As a registered nurse working as a case manager within the home health care setting, I have had the opportunity to provide care to patients diagnosed with various respiratory disorders. A majority of the patients I have worked with were diagnosed with chronic obstructive pulmonary disease (COPD). COPD is defined as a common preventable and treatable disease characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases (Huether, 2017). Two important facts regarding this respiratory disorder include the following:
- COPD is the third leading cause of death in the United States accounting for 138,080 deaths in 2010.
- In 2010, the cost of COPD in the United States was estimated to be nearly $50 billion, including nearly $30 billion in direct health care expenditures.
These figures detail the staggering numbers of patients living with COPD and the significant impact on patients, families, communities and the health care system.
During the time that I worked with COPD patients, one of the respiratory disorders of particular interest was emphysema. I wanted to make sure I understood the disease process so I could provide the most appropriate care and teaching to my patients, families and caregivers. Emphysema is abnormal permanent enlargement of gas-exchange airways (acini) accompanied by destruction of alveolar walls without obvious fibrosis (Huether, 2017). Furthermore, the American Lung Association defined emphysema as the gradual damage of lung tissue, specifically thinning and destruction of the alveoli or air sacs (www.lung.org). I often used this definition with patients to help them understand how this respiratory disorder effects the body. The pathophysiology of emphysema includes the following:
- Air sacs are destroyed in emphysema, making it progressively difficult to breathe.
- Emphysema is usually accompanied by chronic bronchitis, with almost-daily or daily cough and phlegm.
- Cigarette smoking is the major cause of emphysema.
- People with emphysema experience shortness of breath with activities
- It is not curable, but there are treatments that can help you manage the disease (www.lung.org).
Medication management of emphysema varies depending upon severity of the disease. Initial drug therapy selection depends on COPD severity, symptoms, and exacerbation risk. In addition, medication therapy may be based upon Global Obstructive Lung Disease (GOLD) guidelines which categorized COPD into four groups (A, B, C, D) ranging from low risk, less symptoms to high risk, high symptoms (Arcangelo, 2017). Medications may include the following:
- Short-acting beta2 agonists, short-acting anticholinergics, combination of short-acting anticholinergic and short-acting beta2-adrenergic agonists, long-acting beta2-agonists, long-acting anticholinergics, combination long-acting anticholinergic and long-acting beta2-agonists, combination long-acting beta2-agonists and corticosteroids, oral corticosteroids, methylxanthines, phosphodiesterase 4 inhibitors.
- All persons with COPD should receive an annual influenza vaccine.
- Some patients may also require oxygen therapy.
All persons with COPD need first line therapy which includes at least one short-acting bronchodilator for self-management of acute symptoms. In addition, second-line therapy is based upon GOLD recommendations depending upon the group (A, B, C, D) classification of each patient’s health status and disease progression.
Nondrug therapy includes tobacco cessation, avoidance of environmental and occupational irritants, and energy conservation. A variety of drug and nondrug therapies are available for tobacco cessation. All health care professionals should ask every patient at every encounter about tobacco smoking and then advise, assess, assist, and arrange for smoking cessation interventions as appropriate. Outdoor exercise and exertion should be avoided when pollution levels are high or temperatures are extreme.
Ethnicity was the factor reviewed to identify if it had an impact on the pathophysiological process related to emphysema and treatment with prescription medications. One article noted that the factor of ethnicity has a significant impact on COPD and the effects of prescribed drugs.
- Socioeconomic status (SES) has an important influence on health and longevity. Studies indicate that race – ethnicity and SES have important impacts on adult asthma outcomes.
- The effects of race – ethnicity and SES on health outcomes in chronic obstructive pulmonary disease (COPD), however, have not been well characterized
- Lower SES was strongly linked with poorer COPD outcomes across all measured domains among subjects who had broad access to healthcare.
- Black race was related to greater COPD severity, but this was entirely explained by SES and other covariates.
- Black race was associated with poorer exercise performance and lower extremity function, even after controlling for SES.
- Clinicians, researchers and public health professionals should consider race – ethnicity as an important factor in COPD (Eisner, 2011).
In addition, it was noted that culturally specific beliefs regarding cause of disease, acceptance of
acute or chronic medications, medication color, dosage formulation, and route of administration may influence a person’s acceptance and adherence to the prescribed drug and nondrug therapy (Arcangelo, 2017). It is important that nurses respect the values, thoughts, concerns of all patients regardless of ethnic differences.
As a nurse providing care to the patient, it is imperative to perform a thorough patient health assessment, communicate and coordinate care with other interdisciplinary team members. Furthermore, nurses need to understand the disease process to effectively provide care and teaching to patients to help decrease complications. As stated previously, patient teaching is essential. Advise persons with COPD to avoid medications that suppress the respiratory system, including first-generation antihistamines, cough suppressants, narcotics, and tranquilizers (Arcangelo, 2017. Moreover, instruct patients onto stop smoking, take medications as prescribed, energy conservation, oxygen safety (if used), maintaining medical appointments
Arcangelo, V. P., Peterson, A. M., Wilbur, V. & Reinhold, J. A. (Eds.). (2017).
Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA:
Lippincott Williams & Wilkins.
Eisner, M.D., Blanc, P.D., Omachi, T.A., Yelin, E.H., Sidney, S., Katz, P.P., Ackerson, L.M.,
Sanchez, G., Tolstykh, I., and Iribarren, C. (2011). Socioeconomic status, race and COPD
health outcomes. Journal of Epidemiology & Community Health, 65(1), 26-34.
Huether, S. E., & McCance, K. L. (2017). Understanding pathophysiology (6th ed.). St. Louis,