DISEASE (COPD) AND ASTHMA
a. Chronic obstructive pulmonary disease (COPD): chronic
obstructive bronchitis and emphysema
i. Chronic airflow limitations (CAL): caused by a mixture
of small airway disease (obstructive bonchiolitis) and
parenchymal destruction (emphysema)
ii. Airway inflammation: causes structural changes, narrowing
of lumina, and loss of elastic recoil in parenchyma
b. Asthma (also called chronic reactive airway disease)
i. Chronic inflammatory disorder—episodic exacerbations
of reversible inflammation and hyperreactivity and
variable constriction of bronchial smooth muscle,
hypersecretion of mucus, and edema
II. Spirometric Classification of Severity of COPD—2007
Global Initiative for Chronic Obstructive Lung Disease
a. Stage I (mild COPD)—mild airflow limitation (FEV1/FVC
0.70; FEV1 to 80% predicted)
b. Stage II (moderate COPD)—worsening airflow limitation
(FEV1/FVC 0.70; 50% to FEV1 80% predicted);
shortness of breath on exertion, and cough and sputum
production may be present
c. Stage III (severe COPD)—continued worsening of airflow
limitation (FEV1/FVC 0.70; 30% to FEV1 50%
predicted); increasing shortness of breath, reduced exercise
capacity, fatigue, and repeated exacerbations
d. Stage IV (very severe COPD)—severe airflow limitation
(FEV1/FVC 0.70; FEV1 30% predicted or FEV1
50% predicted plus presence of chronic respiratory
i. Risk factors: smoking (primary irritant), air pollution,
secondhand smoke, history of childhood respiratory
infections, heredity— 1-antitrypsin deficiency
ii. Acute exacerbations usually due to pulmonary infections
i. Tends to be acute and intermittent or episodic
ii. Genetic and environmental: household substances (such
as dust mites, pets, cockroaches, mold), pollen, foods,
latex, emotional upheaval, air pollution, cold weather,
exercise, chemicals, medications, viral infections
IV. Statistics (American Lung Association, 2006, 2007a;
National Heart, Lung and Blood Institute [NHLBI], 2008b)
i. Morbidity: COPD affects more than 12 million people.
ii. Mortality: It is the fourth leading cause of death in the
United States with 122,000 deaths in 2003; women’s
deaths exceed that of men (63,000 females to 59,000
iii. Cost: $37.2 billion is spent each year.
i. Morbidity: Asthma is most common chronic disorder in
children, affecting 6.8 million under age 18; affects
15.4 million adults.
ii. Cost: $14.7 billion is spent each year.
Primarily community level; however, severe exacerbations
may necessitate emergency or inpatient hospital stay
1. Maintain airway patency.
2. Assist with measures to facilitate gas exchange.
3. Enhance nutritional intake.
4. Prevent complications and slow progression of condition.
5. Provide information about disease process, prognosis,
and treatment regimen.
1. Ventilation/oxygenation adequate to meet self-care needs.
2. Nutritional intake meeting caloric needs.
3. Infection treated or prevented.
4. Disease process, prognosis, and therapeutic regimen
5. Plan in place to meet needs after discharge.
NURSING DIAGNOSIS: ineffective Airway Clearance
May be related to
Increased production of secretions, retained secretions, thick, viscous secretions
Decreased energy or fatigue
Possibly evidenced by
Statement of difficulty breathing
Changes in depth and rate of respirations, use of accessory muscles
Abnormal breath sounds such as wheezes, rhonchi, crackles
Cough (persistent), with or without sputum production
Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: Airway Patency
Maintain patent airway with breath sounds clear or clearing.
Demonstrate behaviors to improve airway clearance.
Auscultate breath sounds. Note adventitious breath sounds
such as wheezes, crackles, or rhonchi.
Assess and monitor respiratory rate. Note inspiratory-toexpiratory
Note presence and degree of dyspnea, for example, reports of
“air hunger,” restlessness, anxiety, respiratory distress, and
use of accessory muscles. Use a 0 to 10 scale or American
Thoracic Society’s Grade of Breathlessness Scale to rate
breathing difficulty. Ascertain precipitating factors when
possible. Differentiate acute episode from exacerbation of
Assist client to maintain a comfortable position to facilitate
breathing by elevating the head of bed, leaning on or over
bed table, or sitting on edge of bed.
Keep environmental pollution from sources such as dust,
smoke, and feather pillows to a minimum according to
Encourage and assist with abdominal or pursed-lip breathing
Observe for persistent, hacking, or moist cough. Assist with
measures to improve effectiveness of cough effort.
Increase fluid intake to 3,000 mL/day within cardiac tolerance.
Provide warm or tepid liquids. Recommend intake of fluids
between, instead of during, meals.
Administer medications, as indicated, for example:
Beta-agonists, such as epinephrine (Adrenalin,
AsthmaNefrin, Primatene, Sus-Phrine), albuterol (Proventil,
Velmax, Ventolin, AccuNeb, Airet), formoterol (Foradil), levalbuterol
(Xopenex); metaproterenol (Alupent), pirbuterol
(Maxair), terbutaline (Brethine), and salmeterol (Serevent)
Bronchodilators, such as anticholinergic agents: ipratropium
Leukotriene antagonists, such as montelukast (Singulair),
zafirlukast (Accolate), and zileuton (Zyflo)
Anti-inflammatory drugs: oral, intravenous (IV), and inhaled
steroids, such as prednisone (Cordrol, Deltasone, Pred-
Pak, Liquid Pred), methylprednisolone (Medrol), dexamethasone
(Decadron), beclomethasone (Beclovent,
Vanceril), budesonide (Pulmacort), fluticasone (Flovent),
and triamcinolone (Azmacort)
Methylxanthine derivatives, such as aminophylline, oxtriphylline
(Choledyl), and theophylline (Bronkodyl, Theo-
Dur, Elixophyllin, Slo-Bid, Slo-Phyllin)
Analgesics, cough suppressants, or antitussives, such as
codeine and dextromethorphan products (Benylin DM,
Artificial surfactant such as colfosceril palmitate (Exosurf)
Provide supplemental humidification, such as ultrasonic
nebulizer and aerosol room humidifier.
Assist with respiratory treatments, such as spirometry and
Monitor and graph serial ABGs, pulse oximetry, and chest x-ray.
Some degree of bronchospasm is present with obstructions in
airway and may or may not be manifested in adventitious
breath sounds, such as scattered, moist crackles (bronchitis);
faint sounds, with expiratory wheezes (emphysema); or
absent breath sounds (severe asthma).
Tachypnea is usually present to some degree and may be pronounced
on admission, during stress, or during concurrent
acute infectious process. Respirations may be shallow and
rapid, with prolonged expiration in comparison to
Respiratory dysfunction is variable depending on the underlying
process; for example, infection, allergic reaction, and
the stage of chronicity in a client with established COPD.
Note: Using a scale to rate dyspnea aids in quantifying and
tracking changes in respiratory distress. Rapid onset of
acute dyspnea may reflect pulmonary embolus.
Elevation of the head of the bed facilitates respiratory function
using gravity; however, client in severe distress will seek
the position that most eases breathing. Supporting arms
and legs with table, pillows, and so on helps reduce muscle
fatigue and can aid chest expansion.
Precipitators of allergic type of respiratory reactions that can
trigger or exacerbate onset of acute episode.
Provides client with some means to cope with and control
dyspnea and reduce air-trapping.
Cough can be persistent but ineffective, especially if client is
elderly, acutely ill, or debilitated. Coughing is most effective in
an upright or in a head-down position after chest percussion.
Hydration helps decrease the viscosity of secretions, facilitating
expectoration. Using warm liquids may decrease
bronchospasm. Fluids during meals can increase gastric
distention and pressure on the diaphragm.
Inhaled 2-adrenergic agonists are first-line therapies for rapid
symptomatic improvement of bronchoconstriction. These
medications relax smooth muscles and reduce local
congestion, reducing airway spasm, wheezing, and mucus
production. Medications may be oral, injected, or inhaled.
Inhalation by metered-dose inhaler (MDI) with a spacer is
recommended, but medications may be nebulized in the
event client has severe coughing or is too dyspneic to puff
Inhaled anticholinergic agents are now considered the first-line
drugs for clients with stable COPD because studies indicate
they have a longer duration of action with less toxicity
potential, whereas still providing the effective relief of the
beta-agonists. Some of these medications are available in
combinations; for example, albuterol and Atrovent are
available as Combivent.
Reduce leukotriene activity to limit inflammatory response.
In mild to moderate asthma, reduces need for inhaled
2-agonists and systemic corticosteroids. Not effective in
acute exacerbations because there is no bronchodilator
effect. Note: This drug class is not recommended for clients
with COPD because of insufficient testing.
Decrease local airway inflammation and edema by inhibiting
effects of histamine and other mediators to reduce severity
and frequency of airway spasm, respiratory inflammation,
and dyspnea. Studies have shown benefits of systemic
steroids in the management of COPD exacerbations. Inhaled
steroids may serve as a systemic steroid-sparing agent.
Note: The aim of inhaled corticosteroids is to reduce exacerbation
rates and slow decline in health status. Maintenance
use of oral corticosteroids is not recommended unless
absolutely necessary. Clients must be monitored for osteoporosis
as a side effect. Clients over age 65 should be
treated prophylactically to prevent osteoporosis.
Various antimicrobials may be indicated for control of bacterial
exacerbations of COPD, such as pneumonia. (Refer to CP,
Decrease mucosal edema and smooth muscle spasm
(bronchospasm) by indirectly increasing cyclic adenosine
monophosphate (AMP). May also reduce muscle fatigue and
respiratory failure by increasing diaphragmatic contractility.
Use of theophylline may be of little or no benefit in the presence
of adequate beta-agonist regimen; however, it may sustain
bronchodilation because effect of beta-agonist diminishes
between doses. Note: Theophylline products are used with
less frequency now and are not recommended in older clients
because of their potentially adverse cardiovascular effects.
Persistent, exhausting cough may need to be suppressed to
conserve energy and permit client to rest. Note: Regular
use of antitussives is not recommended for COPD clients as
cough can have a significant protective effect.
Research suggests aerosol administration may enhance
expectoration of sputum, improve pulmonary function, and
reduce lung volumes (air-trapping).
Humidity helps reduce viscosity of secretions, facilitating
expectoration, and may reduce or prevent formation of
thick mucous plugs in bronchioles.
Breathing exercises help enhance diffusion; aerosol or nebulizer
medications can reduce bronchospasm and stimulate
expectoration. Postural drainage and percussion enhance
removal of excessive and sticky secretions and improve
ventilation of bottom lung segments. Note: Chest physiotherapy
may aggravate bronchospasm in asthmatics.
Establishes baseline for monitoring progression or regression
of disease process and complications. Note: Pulse
oximetry readings detect changes in saturation as they are
happening, helping to identify trends possibly before client
is symptomatic. However, studies have shown that the
accuracy of pulse oximetry may be questioned if client has
severe peripheral vasoconstriction.