the same situation
ndashFind out how they cope
ndashSocialize
bull Regular influenza and pneumonia vaccines
97
DOS CME Course 2011
COPD
bull Oxygen therapy
bull Recommended for stage IV disease ndash PaO2 lt or = 55 mmHg
ndash SaO2 lt or = 88
bull Increases survival improves hemodynamicsbenefits mental state
bull Surgical options reviewed on a case-by-case basisndash Bullectomy
ndash Lung volume reduction ndashNo evidence to support this as a widespread therapy
98
DOS CME Course 2011
COPD
bull Managing exacerbations
bull An event in the natural course of the disease characterized by a change in baseline dyspnea cough or sputum beyond day to day variance is acute in onset and may warrant a change in medication
bull Air pollution and tracheobronchial infections are the most common causes
bull 30 of exacerbations no cause identified
(GOLD 2009 p 22)
99
DOS CME Course 2011
COPD
bull Hospitalization is recommended for patients exhibiting the following
ndash Failure of exacerbation to respond to medical treatment
ndash Development of new symptoms ie peripheral edema cyanosis
ndash Significant co-morbidities
ndash History of frequent exacerbations
ndash Newly occurring arrhythmias
ndash Advanced age
ndash Insufficient home support
ndash Unclear diagnosis
(GOLD 2009 p 23)
100
DOS CME Course 2011
COPD
bull Mechanical ventilation is not recognized as an effective management strategy for stable COPD
bull May be required as supportive therapy during an exacerbation
bull Associated with mortality
bull Carries risks of its ownndash Ventilator acquired pneumonia
ndash Ventilator induced lung injury
ndash Failure to wean
(GOLD 2009)
101
DOS CME Course 2011DOS CME Course 2011102
Every Life Deserves World Class Care
Smoking
102
DOS CME Course 2011
Smoking bull By the numbers
bull More than 400 000 Americans die from smoking-related illnesses each yearndash Thatrsquos one of every 5 deaths
bull In a study of 2963 health care encounters smoking was discussed 633 times
bull Nicotine released into the body within 10 seconds of inhalation
bull If a person smokes one pack per day and takes ten puffs of each cigarette that equates to 200 ldquohitsrdquo of nicotine daily
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
103
DOS CME Course 2011
Nicotine
bull Nicotinic receptors occur naturally
bull N1 receptors in the adrenal medulla
bull Neuromuscular junction of autonomic ganglia
bull N2 receptors in skeletal muscle
bull Number of receptor sites increases with regular stimulation
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
104
DOS CME Course 2011
Nicotinebull Addictive
bull Vasoconstrictor
bull Releases adrenaline from the adrenal cortex
ndashFeeling of increased energy
bull Releases dopamine to produce feelings of well-beingndash Actually improves memory and cognition
bull Sensitivity actually declines overnight
bull Release of insulinndash Slightly hyperglycemic
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
105
DOS CME Course 2011
Genetic componentbull About 10 of smokers lack the gene for nicotine
dependence
ndashldquosocial or occasionalrdquo smokers
ndashThey really can quit anytime they want to
ndashNo withdrawal symptoms
ndashStill poses a health risk
bull The other 90 will demonstrate physical and psychological symptoms of withdrawal
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
106
DOS CME Course 2011
Smoking
bull Identify tobacco users ndash Ask every patient every visit
ndash Have you used tobacco in the last 12 months
ndash Clinic-wide program
bull Advise every tobacco user to quitndash Personalize the message
ndash Be clear
ndash Be firm
If at first you donrsquot succeed try tryagain Bring it up at every encounter
107
DOS CME Course 2011
Smoking cessationbull Some more good reasons to quit
ndashSmoking costs over $2000 a year in current US dollars
ndashThere is no accepted safe level of cigarette smoke
ndashSecondhand smoke carries the same hazards
ndashIncreased risk of SIDS and asthma exacerbations in children
httpwwwlungusaorgstop-smokingabout-smokingfacts-figuresgeneral-smoking-factshtml
108
DOS CME Course 2011
Smoking cessation
bull Nicotine is a powerful drug addiction
bull Treat as a chronic illness
bull All healthcare providers encouraged to participate
bull Assess willingness to quit
bull Promote motivation
109
DOS CME Course 2011
Smoking cessation
bull Prochaskarsquos change theory
bull Precontemplation
ndashNot even thinking about quitting
ndashProvide education on the risks and costs of smoking
bull Contemplation
ndashAwareness that a problem exists
ndashContinue to find motivations to stop
NorcrossJC Krebs PM Prochaska JO(2011)
110
DOS CME Course 2011
Change is good
bull Determination
ndashExpressing willingness to act
ndashSelf-efficacy
bull Action ndash Currently not smoking
ndash May relapse
bull It is not unusual for a patient to ldquoquitrdquo three or four times
bull Continue to encourage and motivate himher to stop
NorcrossJC Krebs PM Prochaska JO(2011)
111
DOS CME Course 2011
Smoking cessationbull Assist the patient
ndashCollaborate with the patient to develop a plan to quit
ndashAchievable clearly defined goals
ndashIdentify and engage social supports
ndashFamily support groups
ndashPharmacologic (more on this later)
bull Arrange follow-up
ndashAt each successive visit review progress on quitting strategy
ndashLets the patient know heshe is not alone in this effort
ndashAccountability
112
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
Diagnosis
bull Chest x-ray
ndashRule out pneumonia cardiomyopathy
ndashNot diagnostic for COPD but may reveal other causes for symptoms
bull Arterial blood gases
ndashRecommended for patients with FEVlt 50
ndashPaO2lt 60 mmHg suggests respiratory failure
bull Sputum culture
ndashRule out infectious process
87
DOS CME Course 2011
Disease stages
bull Stage Indash FEVFVC lt 70
ndash FEV gt 80
ndash Few symptoms if any patient may be unaware
bull Stage II moderate ndash FEVFVC lt 70
ndash FEV lt 80
ndash Along with shortness of breath
88
DOS CME Course 2011
Disease stages
bull Stage IV very severe ndash FEVFVC lt 70
ndash FEV lt 30
ndash At this stage exacerbations are life-threatening
ndash Quality of life is impaired further
bull Stage III severe ndash FEVFVC lt 70
ndash FEV lt 50
ndash Worsening symptoms increasing frequency of exacerbations
89
DOS CME Course 2011
COPD vs Asthma
bull COPD
ndashOnset later in life
ndashProgressive worsening symptoms
ndashSmoking history
ndashDyspnea with exercise
ndashLargely irreversible airflow limitation
bull Asthma
ndashOnset of symptoms usually earlier in life
ndashWorsening at night
ndashLargely reversible airflow limitation
ndashSymptoms vary from day to day
90
DOS CME Course 2011
COPD Treatmentbull Now that we have diagnosis what do I do about it
bull Assess and monitor diseasendash Assess for risk factors ie smoking family history
ndash Co-morbidities such as heart failure
ndash Pattern of symptoms
ndash Impact on quality of life
bull Reduce risk factors ndash Identify environmentaloccupational factors which can be modified
ndash Smoking cessation is essential
ndash Manage exacerbations
91
DOS CME Course 2011
COPDbull Manage stable COPD
ndash Determine disease severity based on frequency and severity of symptoms
ndash Educate the patient about risk factors and disease management regimen
ndash Collaborate with the patient to develop a personalized regimen
ndashFits their lifestyle
ndashAccounts for cultural preferences family involvement
ndashAvailability of testing and medications
92
DOS CME Course 2011
Pharmacologybull Goals
ndash Improve exercise tolerance
ndash Control symptoms
ndash Reduce frequency and severity of exacerbations
ndash Improve health status
bull Bronchodilators ndash Include long-acting therapy with short-acting for better control
bull Combine medications from different classes rather than increasing dosage of just onendash Minimizes side effects
93
DOS CME Course 2011
Pharmacologybull Glucocorticosteroids
ndashCan reduce the number of exacerbations
ndashIncreased risk of pneumonia
ndashNo noted reduction in mortality
bull Vaccines
ndashInfluenza vaccines decrease serious illness and death by 50
ndashRecommended annually
ndashPneumococcal vaccines recommended for all COPD sufferers even under age 65
GOLD 2009
94
DOS CME Course 2011
Antibiotics
bull Antibiotics are not a treatment for COPD nor do they manage symptoms of an exacerbation
bull Should be given only if the following are metndash Presence of three cardinal symptoms increased dyspnea
increased sputum volume increased sputum purulence
ndash Increased sputum purulence plus one other cardinal symptom
ndash Mechanically ventilated
bull May be difficult for patients to understand why antibiotics will not ldquofixrdquo what is wrong
bull Good opportunity for learning needs assessment
GOLD 2009
95
DOS CME Course 2011
COPD
bull Pulmonary rehabilitation
bull Encourage the patient to continue activities as tolerated ndash Move as much as you can before you canrsquot move
bull Uses low impact exercise to maintain physical function
bull Exercise can be done while seatedndash Monitor pulse oximetry respiratory rate and effort before during
and after activity
bull Set goals which are realistic for both of you
96
DOS CME Course 2011
COPD
bull Pulmonary rehab includes education nutrition and exercise
bull Can be a good source of social support for someone who has seen function decline
ndashTalk with others in the same situation
ndashFind out how they cope
ndashSocialize
bull Regular influenza and pneumonia vaccines
97
DOS CME Course 2011
COPD
bull Oxygen therapy
bull Recommended for stage IV disease ndash PaO2 lt or = 55 mmHg
ndash SaO2 lt or = 88
bull Increases survival improves hemodynamicsbenefits mental state
bull Surgical options reviewed on a case-by-case basisndash Bullectomy
ndash Lung volume reduction ndashNo evidence to support this as a widespread therapy
98
DOS CME Course 2011
COPD
bull Managing exacerbations
bull An event in the natural course of the disease characterized by a change in baseline dyspnea cough or sputum beyond day to day variance is acute in onset and may warrant a change in medication
bull Air pollution and tracheobronchial infections are the most common causes
bull 30 of exacerbations no cause identified
(GOLD 2009 p 22)
99
DOS CME Course 2011
COPD
bull Hospitalization is recommended for patients exhibiting the following
ndash Failure of exacerbation to respond to medical treatment
ndash Development of new symptoms ie peripheral edema cyanosis
ndash Significant co-morbidities
ndash History of frequent exacerbations
ndash Newly occurring arrhythmias
ndash Advanced age
ndash Insufficient home support
ndash Unclear diagnosis
(GOLD 2009 p 23)
100
DOS CME Course 2011
COPD
bull Mechanical ventilation is not recognized as an effective management strategy for stable COPD
bull May be required as supportive therapy during an exacerbation
bull Associated with mortality
bull Carries risks of its ownndash Ventilator acquired pneumonia
ndash Ventilator induced lung injury
ndash Failure to wean
(GOLD 2009)
101
DOS CME Course 2011DOS CME Course 2011102
Every Life Deserves World Class Care
Smoking
102
DOS CME Course 2011
Smoking bull By the numbers
bull More than 400 000 Americans die from smoking-related illnesses each yearndash Thatrsquos one of every 5 deaths
bull In a study of 2963 health care encounters smoking was discussed 633 times
bull Nicotine released into the body within 10 seconds of inhalation
bull If a person smokes one pack per day and takes ten puffs of each cigarette that equates to 200 ldquohitsrdquo of nicotine daily
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
103
DOS CME Course 2011
Nicotine
bull Nicotinic receptors occur naturally
bull N1 receptors in the adrenal medulla
bull Neuromuscular junction of autonomic ganglia
bull N2 receptors in skeletal muscle
bull Number of receptor sites increases with regular stimulation
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
104
DOS CME Course 2011
Nicotinebull Addictive
bull Vasoconstrictor
bull Releases adrenaline from the adrenal cortex
ndashFeeling of increased energy
bull Releases dopamine to produce feelings of well-beingndash Actually improves memory and cognition
bull Sensitivity actually declines overnight
bull Release of insulinndash Slightly hyperglycemic
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
105
DOS CME Course 2011
Genetic componentbull About 10 of smokers lack the gene for nicotine
dependence
ndashldquosocial or occasionalrdquo smokers
ndashThey really can quit anytime they want to
ndashNo withdrawal symptoms
ndashStill poses a health risk
bull The other 90 will demonstrate physical and psychological symptoms of withdrawal
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
106
DOS CME Course 2011
Smoking
bull Identify tobacco users ndash Ask every patient every visit
ndash Have you used tobacco in the last 12 months
ndash Clinic-wide program
bull Advise every tobacco user to quitndash Personalize the message
ndash Be clear
ndash Be firm
If at first you donrsquot succeed try tryagain Bring it up at every encounter
107
DOS CME Course 2011
Smoking cessationbull Some more good reasons to quit
ndashSmoking costs over $2000 a year in current US dollars
ndashThere is no accepted safe level of cigarette smoke
ndashSecondhand smoke carries the same hazards
ndashIncreased risk of SIDS and asthma exacerbations in children
httpwwwlungusaorgstop-smokingabout-smokingfacts-figuresgeneral-smoking-factshtml
108
DOS CME Course 2011
Smoking cessation
bull Nicotine is a powerful drug addiction
bull Treat as a chronic illness
bull All healthcare providers encouraged to participate
bull Assess willingness to quit
bull Promote motivation
109
DOS CME Course 2011
Smoking cessation
bull Prochaskarsquos change theory
bull Precontemplation
ndashNot even thinking about quitting
ndashProvide education on the risks and costs of smoking
bull Contemplation
ndashAwareness that a problem exists
ndashContinue to find motivations to stop
NorcrossJC Krebs PM Prochaska JO(2011)
110
DOS CME Course 2011
Change is good
bull Determination
ndashExpressing willingness to act
ndashSelf-efficacy
bull Action ndash Currently not smoking
ndash May relapse
bull It is not unusual for a patient to ldquoquitrdquo three or four times
bull Continue to encourage and motivate himher to stop
NorcrossJC Krebs PM Prochaska JO(2011)
111
DOS CME Course 2011
Smoking cessationbull Assist the patient
ndashCollaborate with the patient to develop a plan to quit
ndashAchievable clearly defined goals
ndashIdentify and engage social supports
ndashFamily support groups
ndashPharmacologic (more on this later)
bull Arrange follow-up
ndashAt each successive visit review progress on quitting strategy
ndashLets the patient know heshe is not alone in this effort
ndashAccountability
112
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
Disease stages
bull Stage IV very severe ndash FEVFVC lt 70
ndash FEV lt 30
ndash At this stage exacerbations are life-threatening
ndash Quality of life is impaired further
bull Stage III severe ndash FEVFVC lt 70
ndash FEV lt 50
ndash Worsening symptoms increasing frequency of exacerbations
89
DOS CME Course 2011
COPD vs Asthma
bull COPD
ndashOnset later in life
ndashProgressive worsening symptoms
ndashSmoking history
ndashDyspnea with exercise
ndashLargely irreversible airflow limitation
bull Asthma
ndashOnset of symptoms usually earlier in life
ndashWorsening at night
ndashLargely reversible airflow limitation
ndashSymptoms vary from day to day
90
DOS CME Course 2011
COPD Treatmentbull Now that we have diagnosis what do I do about it
bull Assess and monitor diseasendash Assess for risk factors ie smoking family history
ndash Co-morbidities such as heart failure
ndash Pattern of symptoms
ndash Impact on quality of life
bull Reduce risk factors ndash Identify environmentaloccupational factors which can be modified
ndash Smoking cessation is essential
ndash Manage exacerbations
91
DOS CME Course 2011
COPDbull Manage stable COPD
ndash Determine disease severity based on frequency and severity of symptoms
ndash Educate the patient about risk factors and disease management regimen
ndash Collaborate with the patient to develop a personalized regimen
ndashFits their lifestyle
ndashAccounts for cultural preferences family involvement
ndashAvailability of testing and medications
92
DOS CME Course 2011
Pharmacologybull Goals
ndash Improve exercise tolerance
ndash Control symptoms
ndash Reduce frequency and severity of exacerbations
ndash Improve health status
bull Bronchodilators ndash Include long-acting therapy with short-acting for better control
bull Combine medications from different classes rather than increasing dosage of just onendash Minimizes side effects
93
DOS CME Course 2011
Pharmacologybull Glucocorticosteroids
ndashCan reduce the number of exacerbations
ndashIncreased risk of pneumonia
ndashNo noted reduction in mortality
bull Vaccines
ndashInfluenza vaccines decrease serious illness and death by 50
ndashRecommended annually
ndashPneumococcal vaccines recommended for all COPD sufferers even under age 65
GOLD 2009
94
DOS CME Course 2011
Antibiotics
bull Antibiotics are not a treatment for COPD nor do they manage symptoms of an exacerbation
bull Should be given only if the following are metndash Presence of three cardinal symptoms increased dyspnea
increased sputum volume increased sputum purulence
ndash Increased sputum purulence plus one other cardinal symptom
ndash Mechanically ventilated
bull May be difficult for patients to understand why antibiotics will not ldquofixrdquo what is wrong
bull Good opportunity for learning needs assessment
GOLD 2009
95
DOS CME Course 2011
COPD
bull Pulmonary rehabilitation
bull Encourage the patient to continue activities as tolerated ndash Move as much as you can before you canrsquot move
bull Uses low impact exercise to maintain physical function
bull Exercise can be done while seatedndash Monitor pulse oximetry respiratory rate and effort before during
and after activity
bull Set goals which are realistic for both of you
96
DOS CME Course 2011
COPD
bull Pulmonary rehab includes education nutrition and exercise
bull Can be a good source of social support for someone who has seen function decline
ndashTalk with others in the same situation
ndashFind out how they cope
ndashSocialize
bull Regular influenza and pneumonia vaccines
97
DOS CME Course 2011
COPD
bull Oxygen therapy
bull Recommended for stage IV disease ndash PaO2 lt or = 55 mmHg
ndash SaO2 lt or = 88
bull Increases survival improves hemodynamicsbenefits mental state
bull Surgical options reviewed on a case-by-case basisndash Bullectomy
ndash Lung volume reduction ndashNo evidence to support this as a widespread therapy
98
DOS CME Course 2011
COPD
bull Managing exacerbations
bull An event in the natural course of the disease characterized by a change in baseline dyspnea cough or sputum beyond day to day variance is acute in onset and may warrant a change in medication
bull Air pollution and tracheobronchial infections are the most common causes
bull 30 of exacerbations no cause identified
(GOLD 2009 p 22)
99
DOS CME Course 2011
COPD
bull Hospitalization is recommended for patients exhibiting the following
ndash Failure of exacerbation to respond to medical treatment
ndash Development of new symptoms ie peripheral edema cyanosis
ndash Significant co-morbidities
ndash History of frequent exacerbations
ndash Newly occurring arrhythmias
ndash Advanced age
ndash Insufficient home support
ndash Unclear diagnosis
(GOLD 2009 p 23)
100
DOS CME Course 2011
COPD
bull Mechanical ventilation is not recognized as an effective management strategy for stable COPD
bull May be required as supportive therapy during an exacerbation
bull Associated with mortality
bull Carries risks of its ownndash Ventilator acquired pneumonia
ndash Ventilator induced lung injury
ndash Failure to wean
(GOLD 2009)
101
DOS CME Course 2011DOS CME Course 2011102
Every Life Deserves World Class Care
Smoking
102
DOS CME Course 2011
Smoking bull By the numbers
bull More than 400 000 Americans die from smoking-related illnesses each yearndash Thatrsquos one of every 5 deaths
bull In a study of 2963 health care encounters smoking was discussed 633 times
bull Nicotine released into the body within 10 seconds of inhalation
bull If a person smokes one pack per day and takes ten puffs of each cigarette that equates to 200 ldquohitsrdquo of nicotine daily
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
103
DOS CME Course 2011
Nicotine
bull Nicotinic receptors occur naturally
bull N1 receptors in the adrenal medulla
bull Neuromuscular junction of autonomic ganglia
bull N2 receptors in skeletal muscle
bull Number of receptor sites increases with regular stimulation
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
104
DOS CME Course 2011
Nicotinebull Addictive
bull Vasoconstrictor
bull Releases adrenaline from the adrenal cortex
ndashFeeling of increased energy
bull Releases dopamine to produce feelings of well-beingndash Actually improves memory and cognition
bull Sensitivity actually declines overnight
bull Release of insulinndash Slightly hyperglycemic
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
105
DOS CME Course 2011
Genetic componentbull About 10 of smokers lack the gene for nicotine
dependence
ndashldquosocial or occasionalrdquo smokers
ndashThey really can quit anytime they want to
ndashNo withdrawal symptoms
ndashStill poses a health risk
bull The other 90 will demonstrate physical and psychological symptoms of withdrawal
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
106
DOS CME Course 2011
Smoking
bull Identify tobacco users ndash Ask every patient every visit
ndash Have you used tobacco in the last 12 months
ndash Clinic-wide program
bull Advise every tobacco user to quitndash Personalize the message
ndash Be clear
ndash Be firm
If at first you donrsquot succeed try tryagain Bring it up at every encounter
107
DOS CME Course 2011
Smoking cessationbull Some more good reasons to quit
ndashSmoking costs over $2000 a year in current US dollars
ndashThere is no accepted safe level of cigarette smoke
ndashSecondhand smoke carries the same hazards
ndashIncreased risk of SIDS and asthma exacerbations in children
httpwwwlungusaorgstop-smokingabout-smokingfacts-figuresgeneral-smoking-factshtml
108
DOS CME Course 2011
Smoking cessation
bull Nicotine is a powerful drug addiction
bull Treat as a chronic illness
bull All healthcare providers encouraged to participate
bull Assess willingness to quit
bull Promote motivation
109
DOS CME Course 2011
Smoking cessation
bull Prochaskarsquos change theory
bull Precontemplation
ndashNot even thinking about quitting
ndashProvide education on the risks and costs of smoking
bull Contemplation
ndashAwareness that a problem exists
ndashContinue to find motivations to stop
NorcrossJC Krebs PM Prochaska JO(2011)
110
DOS CME Course 2011
Change is good
bull Determination
ndashExpressing willingness to act
ndashSelf-efficacy
bull Action ndash Currently not smoking
ndash May relapse
bull It is not unusual for a patient to ldquoquitrdquo three or four times
bull Continue to encourage and motivate himher to stop
NorcrossJC Krebs PM Prochaska JO(2011)
111
DOS CME Course 2011
Smoking cessationbull Assist the patient
ndashCollaborate with the patient to develop a plan to quit
ndashAchievable clearly defined goals
ndashIdentify and engage social supports
ndashFamily support groups
ndashPharmacologic (more on this later)
bull Arrange follow-up
ndashAt each successive visit review progress on quitting strategy
ndashLets the patient know heshe is not alone in this effort
ndashAccountability
112
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
COPD Treatmentbull Now that we have diagnosis what do I do about it
bull Assess and monitor diseasendash Assess for risk factors ie smoking family history
ndash Co-morbidities such as heart failure
ndash Pattern of symptoms
ndash Impact on quality of life
bull Reduce risk factors ndash Identify environmentaloccupational factors which can be modified
ndash Smoking cessation is essential
ndash Manage exacerbations
91
DOS CME Course 2011
COPDbull Manage stable COPD
ndash Determine disease severity based on frequency and severity of symptoms
ndash Educate the patient about risk factors and disease management regimen
ndash Collaborate with the patient to develop a personalized regimen
ndashFits their lifestyle
ndashAccounts for cultural preferences family involvement
ndashAvailability of testing and medications
92
DOS CME Course 2011
Pharmacologybull Goals
ndash Improve exercise tolerance
ndash Control symptoms
ndash Reduce frequency and severity of exacerbations
ndash Improve health status
bull Bronchodilators ndash Include long-acting therapy with short-acting for better control
bull Combine medications from different classes rather than increasing dosage of just onendash Minimizes side effects
93
DOS CME Course 2011
Pharmacologybull Glucocorticosteroids
ndashCan reduce the number of exacerbations
ndashIncreased risk of pneumonia
ndashNo noted reduction in mortality
bull Vaccines
ndashInfluenza vaccines decrease serious illness and death by 50
ndashRecommended annually
ndashPneumococcal vaccines recommended for all COPD sufferers even under age 65
GOLD 2009
94
DOS CME Course 2011
Antibiotics
bull Antibiotics are not a treatment for COPD nor do they manage symptoms of an exacerbation
bull Should be given only if the following are metndash Presence of three cardinal symptoms increased dyspnea
increased sputum volume increased sputum purulence
ndash Increased sputum purulence plus one other cardinal symptom
ndash Mechanically ventilated
bull May be difficult for patients to understand why antibiotics will not ldquofixrdquo what is wrong
bull Good opportunity for learning needs assessment
GOLD 2009
95
DOS CME Course 2011
COPD
bull Pulmonary rehabilitation
bull Encourage the patient to continue activities as tolerated ndash Move as much as you can before you canrsquot move
bull Uses low impact exercise to maintain physical function
bull Exercise can be done while seatedndash Monitor pulse oximetry respiratory rate and effort before during
and after activity
bull Set goals which are realistic for both of you
96
DOS CME Course 2011
COPD
bull Pulmonary rehab includes education nutrition and exercise
bull Can be a good source of social support for someone who has seen function decline
ndashTalk with others in the same situation
ndashFind out how they cope
ndashSocialize
bull Regular influenza and pneumonia vaccines
97
DOS CME Course 2011
COPD
bull Oxygen therapy
bull Recommended for stage IV disease ndash PaO2 lt or = 55 mmHg
ndash SaO2 lt or = 88
bull Increases survival improves hemodynamicsbenefits mental state
bull Surgical options reviewed on a case-by-case basisndash Bullectomy
ndash Lung volume reduction ndashNo evidence to support this as a widespread therapy
98
DOS CME Course 2011
COPD
bull Managing exacerbations
bull An event in the natural course of the disease characterized by a change in baseline dyspnea cough or sputum beyond day to day variance is acute in onset and may warrant a change in medication
bull Air pollution and tracheobronchial infections are the most common causes
bull 30 of exacerbations no cause identified
(GOLD 2009 p 22)
99
DOS CME Course 2011
COPD
bull Hospitalization is recommended for patients exhibiting the following
ndash Failure of exacerbation to respond to medical treatment
ndash Development of new symptoms ie peripheral edema cyanosis
ndash Significant co-morbidities
ndash History of frequent exacerbations
ndash Newly occurring arrhythmias
ndash Advanced age
ndash Insufficient home support
ndash Unclear diagnosis
(GOLD 2009 p 23)
100
DOS CME Course 2011
COPD
bull Mechanical ventilation is not recognized as an effective management strategy for stable COPD
bull May be required as supportive therapy during an exacerbation
bull Associated with mortality
bull Carries risks of its ownndash Ventilator acquired pneumonia
ndash Ventilator induced lung injury
ndash Failure to wean
(GOLD 2009)
101
DOS CME Course 2011DOS CME Course 2011102
Every Life Deserves World Class Care
Smoking
102
DOS CME Course 2011
Smoking bull By the numbers
bull More than 400 000 Americans die from smoking-related illnesses each yearndash Thatrsquos one of every 5 deaths
bull In a study of 2963 health care encounters smoking was discussed 633 times
bull Nicotine released into the body within 10 seconds of inhalation
bull If a person smokes one pack per day and takes ten puffs of each cigarette that equates to 200 ldquohitsrdquo of nicotine daily
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
103
DOS CME Course 2011
Nicotine
bull Nicotinic receptors occur naturally
bull N1 receptors in the adrenal medulla
bull Neuromuscular junction of autonomic ganglia
bull N2 receptors in skeletal muscle
bull Number of receptor sites increases with regular stimulation
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
104
DOS CME Course 2011
Nicotinebull Addictive
bull Vasoconstrictor
bull Releases adrenaline from the adrenal cortex
ndashFeeling of increased energy
bull Releases dopamine to produce feelings of well-beingndash Actually improves memory and cognition
bull Sensitivity actually declines overnight
bull Release of insulinndash Slightly hyperglycemic
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
105
DOS CME Course 2011
Genetic componentbull About 10 of smokers lack the gene for nicotine
dependence
ndashldquosocial or occasionalrdquo smokers
ndashThey really can quit anytime they want to
ndashNo withdrawal symptoms
ndashStill poses a health risk
bull The other 90 will demonstrate physical and psychological symptoms of withdrawal
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
106
DOS CME Course 2011
Smoking
bull Identify tobacco users ndash Ask every patient every visit
ndash Have you used tobacco in the last 12 months
ndash Clinic-wide program
bull Advise every tobacco user to quitndash Personalize the message
ndash Be clear
ndash Be firm
If at first you donrsquot succeed try tryagain Bring it up at every encounter
107
DOS CME Course 2011
Smoking cessationbull Some more good reasons to quit
ndashSmoking costs over $2000 a year in current US dollars
ndashThere is no accepted safe level of cigarette smoke
ndashSecondhand smoke carries the same hazards
ndashIncreased risk of SIDS and asthma exacerbations in children
httpwwwlungusaorgstop-smokingabout-smokingfacts-figuresgeneral-smoking-factshtml
108
DOS CME Course 2011
Smoking cessation
bull Nicotine is a powerful drug addiction
bull Treat as a chronic illness
bull All healthcare providers encouraged to participate
bull Assess willingness to quit
bull Promote motivation
109
DOS CME Course 2011
Smoking cessation
bull Prochaskarsquos change theory
bull Precontemplation
ndashNot even thinking about quitting
ndashProvide education on the risks and costs of smoking
bull Contemplation
ndashAwareness that a problem exists
ndashContinue to find motivations to stop
NorcrossJC Krebs PM Prochaska JO(2011)
110
DOS CME Course 2011
Change is good
bull Determination
ndashExpressing willingness to act
ndashSelf-efficacy
bull Action ndash Currently not smoking
ndash May relapse
bull It is not unusual for a patient to ldquoquitrdquo three or four times
bull Continue to encourage and motivate himher to stop
NorcrossJC Krebs PM Prochaska JO(2011)
111
DOS CME Course 2011
Smoking cessationbull Assist the patient
ndashCollaborate with the patient to develop a plan to quit
ndashAchievable clearly defined goals
ndashIdentify and engage social supports
ndashFamily support groups
ndashPharmacologic (more on this later)
bull Arrange follow-up
ndashAt each successive visit review progress on quitting strategy
ndashLets the patient know heshe is not alone in this effort
ndashAccountability
112
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
Pharmacologybull Goals
ndash Improve exercise tolerance
ndash Control symptoms
ndash Reduce frequency and severity of exacerbations
ndash Improve health status
bull Bronchodilators ndash Include long-acting therapy with short-acting for better control
bull Combine medications from different classes rather than increasing dosage of just onendash Minimizes side effects
93
DOS CME Course 2011
Pharmacologybull Glucocorticosteroids
ndashCan reduce the number of exacerbations
ndashIncreased risk of pneumonia
ndashNo noted reduction in mortality
bull Vaccines
ndashInfluenza vaccines decrease serious illness and death by 50
ndashRecommended annually
ndashPneumococcal vaccines recommended for all COPD sufferers even under age 65
GOLD 2009
94
DOS CME Course 2011
Antibiotics
bull Antibiotics are not a treatment for COPD nor do they manage symptoms of an exacerbation
bull Should be given only if the following are metndash Presence of three cardinal symptoms increased dyspnea
increased sputum volume increased sputum purulence
ndash Increased sputum purulence plus one other cardinal symptom
ndash Mechanically ventilated
bull May be difficult for patients to understand why antibiotics will not ldquofixrdquo what is wrong
bull Good opportunity for learning needs assessment
GOLD 2009
95
DOS CME Course 2011
COPD
bull Pulmonary rehabilitation
bull Encourage the patient to continue activities as tolerated ndash Move as much as you can before you canrsquot move
bull Uses low impact exercise to maintain physical function
bull Exercise can be done while seatedndash Monitor pulse oximetry respiratory rate and effort before during
and after activity
bull Set goals which are realistic for both of you
96
DOS CME Course 2011
COPD
bull Pulmonary rehab includes education nutrition and exercise
bull Can be a good source of social support for someone who has seen function decline
ndashTalk with others in the same situation
ndashFind out how they cope
ndashSocialize
bull Regular influenza and pneumonia vaccines
97
DOS CME Course 2011
COPD
bull Oxygen therapy
bull Recommended for stage IV disease ndash PaO2 lt or = 55 mmHg
ndash SaO2 lt or = 88
bull Increases survival improves hemodynamicsbenefits mental state
bull Surgical options reviewed on a case-by-case basisndash Bullectomy
ndash Lung volume reduction ndashNo evidence to support this as a widespread therapy
98
DOS CME Course 2011
COPD
bull Managing exacerbations
bull An event in the natural course of the disease characterized by a change in baseline dyspnea cough or sputum beyond day to day variance is acute in onset and may warrant a change in medication
bull Air pollution and tracheobronchial infections are the most common causes
bull 30 of exacerbations no cause identified
(GOLD 2009 p 22)
99
DOS CME Course 2011
COPD
bull Hospitalization is recommended for patients exhibiting the following
ndash Failure of exacerbation to respond to medical treatment
ndash Development of new symptoms ie peripheral edema cyanosis
ndash Significant co-morbidities
ndash History of frequent exacerbations
ndash Newly occurring arrhythmias
ndash Advanced age
ndash Insufficient home support
ndash Unclear diagnosis
(GOLD 2009 p 23)
100
DOS CME Course 2011
COPD
bull Mechanical ventilation is not recognized as an effective management strategy for stable COPD
bull May be required as supportive therapy during an exacerbation
bull Associated with mortality
bull Carries risks of its ownndash Ventilator acquired pneumonia
ndash Ventilator induced lung injury
ndash Failure to wean
(GOLD 2009)
101
DOS CME Course 2011DOS CME Course 2011102
Every Life Deserves World Class Care
Smoking
102
DOS CME Course 2011
Smoking bull By the numbers
bull More than 400 000 Americans die from smoking-related illnesses each yearndash Thatrsquos one of every 5 deaths
bull In a study of 2963 health care encounters smoking was discussed 633 times
bull Nicotine released into the body within 10 seconds of inhalation
bull If a person smokes one pack per day and takes ten puffs of each cigarette that equates to 200 ldquohitsrdquo of nicotine daily
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
103
DOS CME Course 2011
Nicotine
bull Nicotinic receptors occur naturally
bull N1 receptors in the adrenal medulla
bull Neuromuscular junction of autonomic ganglia
bull N2 receptors in skeletal muscle
bull Number of receptor sites increases with regular stimulation
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
104
DOS CME Course 2011
Nicotinebull Addictive
bull Vasoconstrictor
bull Releases adrenaline from the adrenal cortex
ndashFeeling of increased energy
bull Releases dopamine to produce feelings of well-beingndash Actually improves memory and cognition
bull Sensitivity actually declines overnight
bull Release of insulinndash Slightly hyperglycemic
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
105
DOS CME Course 2011
Genetic componentbull About 10 of smokers lack the gene for nicotine
dependence
ndashldquosocial or occasionalrdquo smokers
ndashThey really can quit anytime they want to
ndashNo withdrawal symptoms
ndashStill poses a health risk
bull The other 90 will demonstrate physical and psychological symptoms of withdrawal
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
106
DOS CME Course 2011
Smoking
bull Identify tobacco users ndash Ask every patient every visit
ndash Have you used tobacco in the last 12 months
ndash Clinic-wide program
bull Advise every tobacco user to quitndash Personalize the message
ndash Be clear
ndash Be firm
If at first you donrsquot succeed try tryagain Bring it up at every encounter
107
DOS CME Course 2011
Smoking cessationbull Some more good reasons to quit
ndashSmoking costs over $2000 a year in current US dollars
ndashThere is no accepted safe level of cigarette smoke
ndashSecondhand smoke carries the same hazards
ndashIncreased risk of SIDS and asthma exacerbations in children
httpwwwlungusaorgstop-smokingabout-smokingfacts-figuresgeneral-smoking-factshtml
108
DOS CME Course 2011
Smoking cessation
bull Nicotine is a powerful drug addiction
bull Treat as a chronic illness
bull All healthcare providers encouraged to participate
bull Assess willingness to quit
bull Promote motivation
109
DOS CME Course 2011
Smoking cessation
bull Prochaskarsquos change theory
bull Precontemplation
ndashNot even thinking about quitting
ndashProvide education on the risks and costs of smoking
bull Contemplation
ndashAwareness that a problem exists
ndashContinue to find motivations to stop
NorcrossJC Krebs PM Prochaska JO(2011)
110
DOS CME Course 2011
Change is good
bull Determination
ndashExpressing willingness to act
ndashSelf-efficacy
bull Action ndash Currently not smoking
ndash May relapse
bull It is not unusual for a patient to ldquoquitrdquo three or four times
bull Continue to encourage and motivate himher to stop
NorcrossJC Krebs PM Prochaska JO(2011)
111
DOS CME Course 2011
Smoking cessationbull Assist the patient
ndashCollaborate with the patient to develop a plan to quit
ndashAchievable clearly defined goals
ndashIdentify and engage social supports
ndashFamily support groups
ndashPharmacologic (more on this later)
bull Arrange follow-up
ndashAt each successive visit review progress on quitting strategy
ndashLets the patient know heshe is not alone in this effort
ndashAccountability
112
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
Antibiotics
bull Antibiotics are not a treatment for COPD nor do they manage symptoms of an exacerbation
bull Should be given only if the following are metndash Presence of three cardinal symptoms increased dyspnea
increased sputum volume increased sputum purulence
ndash Increased sputum purulence plus one other cardinal symptom
ndash Mechanically ventilated
bull May be difficult for patients to understand why antibiotics will not ldquofixrdquo what is wrong
bull Good opportunity for learning needs assessment
GOLD 2009
95
DOS CME Course 2011
COPD
bull Pulmonary rehabilitation
bull Encourage the patient to continue activities as tolerated ndash Move as much as you can before you canrsquot move
bull Uses low impact exercise to maintain physical function
bull Exercise can be done while seatedndash Monitor pulse oximetry respiratory rate and effort before during
and after activity
bull Set goals which are realistic for both of you
96
DOS CME Course 2011
COPD
bull Pulmonary rehab includes education nutrition and exercise
bull Can be a good source of social support for someone who has seen function decline
ndashTalk with others in the same situation
ndashFind out how they cope
ndashSocialize
bull Regular influenza and pneumonia vaccines
97
DOS CME Course 2011
COPD
bull Oxygen therapy
bull Recommended for stage IV disease ndash PaO2 lt or = 55 mmHg
ndash SaO2 lt or = 88
bull Increases survival improves hemodynamicsbenefits mental state
bull Surgical options reviewed on a case-by-case basisndash Bullectomy
ndash Lung volume reduction ndashNo evidence to support this as a widespread therapy
98
DOS CME Course 2011
COPD
bull Managing exacerbations
bull An event in the natural course of the disease characterized by a change in baseline dyspnea cough or sputum beyond day to day variance is acute in onset and may warrant a change in medication
bull Air pollution and tracheobronchial infections are the most common causes
bull 30 of exacerbations no cause identified
(GOLD 2009 p 22)
99
DOS CME Course 2011
COPD
bull Hospitalization is recommended for patients exhibiting the following
ndash Failure of exacerbation to respond to medical treatment
ndash Development of new symptoms ie peripheral edema cyanosis
ndash Significant co-morbidities
ndash History of frequent exacerbations
ndash Newly occurring arrhythmias
ndash Advanced age
ndash Insufficient home support
ndash Unclear diagnosis
(GOLD 2009 p 23)
100
DOS CME Course 2011
COPD
bull Mechanical ventilation is not recognized as an effective management strategy for stable COPD
bull May be required as supportive therapy during an exacerbation
bull Associated with mortality
bull Carries risks of its ownndash Ventilator acquired pneumonia
ndash Ventilator induced lung injury
ndash Failure to wean
(GOLD 2009)
101
DOS CME Course 2011DOS CME Course 2011102
Every Life Deserves World Class Care
Smoking
102
DOS CME Course 2011
Smoking bull By the numbers
bull More than 400 000 Americans die from smoking-related illnesses each yearndash Thatrsquos one of every 5 deaths
bull In a study of 2963 health care encounters smoking was discussed 633 times
bull Nicotine released into the body within 10 seconds of inhalation
bull If a person smokes one pack per day and takes ten puffs of each cigarette that equates to 200 ldquohitsrdquo of nicotine daily
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
103
DOS CME Course 2011
Nicotine
bull Nicotinic receptors occur naturally
bull N1 receptors in the adrenal medulla
bull Neuromuscular junction of autonomic ganglia
bull N2 receptors in skeletal muscle
bull Number of receptor sites increases with regular stimulation
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
104
DOS CME Course 2011
Nicotinebull Addictive
bull Vasoconstrictor
bull Releases adrenaline from the adrenal cortex
ndashFeeling of increased energy
bull Releases dopamine to produce feelings of well-beingndash Actually improves memory and cognition
bull Sensitivity actually declines overnight
bull Release of insulinndash Slightly hyperglycemic
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
105
DOS CME Course 2011
Genetic componentbull About 10 of smokers lack the gene for nicotine
dependence
ndashldquosocial or occasionalrdquo smokers
ndashThey really can quit anytime they want to
ndashNo withdrawal symptoms
ndashStill poses a health risk
bull The other 90 will demonstrate physical and psychological symptoms of withdrawal
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
106
DOS CME Course 2011
Smoking
bull Identify tobacco users ndash Ask every patient every visit
ndash Have you used tobacco in the last 12 months
ndash Clinic-wide program
bull Advise every tobacco user to quitndash Personalize the message
ndash Be clear
ndash Be firm
If at first you donrsquot succeed try tryagain Bring it up at every encounter
107
DOS CME Course 2011
Smoking cessationbull Some more good reasons to quit
ndashSmoking costs over $2000 a year in current US dollars
ndashThere is no accepted safe level of cigarette smoke
ndashSecondhand smoke carries the same hazards
ndashIncreased risk of SIDS and asthma exacerbations in children
httpwwwlungusaorgstop-smokingabout-smokingfacts-figuresgeneral-smoking-factshtml
108
DOS CME Course 2011
Smoking cessation
bull Nicotine is a powerful drug addiction
bull Treat as a chronic illness
bull All healthcare providers encouraged to participate
bull Assess willingness to quit
bull Promote motivation
109
DOS CME Course 2011
Smoking cessation
bull Prochaskarsquos change theory
bull Precontemplation
ndashNot even thinking about quitting
ndashProvide education on the risks and costs of smoking
bull Contemplation
ndashAwareness that a problem exists
ndashContinue to find motivations to stop
NorcrossJC Krebs PM Prochaska JO(2011)
110
DOS CME Course 2011
Change is good
bull Determination
ndashExpressing willingness to act
ndashSelf-efficacy
bull Action ndash Currently not smoking
ndash May relapse
bull It is not unusual for a patient to ldquoquitrdquo three or four times
bull Continue to encourage and motivate himher to stop
NorcrossJC Krebs PM Prochaska JO(2011)
111
DOS CME Course 2011
Smoking cessationbull Assist the patient
ndashCollaborate with the patient to develop a plan to quit
ndashAchievable clearly defined goals
ndashIdentify and engage social supports
ndashFamily support groups
ndashPharmacologic (more on this later)
bull Arrange follow-up
ndashAt each successive visit review progress on quitting strategy
ndashLets the patient know heshe is not alone in this effort
ndashAccountability
112
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
COPD
bull Pulmonary rehab includes education nutrition and exercise
bull Can be a good source of social support for someone who has seen function decline
ndashTalk with others in the same situation
ndashFind out how they cope
ndashSocialize
bull Regular influenza and pneumonia vaccines
97
DOS CME Course 2011
COPD
bull Oxygen therapy
bull Recommended for stage IV disease ndash PaO2 lt or = 55 mmHg
ndash SaO2 lt or = 88
bull Increases survival improves hemodynamicsbenefits mental state
bull Surgical options reviewed on a case-by-case basisndash Bullectomy
ndash Lung volume reduction ndashNo evidence to support this as a widespread therapy
98
DOS CME Course 2011
COPD
bull Managing exacerbations
bull An event in the natural course of the disease characterized by a change in baseline dyspnea cough or sputum beyond day to day variance is acute in onset and may warrant a change in medication
bull Air pollution and tracheobronchial infections are the most common causes
bull 30 of exacerbations no cause identified
(GOLD 2009 p 22)
99
DOS CME Course 2011
COPD
bull Hospitalization is recommended for patients exhibiting the following
ndash Failure of exacerbation to respond to medical treatment
ndash Development of new symptoms ie peripheral edema cyanosis
ndash Significant co-morbidities
ndash History of frequent exacerbations
ndash Newly occurring arrhythmias
ndash Advanced age
ndash Insufficient home support
ndash Unclear diagnosis
(GOLD 2009 p 23)
100
DOS CME Course 2011
COPD
bull Mechanical ventilation is not recognized as an effective management strategy for stable COPD
bull May be required as supportive therapy during an exacerbation
bull Associated with mortality
bull Carries risks of its ownndash Ventilator acquired pneumonia
ndash Ventilator induced lung injury
ndash Failure to wean
(GOLD 2009)
101
DOS CME Course 2011DOS CME Course 2011102
Every Life Deserves World Class Care
Smoking
102
DOS CME Course 2011
Smoking bull By the numbers
bull More than 400 000 Americans die from smoking-related illnesses each yearndash Thatrsquos one of every 5 deaths
bull In a study of 2963 health care encounters smoking was discussed 633 times
bull Nicotine released into the body within 10 seconds of inhalation
bull If a person smokes one pack per day and takes ten puffs of each cigarette that equates to 200 ldquohitsrdquo of nicotine daily
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
103
DOS CME Course 2011
Nicotine
bull Nicotinic receptors occur naturally
bull N1 receptors in the adrenal medulla
bull Neuromuscular junction of autonomic ganglia
bull N2 receptors in skeletal muscle
bull Number of receptor sites increases with regular stimulation
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
104
DOS CME Course 2011
Nicotinebull Addictive
bull Vasoconstrictor
bull Releases adrenaline from the adrenal cortex
ndashFeeling of increased energy
bull Releases dopamine to produce feelings of well-beingndash Actually improves memory and cognition
bull Sensitivity actually declines overnight
bull Release of insulinndash Slightly hyperglycemic
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
105
DOS CME Course 2011
Genetic componentbull About 10 of smokers lack the gene for nicotine
dependence
ndashldquosocial or occasionalrdquo smokers
ndashThey really can quit anytime they want to
ndashNo withdrawal symptoms
ndashStill poses a health risk
bull The other 90 will demonstrate physical and psychological symptoms of withdrawal
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
106
DOS CME Course 2011
Smoking
bull Identify tobacco users ndash Ask every patient every visit
ndash Have you used tobacco in the last 12 months
ndash Clinic-wide program
bull Advise every tobacco user to quitndash Personalize the message
ndash Be clear
ndash Be firm
If at first you donrsquot succeed try tryagain Bring it up at every encounter
107
DOS CME Course 2011
Smoking cessationbull Some more good reasons to quit
ndashSmoking costs over $2000 a year in current US dollars
ndashThere is no accepted safe level of cigarette smoke
ndashSecondhand smoke carries the same hazards
ndashIncreased risk of SIDS and asthma exacerbations in children
httpwwwlungusaorgstop-smokingabout-smokingfacts-figuresgeneral-smoking-factshtml
108
DOS CME Course 2011
Smoking cessation
bull Nicotine is a powerful drug addiction
bull Treat as a chronic illness
bull All healthcare providers encouraged to participate
bull Assess willingness to quit
bull Promote motivation
109
DOS CME Course 2011
Smoking cessation
bull Prochaskarsquos change theory
bull Precontemplation
ndashNot even thinking about quitting
ndashProvide education on the risks and costs of smoking
bull Contemplation
ndashAwareness that a problem exists
ndashContinue to find motivations to stop
NorcrossJC Krebs PM Prochaska JO(2011)
110
DOS CME Course 2011
Change is good
bull Determination
ndashExpressing willingness to act
ndashSelf-efficacy
bull Action ndash Currently not smoking
ndash May relapse
bull It is not unusual for a patient to ldquoquitrdquo three or four times
bull Continue to encourage and motivate himher to stop
NorcrossJC Krebs PM Prochaska JO(2011)
111
DOS CME Course 2011
Smoking cessationbull Assist the patient
ndashCollaborate with the patient to develop a plan to quit
ndashAchievable clearly defined goals
ndashIdentify and engage social supports
ndashFamily support groups
ndashPharmacologic (more on this later)
bull Arrange follow-up
ndashAt each successive visit review progress on quitting strategy
ndashLets the patient know heshe is not alone in this effort
ndashAccountability
112
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
COPD
bull Managing exacerbations
bull An event in the natural course of the disease characterized by a change in baseline dyspnea cough or sputum beyond day to day variance is acute in onset and may warrant a change in medication
bull Air pollution and tracheobronchial infections are the most common causes
bull 30 of exacerbations no cause identified
(GOLD 2009 p 22)
99
DOS CME Course 2011
COPD
bull Hospitalization is recommended for patients exhibiting the following
ndash Failure of exacerbation to respond to medical treatment
ndash Development of new symptoms ie peripheral edema cyanosis
ndash Significant co-morbidities
ndash History of frequent exacerbations
ndash Newly occurring arrhythmias
ndash Advanced age
ndash Insufficient home support
ndash Unclear diagnosis
(GOLD 2009 p 23)
100
DOS CME Course 2011
COPD
bull Mechanical ventilation is not recognized as an effective management strategy for stable COPD
bull May be required as supportive therapy during an exacerbation
bull Associated with mortality
bull Carries risks of its ownndash Ventilator acquired pneumonia
ndash Ventilator induced lung injury
ndash Failure to wean
(GOLD 2009)
101
DOS CME Course 2011DOS CME Course 2011102
Every Life Deserves World Class Care
Smoking
102
DOS CME Course 2011
Smoking bull By the numbers
bull More than 400 000 Americans die from smoking-related illnesses each yearndash Thatrsquos one of every 5 deaths
bull In a study of 2963 health care encounters smoking was discussed 633 times
bull Nicotine released into the body within 10 seconds of inhalation
bull If a person smokes one pack per day and takes ten puffs of each cigarette that equates to 200 ldquohitsrdquo of nicotine daily
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
103
DOS CME Course 2011
Nicotine
bull Nicotinic receptors occur naturally
bull N1 receptors in the adrenal medulla
bull Neuromuscular junction of autonomic ganglia
bull N2 receptors in skeletal muscle
bull Number of receptor sites increases with regular stimulation
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
104
DOS CME Course 2011
Nicotinebull Addictive
bull Vasoconstrictor
bull Releases adrenaline from the adrenal cortex
ndashFeeling of increased energy
bull Releases dopamine to produce feelings of well-beingndash Actually improves memory and cognition
bull Sensitivity actually declines overnight
bull Release of insulinndash Slightly hyperglycemic
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
105
DOS CME Course 2011
Genetic componentbull About 10 of smokers lack the gene for nicotine
dependence
ndashldquosocial or occasionalrdquo smokers
ndashThey really can quit anytime they want to
ndashNo withdrawal symptoms
ndashStill poses a health risk
bull The other 90 will demonstrate physical and psychological symptoms of withdrawal
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
106
DOS CME Course 2011
Smoking
bull Identify tobacco users ndash Ask every patient every visit
ndash Have you used tobacco in the last 12 months
ndash Clinic-wide program
bull Advise every tobacco user to quitndash Personalize the message
ndash Be clear
ndash Be firm
If at first you donrsquot succeed try tryagain Bring it up at every encounter
107
DOS CME Course 2011
Smoking cessationbull Some more good reasons to quit
ndashSmoking costs over $2000 a year in current US dollars
ndashThere is no accepted safe level of cigarette smoke
ndashSecondhand smoke carries the same hazards
ndashIncreased risk of SIDS and asthma exacerbations in children
httpwwwlungusaorgstop-smokingabout-smokingfacts-figuresgeneral-smoking-factshtml
108
DOS CME Course 2011
Smoking cessation
bull Nicotine is a powerful drug addiction
bull Treat as a chronic illness
bull All healthcare providers encouraged to participate
bull Assess willingness to quit
bull Promote motivation
109
DOS CME Course 2011
Smoking cessation
bull Prochaskarsquos change theory
bull Precontemplation
ndashNot even thinking about quitting
ndashProvide education on the risks and costs of smoking
bull Contemplation
ndashAwareness that a problem exists
ndashContinue to find motivations to stop
NorcrossJC Krebs PM Prochaska JO(2011)
110
DOS CME Course 2011
Change is good
bull Determination
ndashExpressing willingness to act
ndashSelf-efficacy
bull Action ndash Currently not smoking
ndash May relapse
bull It is not unusual for a patient to ldquoquitrdquo three or four times
bull Continue to encourage and motivate himher to stop
NorcrossJC Krebs PM Prochaska JO(2011)
111
DOS CME Course 2011
Smoking cessationbull Assist the patient
ndashCollaborate with the patient to develop a plan to quit
ndashAchievable clearly defined goals
ndashIdentify and engage social supports
ndashFamily support groups
ndashPharmacologic (more on this later)
bull Arrange follow-up
ndashAt each successive visit review progress on quitting strategy
ndashLets the patient know heshe is not alone in this effort
ndashAccountability
112
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
COPD
bull Mechanical ventilation is not recognized as an effective management strategy for stable COPD
bull May be required as supportive therapy during an exacerbation
bull Associated with mortality
bull Carries risks of its ownndash Ventilator acquired pneumonia
ndash Ventilator induced lung injury
ndash Failure to wean
(GOLD 2009)
101
DOS CME Course 2011DOS CME Course 2011102
Every Life Deserves World Class Care
Smoking
102
DOS CME Course 2011
Smoking bull By the numbers
bull More than 400 000 Americans die from smoking-related illnesses each yearndash Thatrsquos one of every 5 deaths
bull In a study of 2963 health care encounters smoking was discussed 633 times
bull Nicotine released into the body within 10 seconds of inhalation
bull If a person smokes one pack per day and takes ten puffs of each cigarette that equates to 200 ldquohitsrdquo of nicotine daily
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
103
DOS CME Course 2011
Nicotine
bull Nicotinic receptors occur naturally
bull N1 receptors in the adrenal medulla
bull Neuromuscular junction of autonomic ganglia
bull N2 receptors in skeletal muscle
bull Number of receptor sites increases with regular stimulation
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
104
DOS CME Course 2011
Nicotinebull Addictive
bull Vasoconstrictor
bull Releases adrenaline from the adrenal cortex
ndashFeeling of increased energy
bull Releases dopamine to produce feelings of well-beingndash Actually improves memory and cognition
bull Sensitivity actually declines overnight
bull Release of insulinndash Slightly hyperglycemic
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
105
DOS CME Course 2011
Genetic componentbull About 10 of smokers lack the gene for nicotine
dependence
ndashldquosocial or occasionalrdquo smokers
ndashThey really can quit anytime they want to
ndashNo withdrawal symptoms
ndashStill poses a health risk
bull The other 90 will demonstrate physical and psychological symptoms of withdrawal
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
106
DOS CME Course 2011
Smoking
bull Identify tobacco users ndash Ask every patient every visit
ndash Have you used tobacco in the last 12 months
ndash Clinic-wide program
bull Advise every tobacco user to quitndash Personalize the message
ndash Be clear
ndash Be firm
If at first you donrsquot succeed try tryagain Bring it up at every encounter
107
DOS CME Course 2011
Smoking cessationbull Some more good reasons to quit
ndashSmoking costs over $2000 a year in current US dollars
ndashThere is no accepted safe level of cigarette smoke
ndashSecondhand smoke carries the same hazards
ndashIncreased risk of SIDS and asthma exacerbations in children
httpwwwlungusaorgstop-smokingabout-smokingfacts-figuresgeneral-smoking-factshtml
108
DOS CME Course 2011
Smoking cessation
bull Nicotine is a powerful drug addiction
bull Treat as a chronic illness
bull All healthcare providers encouraged to participate
bull Assess willingness to quit
bull Promote motivation
109
DOS CME Course 2011
Smoking cessation
bull Prochaskarsquos change theory
bull Precontemplation
ndashNot even thinking about quitting
ndashProvide education on the risks and costs of smoking
bull Contemplation
ndashAwareness that a problem exists
ndashContinue to find motivations to stop
NorcrossJC Krebs PM Prochaska JO(2011)
110
DOS CME Course 2011
Change is good
bull Determination
ndashExpressing willingness to act
ndashSelf-efficacy
bull Action ndash Currently not smoking
ndash May relapse
bull It is not unusual for a patient to ldquoquitrdquo three or four times
bull Continue to encourage and motivate himher to stop
NorcrossJC Krebs PM Prochaska JO(2011)
111
DOS CME Course 2011
Smoking cessationbull Assist the patient
ndashCollaborate with the patient to develop a plan to quit
ndashAchievable clearly defined goals
ndashIdentify and engage social supports
ndashFamily support groups
ndashPharmacologic (more on this later)
bull Arrange follow-up
ndashAt each successive visit review progress on quitting strategy
ndashLets the patient know heshe is not alone in this effort
ndashAccountability
112
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
Smoking bull By the numbers
bull More than 400 000 Americans die from smoking-related illnesses each yearndash Thatrsquos one of every 5 deaths
bull In a study of 2963 health care encounters smoking was discussed 633 times
bull Nicotine released into the body within 10 seconds of inhalation
bull If a person smokes one pack per day and takes ten puffs of each cigarette that equates to 200 ldquohitsrdquo of nicotine daily
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
103
DOS CME Course 2011
Nicotine
bull Nicotinic receptors occur naturally
bull N1 receptors in the adrenal medulla
bull Neuromuscular junction of autonomic ganglia
bull N2 receptors in skeletal muscle
bull Number of receptor sites increases with regular stimulation
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
104
DOS CME Course 2011
Nicotinebull Addictive
bull Vasoconstrictor
bull Releases adrenaline from the adrenal cortex
ndashFeeling of increased energy
bull Releases dopamine to produce feelings of well-beingndash Actually improves memory and cognition
bull Sensitivity actually declines overnight
bull Release of insulinndash Slightly hyperglycemic
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
105
DOS CME Course 2011
Genetic componentbull About 10 of smokers lack the gene for nicotine
dependence
ndashldquosocial or occasionalrdquo smokers
ndashThey really can quit anytime they want to
ndashNo withdrawal symptoms
ndashStill poses a health risk
bull The other 90 will demonstrate physical and psychological symptoms of withdrawal
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
106
DOS CME Course 2011
Smoking
bull Identify tobacco users ndash Ask every patient every visit
ndash Have you used tobacco in the last 12 months
ndash Clinic-wide program
bull Advise every tobacco user to quitndash Personalize the message
ndash Be clear
ndash Be firm
If at first you donrsquot succeed try tryagain Bring it up at every encounter
107
DOS CME Course 2011
Smoking cessationbull Some more good reasons to quit
ndashSmoking costs over $2000 a year in current US dollars
ndashThere is no accepted safe level of cigarette smoke
ndashSecondhand smoke carries the same hazards
ndashIncreased risk of SIDS and asthma exacerbations in children
httpwwwlungusaorgstop-smokingabout-smokingfacts-figuresgeneral-smoking-factshtml
108
DOS CME Course 2011
Smoking cessation
bull Nicotine is a powerful drug addiction
bull Treat as a chronic illness
bull All healthcare providers encouraged to participate
bull Assess willingness to quit
bull Promote motivation
109
DOS CME Course 2011
Smoking cessation
bull Prochaskarsquos change theory
bull Precontemplation
ndashNot even thinking about quitting
ndashProvide education on the risks and costs of smoking
bull Contemplation
ndashAwareness that a problem exists
ndashContinue to find motivations to stop
NorcrossJC Krebs PM Prochaska JO(2011)
110
DOS CME Course 2011
Change is good
bull Determination
ndashExpressing willingness to act
ndashSelf-efficacy
bull Action ndash Currently not smoking
ndash May relapse
bull It is not unusual for a patient to ldquoquitrdquo three or four times
bull Continue to encourage and motivate himher to stop
NorcrossJC Krebs PM Prochaska JO(2011)
111
DOS CME Course 2011
Smoking cessationbull Assist the patient
ndashCollaborate with the patient to develop a plan to quit
ndashAchievable clearly defined goals
ndashIdentify and engage social supports
ndashFamily support groups
ndashPharmacologic (more on this later)
bull Arrange follow-up
ndashAt each successive visit review progress on quitting strategy
ndashLets the patient know heshe is not alone in this effort
ndashAccountability
112
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
Nicotinebull Addictive
bull Vasoconstrictor
bull Releases adrenaline from the adrenal cortex
ndashFeeling of increased energy
bull Releases dopamine to produce feelings of well-beingndash Actually improves memory and cognition
bull Sensitivity actually declines overnight
bull Release of insulinndash Slightly hyperglycemic
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
105
DOS CME Course 2011
Genetic componentbull About 10 of smokers lack the gene for nicotine
dependence
ndashldquosocial or occasionalrdquo smokers
ndashThey really can quit anytime they want to
ndashNo withdrawal symptoms
ndashStill poses a health risk
bull The other 90 will demonstrate physical and psychological symptoms of withdrawal
httpwwwnursingconsultcomdasbook235013911-6view159458html4-u10-B978-0-323-04742-550028-6--cesec56_506
106
DOS CME Course 2011
Smoking
bull Identify tobacco users ndash Ask every patient every visit
ndash Have you used tobacco in the last 12 months
ndash Clinic-wide program
bull Advise every tobacco user to quitndash Personalize the message
ndash Be clear
ndash Be firm
If at first you donrsquot succeed try tryagain Bring it up at every encounter
107
DOS CME Course 2011
Smoking cessationbull Some more good reasons to quit
ndashSmoking costs over $2000 a year in current US dollars
ndashThere is no accepted safe level of cigarette smoke
ndashSecondhand smoke carries the same hazards
ndashIncreased risk of SIDS and asthma exacerbations in children
httpwwwlungusaorgstop-smokingabout-smokingfacts-figuresgeneral-smoking-factshtml
108
DOS CME Course 2011
Smoking cessation
bull Nicotine is a powerful drug addiction
bull Treat as a chronic illness
bull All healthcare providers encouraged to participate
bull Assess willingness to quit
bull Promote motivation
109
DOS CME Course 2011
Smoking cessation
bull Prochaskarsquos change theory
bull Precontemplation
ndashNot even thinking about quitting
ndashProvide education on the risks and costs of smoking
bull Contemplation
ndashAwareness that a problem exists
ndashContinue to find motivations to stop
NorcrossJC Krebs PM Prochaska JO(2011)
110
DOS CME Course 2011
Change is good
bull Determination
ndashExpressing willingness to act
ndashSelf-efficacy
bull Action ndash Currently not smoking
ndash May relapse
bull It is not unusual for a patient to ldquoquitrdquo three or four times
bull Continue to encourage and motivate himher to stop
NorcrossJC Krebs PM Prochaska JO(2011)
111
DOS CME Course 2011
Smoking cessationbull Assist the patient
ndashCollaborate with the patient to develop a plan to quit
ndashAchievable clearly defined goals
ndashIdentify and engage social supports
ndashFamily support groups
ndashPharmacologic (more on this later)
bull Arrange follow-up
ndashAt each successive visit review progress on quitting strategy
ndashLets the patient know heshe is not alone in this effort
ndashAccountability
112
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
Smoking
bull Identify tobacco users ndash Ask every patient every visit
ndash Have you used tobacco in the last 12 months
ndash Clinic-wide program
bull Advise every tobacco user to quitndash Personalize the message
ndash Be clear
ndash Be firm
If at first you donrsquot succeed try tryagain Bring it up at every encounter
107
DOS CME Course 2011
Smoking cessationbull Some more good reasons to quit
ndashSmoking costs over $2000 a year in current US dollars
ndashThere is no accepted safe level of cigarette smoke
ndashSecondhand smoke carries the same hazards
ndashIncreased risk of SIDS and asthma exacerbations in children
httpwwwlungusaorgstop-smokingabout-smokingfacts-figuresgeneral-smoking-factshtml
108
DOS CME Course 2011
Smoking cessation
bull Nicotine is a powerful drug addiction
bull Treat as a chronic illness
bull All healthcare providers encouraged to participate
bull Assess willingness to quit
bull Promote motivation
109
DOS CME Course 2011
Smoking cessation
bull Prochaskarsquos change theory
bull Precontemplation
ndashNot even thinking about quitting
ndashProvide education on the risks and costs of smoking
bull Contemplation
ndashAwareness that a problem exists
ndashContinue to find motivations to stop
NorcrossJC Krebs PM Prochaska JO(2011)
110
DOS CME Course 2011
Change is good
bull Determination
ndashExpressing willingness to act
ndashSelf-efficacy
bull Action ndash Currently not smoking
ndash May relapse
bull It is not unusual for a patient to ldquoquitrdquo three or four times
bull Continue to encourage and motivate himher to stop
NorcrossJC Krebs PM Prochaska JO(2011)
111
DOS CME Course 2011
Smoking cessationbull Assist the patient
ndashCollaborate with the patient to develop a plan to quit
ndashAchievable clearly defined goals
ndashIdentify and engage social supports
ndashFamily support groups
ndashPharmacologic (more on this later)
bull Arrange follow-up
ndashAt each successive visit review progress on quitting strategy
ndashLets the patient know heshe is not alone in this effort
ndashAccountability
112
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
Smoking cessation
bull Nicotine is a powerful drug addiction
bull Treat as a chronic illness
bull All healthcare providers encouraged to participate
bull Assess willingness to quit
bull Promote motivation
109
DOS CME Course 2011
Smoking cessation
bull Prochaskarsquos change theory
bull Precontemplation
ndashNot even thinking about quitting
ndashProvide education on the risks and costs of smoking
bull Contemplation
ndashAwareness that a problem exists
ndashContinue to find motivations to stop
NorcrossJC Krebs PM Prochaska JO(2011)
110
DOS CME Course 2011
Change is good
bull Determination
ndashExpressing willingness to act
ndashSelf-efficacy
bull Action ndash Currently not smoking
ndash May relapse
bull It is not unusual for a patient to ldquoquitrdquo three or four times
bull Continue to encourage and motivate himher to stop
NorcrossJC Krebs PM Prochaska JO(2011)
111
DOS CME Course 2011
Smoking cessationbull Assist the patient
ndashCollaborate with the patient to develop a plan to quit
ndashAchievable clearly defined goals
ndashIdentify and engage social supports
ndashFamily support groups
ndashPharmacologic (more on this later)
bull Arrange follow-up
ndashAt each successive visit review progress on quitting strategy
ndashLets the patient know heshe is not alone in this effort
ndashAccountability
112
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
Change is good
bull Determination
ndashExpressing willingness to act
ndashSelf-efficacy
bull Action ndash Currently not smoking
ndash May relapse
bull It is not unusual for a patient to ldquoquitrdquo three or four times
bull Continue to encourage and motivate himher to stop
NorcrossJC Krebs PM Prochaska JO(2011)
111
DOS CME Course 2011
Smoking cessationbull Assist the patient
ndashCollaborate with the patient to develop a plan to quit
ndashAchievable clearly defined goals
ndashIdentify and engage social supports
ndashFamily support groups
ndashPharmacologic (more on this later)
bull Arrange follow-up
ndashAt each successive visit review progress on quitting strategy
ndashLets the patient know heshe is not alone in this effort
ndashAccountability
112
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
What makes you tick
bull Assess and address individual motivation for smoking
bull Itrsquos a pick me up
bull It gives me something to do with my hands
bull Smoking relaxes me
bull It makes me feel better when Irsquom down
113
DOS CME Course 2011
But Irsquom smoking for two
bull Nicotine increases the risk of fetal death and heart abnormalities
bull Nicotine exposure associated with lower birth weights
bull Found in breast milk
bull Inhaling secondhand smoke associated with otitis media and upper respiratory tract infections
bull Exacerbates asthma
114
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
Smoking cessationbull Pharmacologic therapy
bull Nicotine replacementndash Provides controlled doses of the drug
ndash Prevents sudden withdrawal
ndash Multiple delivery systems ndashPatch gum lozenges nasal spray
bull Start with 2 mg dose
bull Chew until a peppery taste is released then hold the gum in the cheek for 30 minutes
bull Use with caution in patients with cardiovascular disease
115
DOS CME Course 2011
Smoking cessation
bull Buproprion hydrochloride (Zyban)
bull Thought slow the uptake of dopamine mimicking nicotine
ndashAlso used as an antidepressant (Wellbutrin)
ndashBegin one week before patient attempts to stop smoking
ndashCaution with history of seizures eating disorders or MAOIrsquos
bull A better option than NRT for those who continue to smoke
116
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
Strategizing
bull Collaborate with the patient to develop a customized strategy
bull Combine interventions for a multi-pronged approach
ndashNRT patch at night with gum daily to cover cravings
ndashPharmacologic therapy with behavior modification
117
DOS CME Course 2011
Smoking cessation
bull Varenicline (Chantix)ndash Binds nicotinic receptors which produces some of the same effect
as nicotine
ndash Blocks these receptors from nicotine
ndash Associated with mood changes
ndash Caution with elderly patients and those with impaired renal function
bull None of these medications promises success
bull Assess the patient regularly for side effects and success with their plan
118
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011DOS CME Course 2011119
Every Life Deserves World Class Care
Arterial Blood Gases
119
DOS CME Course 2011
Oxyhemoglobin dissociation curve
Kacmarek RM Stoller JK Current Respiratory Care Toronto Decker 1988)
120
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
What it means
bull Shift to the Right
ndashLow HgB affinity for O2
ndashMore O2 is unloaded for a given PaO2
ndashO2 delivery to the tissues is increased
ndashcaused by acidosis and increased temperature
bull Shift to the Left
ndashHigh HgB affinity for O2
ndashImpaired release of O2
at the tissue level
ndashO2 is transported by the blood but not released
ndashcaused by alkalosis and decreased temperature
121
DOS CME Course 2011
Pulse oximetry
bull Uses a beam of light through a finger earlobe
bull The light is selectively absorbed by hemoglobin depending on how many molecules of oxygen it carries
bull The result is displayed as a percentage of the total amount of available hemoglobin binding sites which are occupied by oxygen
122
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
Pulse oximetry
bull Pros
ndashNon-invasive
ndashPainless
ndashQuick results easily read
ndashInexpensive
ndashCan be done at home by the patient
bull Cons
ndashResults affected by skin color nail polish movement
ndashBaseline will vary with each patient
123
DOS CME Course 2011
Oxygen therapy
bull Joan is a 65-year old female who walks into your clinic complaining of ldquotrouble breathingrdquo and asks you to ldquogive me something so I can go to my grandsonrsquos birthdayrdquo
bull What more would you like to know ndash Physical assessment
ndash History
bull What is the first thing you would do
124
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
Hypercapnea
bull Defined as carbon dioxide level above 45 mmHg as measured by ABG
bull May produce acidosis
bull May be chronic in COPD patients ie CO2 retainers
bull Signs and symptoms include
ndashAltered mental status
ndashHeadache
ndashTachypnea
ndashLater stages lethargy stupor coma
125
DOS CME Course 2011
Arterial blood gases
bull Need to evaluate the ventilatory acid-base and oxygenation status
bull Need to quantify the patientrsquos response to therapeutic intervention
bull Hypoxemia- lower than normal oxygen in the bloodstream
ndashABG necessary to establish
bull Hypoxia- decreased availability of oxygen to the tissues
ndashCyanosis dusky
126
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
Arterial blood gases
bull pH= 735-745
bull PaCO2= 35-45 mmHg
bull PaO2= 80-100 mmHg
bull HCO3= 22-26 mmHg
bull Measurements reflect partial pressures of these gases as they are dissolved in the bloodstream
bull ldquoNormalrdquo values may vary slightly with different institutions
127
DOS CME Course 2011
Arterial blood gases
bull PaO2
ndashCheck this number first
ndashAmount of oxygen dissolved in the blood and available to the cells
ndashVariations with age and altitude
ndashFor every year over 60 years of age deduct 1 mmHg
ndashPersons with chronic respiratory disease can maintain lower levels
ndashImportant to know individual baselines
128
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
Arterial blood gases
bull SaO2
ndashReflected as a percentage of the bodyrsquos hemoglobin occupied by oxygen molecules
bull pH
ndashRefers to acid-base balance
ndashHigher number= more basic (alkaline)
ndashLower number= more acidic
129
DOS CME Course 2011
Arterial blood gases
bull HCO3
ndashBicarbonate reacts with acid
ndashActs as a buffer to increase pH
ndashControlled by the kidneys
ndashTakes days to change
bull PCO2
ndashCarbon dioxide is a by-product of aerobic respiration
ndashDissolves in water to form acid
ndashCO2 levels controlled by lungs
ndashRate and depth of respirations can change in minutes
130
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
Arterial Blood Gases
bull Acidosis ndash pHlt 735
bull Alkalosis ndash pHgt 745
131
DOS CME Course 2011
ABG
bull Compensation
ndashThe bodyrsquos response to a change in either CO2 or HCO3
ndashMaintains steady pH in the face of acid-base imbalance
bull The body will correct or compensate for an abnormal pH
bull If the pH is normal and both the CO2 and HCO3 are abnormal the condition is compensated
bull If the pH is abnormal and one value is normal while the other is abnormal the condition is uncompensated
132
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
Interpretation
bull A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak His roommate has just returned from a semester in Africa The patient had been observed admiring his roommates authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare)
bull ABG resultsndash pH=708
ndash CO2=80
ndash PaO2=37
ndash HCO3 = 26
133
DOS CME Course 2011
Interpretation
bull Is the patient acidotic or alkalotic
bull Acidotic
bull Is the imbalance compensated or uncompensated
bull Uncompensated
bull Is the cause respiratory or metabolic
bull Respiratory
bull Answer ndash Uncompensated respiratory acidosis
134
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
Causes of acid-base imbalance
bull Respiratory Acidosis
ndashHypoventilationndashRespiratory depression
ndashParalysis
ndashChest wall disorders
ndashSignsSymptomsndashDecreased LOC
ndashDysrhythmias
ndashPalpitations
ndashInterventionndashReversal agents
ndashMechanical Ventilation
bull Respiratory Alkalosis
ndashAlveolar Hyperventilation
ndashHypermetabolic statesndashEmotionalndashHypoxiaHigh altitudendashMechanical
overventilation
ndashSignsSymptomsndashHeadachendashVertigondashParesthesias
ndashTreatmentndashSedativesndashOxygenation
135
DOS CME Course 2011
Practice makes perfect 1 pH ndash 756pCO2 ndash 40HCO3 ndash 29pO2 ndash 82SaO2 ndash 955
3 pH ndash 756pCO2 ndash 23HCO3 ndash 19pO2 ndash 98SaO2 ndash 999
2 pH ndash 719pCO2 ndash 68HCO3 ndash 25pO2 ndash 54SaO2 ndash 842
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
136
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Nancy is a 20 year old college student While studying for final exams she took a bottle of ldquoNo-Dozerdquo to help her stay awake She experienced chest pain 30
minutes later She now presents to the ED with co CP Her ECG reveals Sinus Tachycardia ndash rate 155 without evidence of ST-T wave changes Her breathing is
rapid and deep No diaphoresis or pallor noted _______
Case Study 1Case Study 1
4 pH ndash 745pCO2 ndash 27HCO3 ndash 19pO2 ndash 78SaO2 ndash 911
137
DOS CME Course 2011
1 pH ndash 756
pCO2 ndash 40
HCO3 ndash 29
pO2 ndash 82
SaO2 ndash 955
2 pH ndash 719
pCO2 ndash 68
HCO3 ndash 25
pO2 ndash 54
SaO2 ndash 842
4 pH ndash 745
pCO2 ndash 27
HCO3 ndash 19
pO2 ndash 78
SaO2 ndash911
3 pH ndash 756
pCO2 ndash 23
HCO3 ndash 19
pO2 ndash 98
SaO2 ndash 999
Shellie is a patient in the CTICU After her open heart surgery (9 days ago) she developed severe pancreatitis She was on tube feeds for 4 days but
those have now been stopped and she has been started on TPN with lipids Her amylase and lipase are lower for the first time in 5 days She does have
an NG to intermittent wall suction which continues to discharge about 600 cc bilious drainage q 12h An ABG is obtained ____
Case Study 3Case Study 3
138
DOS CME Course 2011DOS CME Course 2011139139
DOS CME Course 2011DOS CME Course 2011139139