Introduction
In all patients with COPD, a careful history including smoking, family history, previous respiratory symptoms, childhood illnesses and any atopic features should be made to help to confirm the diagnosis and to rule out other possible diagnoses. Close questioning about a patients ability to perform particular task’s is needed, including how long they need to perform task’s in comparison with the time needed 2, 3 or 5 years ago. Questioning of relatives, friends and partners is also used as other people often appreciate any changes in the patient more easily than the patient themselves. Any changes in functional abilities are good markers of deterioration (Bellamy & Brooker, 23-32)”. Symptoms that change little from day to day are more likely to be COPD related than to asthma. Night time symptoms are more commonly associated with asthma (Levey, Hilton & Barns, 160-61)”.
Tests of Function
Exercise can be used to test the respiratory and cardiovascular responses to the stress of increased oxygen demands. (Mannino, 89-93) There are several tests that can be carried out, each designed to suit patients at differing levels of mobility. The two most commonly used on our ward were the six-minute walk and the shuttle walk. Each patient is different and may have disorders not associated with COPD that still affect their mobility, it is important to understand that results from any of the tests cannot be standardized and rely on the skill of the nurse doing the assessment.
The six-minute walk measures the distance a patient can walk in six minutes, indoors, on the flat. The patient does a practice walk first to give them confidence, measurements are taken on the second walk. The patients are actively encouraged throughout and rests are allowed. In the shuttle test the patient performs a paced walk between two points at either end of the ward, 10 m apart. Like the multi stage fitness test used on athletes, the pace of the walk is dictated by a series of beeps at either end of the shuttle increasing the speed gradually. The patient continues until forced to stop through breathlessness, the number of shuttles completed is then recorded.
Scales of Breathlessness
Breathlessness is a subjective feature, but it is important to quantify this because improvement of breathlessness is one of the most important ways of seeing whether treatment is working. There are several scales for assessing it objectively. The Medical Research Council (MRC) dyspnoea scale allows patients to rate their breathlessness according to the activity that induces it. It is graduated from 0 to 5. Whist the MRC scale is helpful and easy to use, it is relatively insensitive to change and may be more valuable as a baseline assessment rather than as a tool for measuring the effects of a treatment.
Other scales allow patients to grade their breathless according to the intensity of the sensation. The Borg scale is useful for measuring short-term changes in intensity of breathlessness during a particular task. It is both sensitive and reproducible (Siafakas, Vermeire & Pride 1398-1420). A simple visual analogue scale is another method of allowing patients to rate the intensity of their breathlessness. (Tinkelman, 879-84) As with the oxygen cost diagram, a 10 cm line is drawn on a page and the patient them marks on the line how intense their breathlessness is, from 0 cm (breathing normally) to 10 cm (intensely breathless) the score is the length along the line.
Physical Examination
In the early stages of COPD the results of physical examination are normal. Patients with more severe COPD may have breathlessness at rest, increasing with exertion; in later stages breathlessness is easily apparent at rest, becoming more severe with any exertion. At first respirations have a prolonged expiratory phase becoming more pronounced with increasing severity, when pursed lips and fixed shoulder girdles can be seen, together with the use of accessory muscles for breathing.
Chest Radiography
Chest radiography is not routinely required in the management or diagnosis of COPD. It is not useful to assess the severity or progression of COPD. However initial radiography may help in the diagnostic process, especially because other intra-thoracic diseases may produce clinical features similar to COPD. Lung cancer is common in middle and old aged smokers and may manifest with cough and breathlessness. If bullous emphysema is suspected on chest radiography, computer tomography (CT) will confirm its presence (Bradget & Tanaka, 466-72).
Spirometry and Lung Function
Measuring lung function to determine the presence and severity of airflow obstruction in COPD is as fundamental as measuring blood pressure to detect and monitor hypertension. (Osman, 33-36) The preferred and recommended lung function test is spirometry, which provides indications not only of airflow, but also lung volume. (Booker, 11-13) It has been encouraged that any area treating a large number of COPD patients obtain a spirometer.
Although our ward doesn’t have its own spirometry, one is always accessible when needed. (Jeffery, 18-21) In simple terms spirometry measures two parameters – airflow from fully inflated lungs and the total volume of the air that can be exhaled from maximum inhalation to maximum exhalation using maximum force to blow all the air out as hard and as fast as possible. In a healthy individual this forced expiratory maneuver can normally be completed in three to four seconds, but with increasing airflow obstructions it takes longer to push all the air out of the lungs. In severe COPD sufferers it can take up to 16 seconds. (Gosselink, 65-67)
Bronchodilator Trial
Measurement of the FEV1 before, 15 and 30 min after inhalation of a bronchodilator differentiates responses and non-responses and those who have asthma from those who do not. Salbutamol or Terbutaline should be tried first, followed by Ipratropium, then in combination. (Ohri, 11) A rise in FEV1 of more than 15% over the predicted normal value and an absolute increase of 200 ml is considered diagnostic of reversibility. (Kunik, 22-26) Even patients with severe airflow obstructions may demonstrate variability and the post bronchodilator FEV1 is a good prognostic indicator (Crocket, 36-43).
Corticosteroid Trial
Measurement of the FEV1 before and at the end of a course of cortico-steroids helps to distinguish some cases of asthma from COPD. Corticosteroids should be taken orally for 2 weeks at a dose of 30-40 mg each morning or by inhalation at a dose of 500 g twice daily for 6-8 weeks. A positive response is seen as the same as one for bronchodilators. Patients who use reliving bronchodilators more than once a day or who have an equivalent response to a bronchodilator trial should be tested. A positive response implies that the patient will benefit from the long-term use of corticosteroids and may have a better prognosis (Crocket, 36-43).
Conclusion
In conclusion to promote the maximization of heath of a patient with suspected COPD it is obvious you should follow a set protocol when doing an admission assessment and always use the appropriate diagnostic tools for each individual patient. Chronic bronchitis or obstructive emphysema is the best example of chronic obstructive pulmonary disease (COPD). The diseases have features in common like the patients almost invariably have a history of smoking, of which this patient has done. Dyspnea or difficult or labored breathing which gets increasingly worse as the disease progresses.
Coughing and frequent pulmonary infections are common and lastly most COPD victims develop respiratory failure. Due to more needed testing the assumption being made for this patients problem would have to be obstructive emphysema, at this point. Obstructive emphysema is distinguished by permanent enlargement of the alveoli, accompanied by deterioration of the alveolar walls. Chorionic inflammation leads to lung fibrosis, and invariably the lungs lose their elasticity. Arterial O2 and CO2 levels remain essentially normal until late in the disease. As the lungs become less elastic, the airways collapse during expiration and obstruct the outflow of air.
The consequences are accessory muscles must be enlisted to breathe, and victims are perpetually exhausted because breathing requires 15-20% of their total body energy supply. For complex reasons, the bronchioles open during inspiration but collapse during expiration, trapping huge volumes of air in the alveoli. This hyperinflation leads to development of a permanently expanded barrel chest and flattens the diaphragm, thus reducing ventilation efficiency. If this patient does not stop smoking he is jeopardizing his life because the respiratory system which is vital to life, anything which prevents it functioning can result in death.
Works Cited
Bellamy D, Brooker R. Chronic Obstructive Pulmonary Disease in Primary Care. 2000 :-23-32.
Booker, R. (2005). Chronic obstructive pulmonary disease and nice guidelines. Nursing standard, 19(22). 11-13.
Bradget RG, Tanaka DJ. Is Screening for Chronic Obstructive Pulmonary Disease Justified? 1997 :-466-472.
Crocket A. Managing Chronic Obstructive Pulmonary Disease in primary care. 2000 :-36-43.
Gosselink, R. (2003). Controlled breathing and dyspnea in patients with chronic obstructive pulmonary disease. Journal of rehabilitation research and development, 40(5). 65-67.
Jeffery, P. K. (2001). Remodeling in asthma and chronic obstructive lung disease. American Journal of Respiratory and Critical Care Medicine, 164(28) 18-21.
Kunik, M., Roundy, K., Veazey, C., Souchek, J., Richardson, P., Wray, N., & Stanley, M. (2005). Surprisingly high prevalence of anxiety and depression in chronic breathing disorders. American college of chest physicians, 127(4). 22-26.
Levey M, Hilton S, Barns G, et al. Asthma at Your Fingertips. 1999 :-160-161.
Mannino, D. M. (2003). Chronic obstructive pulmonary disease: definition and epidemiology. Respiratory care journal, 48(12). 89-93.
Ohri, C., & Steiner, M. (2004). COPD: the disease and non drug treatment. Hospital pharmacist, 11.
Osman, L. M., & Hyland, M. E. (2005). Patient needs and medication styles in COPD. The European Respiratory Society, 14(7). 33-36.
Siafakas NM, Vermeire P, Pride NB, et al. Optimal Assessment and Management of Chronic Obstructive Pulmonary Disease (COPD). 1995 :-1398-1420.
Tinkelman, O., & Corsello, P. (2003). Chronic obstructive pulmonary disease: the impact occurs earlier than we think. American Journal of Managed Care, 9(6). 879-84.