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Patient Safety / Quality

Taking action against acute COPD

Like most nurses, you’ve probably cared for many patients with chronic obstructive pulmonary disease (COPD). This umbrella term denotes a group of conditions—emphysema, chronic bronchitis, and in some cases, asthma—associated with an abnormal inflammatory response and severe pulmonary airflow obstruction. The condition progresses slowly and isn’t fully reversible; no known cure exists.

Many COPD patients experience acute exacerbations requiring emergency treatment and sometimes hospitalization. Tracheobronchial infection and air pollution are the most common causes of exacerbations, but about one-third of the time, the cause can’t be identified. COPD accounts for about 1.5 million emergency department visits by adults ages 25 and older.
A thorough understanding of COPD and its treatment helps you provide the most effective patient care. Up-to-date knowledge of the disease and appropriate medical treatment and nursing interventions can improve patient outcomes and quality of life. This article discusses management of patients who’ve been hospitalized for acute COPD exacerbations.

The vast toll of COPD
More than 14 million people in the United States have COPD. A leading cause of chronic illness, disability, and death, COPD resulted in 119,000 deaths and 726,000 hospitalizations in 2000. The total cost of the disease was estimated at $32 billion in 2002.

COPD is the fourth leading cause of death in the United States and is expected to become the third leading cause by 2020. COPD deaths have been increasing, while deaths from coronary artery disease and stroke have been declining.

COPD is now equally prevalent in men and women. Although once associated largely with elderly populations, it’s increasingly prevalent among middle-aged adults.

Risk factors and assessment
Cigarette smoking is the leading COPD risk factor. Other risk factors include exposure to occupational and environmental pollutants and childhood respiratory infections. Alpha-1-antitrypsin deficiency is the best documented genetic risk for developing COPD. This deficiency may predispose some persons to emphysema and may be a factor in causing emphysema in people who’ve never used tobacco or who develop the illness at an early age.

General signs and symptoms of COPD include cough, excessive mucus production, and shortness of breath on exertion. During exacerbations, fever, purulent sputum, increased cough, and increased shortness of breath may occur.

Treating acute exacerbations
For patients hospitalized with acute COPD, treatment may entail behavior therapy, pulmonary rehabilitation, medical or surgical interventions, and education. Medical treatment is essential and may involve bronchodilators, inhaled glucocorticoids, oxygen therapy, and antibiotics.

Bronchodilators improve symptoms and functional status in COPD patients. They fall into two broad categories:

• beta-agonists, which relax and open the airways by causing smooth-muscle relaxation
• anticholinergics, which block acetylcholine (a chemical that normally causes the airways to contract) and decrease mucus production.

Exacerbations usually necessitate an increased dosage or dosing frequency of the bronchodilator, which may be given every 2 to 3 hours. Beta-agonists and anticholinergics also may be given to increase the bronchodilatory effect.

Drug delivery devices vary. To provide education and assess the patient’s ability to self-administer the drug effectively, make sure you’re familiar with the appropriate delivery device.

Inhaled glucocorticoids are recommended for patients with repeated exacerbations or whose forced expiratory volume1 (FEV1) is less than 50% of the predicted value. FEV1 is the volume of air forced out of the lungs in the first second of exhalation after a maximal inspiration. During an exacerbation, glucocorticoids initially may be given I.V. and later switched to the oral form.
The dosage must be tapered before discontinuation. Although no standard tapering protocol exists, a treatment course commonly spans 10 to 14 days.

Oxygen therapy
Long-term oxygen therapy increases survival in COPD patients with chronic respiratory failure. Supplemental oxygen improves hemodynamics, exercise endurance, lung mechanics, and mental status.

During an exacerbation, oxygen therapy is adapted to the patient’s condition. Obtain an arterial blood gas sample to evaluate the patient’s arterial oxygenation, carbon dioxide (CO2) level, and acid-base balance. Oxygen delivery must be regulated to avoid increased CO2 levels and acidosis.

As the patient stabilizes, measure room air oxygen saturation (O2 Sat) before and after activity. If O2 Sat is below 90% within 48 hours of the planned discharge, the patient’s eligibility for home oxygen therapy should be evaluated.

Antibiotic therapy
If your patient shows signs of bacterial infection, expect to administer oral or I.V. antibiotics. Signs and symptoms of bacterial infection may include increased dyspnea, sputum production, and sputum purulence.

To prevent exacerbations, COPD patients should receive appropriate vaccinations. Administering the influenza vaccine may reduce serious illness and death by nearly 50%.

Behavior therapy
Behavioral therapy is a key component of COPD treatment. Smoking cessation is the most effective way to prevent COPD or slow its progression. Provide counseling regarding smoking cessation with every hospitalization.

Pulmonary rehabilitation
Pulmonary rehabilitation programs are designed to optimize the patient’s physical and social performance. Goals include improving physical endurance and respiratory muscle strength, easing symptoms, and improving quality of life.

Tailored to each patient, these multidisciplinary programs teach COPD patients about the disease process, self-care, exercise, medications, and proper nutrition. They focus on lower and upper extremity exercise and conditioning, breathing retraining, education, and psychosocial support.

In hospital settings, pulmonary rehabilitation typically involves the use of special breathing techniques, a flutter valve, and incentive spi­rometry to mobilize pulmonary secretions and improve respiratory effort.

Before discharge from an acute-care setting, the patient should be evaluated for eligibility for outpatient pulmonary rehabilitation.

Surgical treatment
Reserved for patients with severe COPD, surgery may involve:

• bullectomy (removal of distended, nonfunctional pulmonary air spaces)
• lung volume reduction surgery (removal of certain lung portions)
• lung transplantation.

Ventilatory support
Although ventilatory support hasn’t been proven effective in routine management of stable COPD, evidence suggests noninvasive mechanical ventilation helps during acute exacerbations in patients with hypercapnea (elevated CO2 and blood pH below 7.35). This type of ventilation reduces the work of breathing, improves ventilation, decreases the respiratory rate, increases tidal volume, boosts oxygenation, reduces acidosis, and decreases mortality rates. Expected patient outcomes include decreased length of stay in the intensive care unit and decreased incidence of infection.

Noninvasive ventilation is delivered by a nasal or face mask—usually in the form of bilevel positive airway pressure (BIPAP) or continuous positive airway pressure (CPAP).

• BIPAP provides continuous high-flow positive pressure, which cycles between high positive pressure during inhalation and lower positive pressure during exhalation.
• CPAP provides continuous high-flow positive pressure set at a constant pressure.

As the underlying condition improves, use of the ventilation device is decreased. Once the patient’s condition stabilizes, ventilatory support is discontinued. Patients who need ventilator but don’t respond to noninvasive mechanical ventilation may require intubation.

Supporting your patient as COPD progresses
Despite high-quality care, COPD patients gradually progress toward the end stages of the disease. Over time, they may require more frequent hospital stays and may have shorter intervals between exacerbations.

Yet, despite this inevitable decline, your expertise and knowledge regarding COPD assessment and management can enhance your patient’s survival and improve quality of life. Inform patients that with proper care, the disease can be managed and its progress can be slowed. Provide emotional support to the patient and family and, as appropriate, refer them for counseling.

Selected references

American Thoracic Society. ATS statement: pulmonary rehabilitation—1999. Am J Respir Crit Care Med. 1999:159:1673.

Braman, S. Update on the ATS guidelines for COPD. Medscape Pulmonary Medicine. 2005;
9(1). Available at: www.medscape.com/viewarticle/498648. Accessed October 14, 2006.

Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of COPD; GOLD executive summary (2005 update). Available at: www.goldcopd.com/Guidelineitem.asp?l1=2&l2=1&intId=996. Accessed September 28, 2006.

Huang M, Singer LG. Surgical interventions for COPD. Geriatrics Aging. 2005;8(3):40-46.

National Heart, Lung, and Blood Institute. Morbidity and Mortality: 2004 Chartbook on Cardiovascular, Lung, and Blood Diseases. Available at: www.nhlbi.nih.gov/resources/docs/cht-book.htm. Accessed September 28, 2006.

Mary Lou Warren, MSN, RN, CNS-CC, CCRN, is a Clinical Nurse Specialist in the Intensive Care Unit at MD Anderson Cancer Center in Houston, Tex. Sarah Livesay, BSN, RN, is Neuroscience Outcomes Manager at St. Luke’s Episcopal Hospital in Houston.

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