PATHOPHYSIOLOGY OF EMPHYSEMA

PATHOPHYSIOLOGY OF EMPHYSEMA

A 73 year old man was admitted to the hospital complaining of having shortness of breath. The patient verbalizes having the feeling of not getting your breath out. Patient describes that at first, he experiences dyspnea only after activities but now it occurs even without physical exertion. The wife of the client shared that the patient worked at a quarry in Lucena. Client has a history of smoking 2 packs of cigarette daily, weight loss and mild chronic cough. Upon assessment, client was found to have an enlarged chest, hyperresonant sounds were heard upon percussion and decreased breath sounds were heard upon exhalation of the patient. Also, client uses accessory muscles when breathing. His review of systems showed positive signs for slight clubbing of the fingers Chest x-ray results were indicative of emphysema. RR= 40 cpm; PR= 102 bpm; T= 37.3°C; BP= 150/90 mmHg

II. PATHOPHYSIOLOGY OF EMPHYSEMA

III. DIAGNOSTIC PROCEDURES AND LABORATORY ANALYSIS

Chest PA
– Hyperlucent lung field
– Multiple blebs
– Avascular zones
– Prominent pulmonary arteries
– Radiologic TLC

Impression
Hyperinflation, suggestive of emphysema

Right Lateral Decubitus
– Hyperlucent lung fields
– AP diameter increased
– Flat diaphragms
– Multiple blebs
– Retrosternal and infracardiac air
– Radiologic TLC

Interpretation:

Chest x-ray showed increase in antero-posterior diameter, flat diaphragms and hyperlucent lung fields. All impressions were indicative of hyperinflation of lungs, suggesting the presence of emphysema on patient.

CBC Results

Normal Values
Results
Interpretations
Hgb
12-14 g/dL
16.4 g/dL
Erythrocytopenia
Hct
0.38-0.48
0.54
Erythrocytopenia
WBC
5-10 x 10 9/L
10.7 x 10 9/L
Tissue damage, Infection
Segmenters
36-66 %
63%
Normal
Lymphocytes
30-40%
32%
Normal

Interpretation:

RBC count is higher than normal. Erythrocytopenia may be resulted from the body’s compensatory mechanism to cope with the body’s need for oxygen. COPD patients, especially those with emphysema, often cannot get enough air into the lungs due to the damage. To cope with the decreased oxygen, the body reacts by producing more red blood cells to try to increase the amount of oxygen in the blood.
The slight increase in WBC may be suggestive of infection due to lung tissue damage or it may be caused by severe emotional distress felt by the patient brought about by the condition.

ABG Test

ABG RESULTS
pH
7.48
pCO2
48 mmHg
pO2
78 mmHg
HCO3
23 mEq/L

Interpretation:

Low Oxygen levels show hypoxemia while high levels of Carbon dioxide show hypercapnia because of carbon dioxide retention resulting from the ineffective exchange of gas in the lungs as a manifestation of the damaged alveolar walls brought by the condition of the patient. Slightly higher than normal pH manifests the possible start of respiratory acidosis.

Pulmonary Function Test

LOWER LIMIT OF NORMAL
PATIENT’S VALUE
% OF PREDICTED
Forced vital capacity (FVC)
2.07 L
2.63 L
96%
Forced expiratory volume
in 1 second (FEV1)
1.80 L
1.64 L
70%
FEV1/FVC ratio
68.3%
81.7%

Forced expiratory time (FET)

8.13 sec

Residual volume (RV)
1.30 L
1.77 L
85%
Total lung capacity (TLC)
3.77 L
4.01 L
83%
Diffusing capacity (DLCO)
16.4 mL/min/mm Hg
9.29 mL/min/mm Hg
43%
Adjusted diffusing capacity (DLVA)
3.34 mL/min/mm Hg/L
2.65 mL/min/mm Hg/L
59%

Interpretation:

Pulmonary function tests include Forced Vital Capacity (FVC) and Forced Expiratory Volume in 1 second (FEV1).
The FVC is the maximum amount of air that can be forcibly exhaled after maximal inspiration. In a normal adult, exhalation time should take 4 to 6 seconds.
Patients with COPD, especially emphysema, need more time to exhale, which decreases FEV1 and FVC. Lung volume measurements show a marked increase in residual volume and an increase in total lung capacity.

IV. MEDICAL- SURGICAL MANAGEMENT
MEDICAL MANAGEMENT
* Improve Ventilation.
-Bronchodilators to reduce airway obstruction and may relieve manifestations. Usually administered via inhalation.
-Beta2 agonists are the most frequently prescribed. They act to smooth muscles of the airways and cause bronchodilation.
-Anticholinergic agents offer greater effect and fewer side effectthan short acting beta2 agonists. Ipratropium bromide is the most commonly used drug in this category.
-Methylxanthines are also used to treat acute exacerbations. In addition to bronchodilatory properties, they also enhance mucociliary clearance, stimulate the central respiratory drive, reduce pulmonary vascular resistance and improve lung function during sleep.
-Corticosteroids are used for acute exacerbations. They appear to work by reducing airway inflammation and edema while also inhibiting the breakdown of epinephrine, thereby potentiating the bronchodilatory effect of catecholamines.
-Oxygen is used cautiously in patients with emphysema, however. Because of long-standing hypercapnia, the respiratory drive in emphysematous clients is triggered by low levels of oxygen rather than increased carbon dioxide levels.

* Promote Exercise.
Aerobic exercise is used to enhance cardiovascular fitness and to train respiratory muscles to function more effectively.
Breathing exercises may also be prescribed. Encourage diaphragmatic breathing and pursed-lip breathing, and discourage rapid, shallow panic breathing.

* Control Complications.
Edema and Cor Pulmonale are treated with diuretics and digitalis.

* Improve General Health.
-Stop smoking.
-Adequate nutrition.

* Education.
-Educate patient and patient’s significant others about the disease. Signs and symptoms and hat to look out for.
* Support.
-Provide encouraging words and support.

SURGICAL MANAGEMENT

Surgery is relatively uncommon in the treatment of emphysema. Lung volume-reduction surgery may provide palliative relief for selected COPD clients. In this procedure, portions of diffusely emphysematous lungs are removed to help restore more normal chest-wall configuration and to improve respiratory mechanics and functional capacity.
Lung volume reduction surgery (LVRS) is a procedure which removes approximately 20-35% of the poorly functioning, space occupying lung tissue from each lung. By reducing the lung size, the remaining lung and surrounding muscles (intercostals and diaphragm) are able to work more efficiently. This makes breathing easier and helps patients achieve greater quality of life.

V. NURSING MANAGEMENT

-Get complete and thorough assessment of the patient.
-Monitor closely for signs of distress.
-Encourage client to live an active life and exercise.
-Vital signs monitoring.
-Provide comfort to client.
-Position client in semi-fowler’s position o facilitate effective breathing.
-Provide client’s needs.
-If patient underwent surgery, monitor closely ABG’s values.
-Assess chest tubs for air leaks and drainage.
-Provide chest physiotherapy.
-Provide adequate ventilation.
-If patient, experiences pain, manage aggressively to promote activity and pulmonary hygiene.
-Assist patient during ROM exercises.
-Educate patient about the disease.

VI. NURSING CARE PLANS

Pamantasan ng Lungsod ng Maynila
University of the City of Manila
Intramuros, Manila

In partial completion
of the requirements
in
Medical-Surgical Nursing I