Copd

Good questions. I'm sure some pulmo nurses with more recent experience can do better than me, but here are some things that come to my mind.

Severe dyspnea:

I think first in terms of airway clearance. Is something obstructing the upper airways? Does the patient have retractions? Will suctioning help? Will humidification/hydration make secretions easier for the patient to raise? Then I think of the mechanical quality of their respiratory effort. Is their chest hyper-resonant, with distant breath sounds. Are they using trapezius and other accessory muscles to inspire? Is expiration an active process or passive? In other words, are the lungs already so full of trapped air that the pt can't maintain an adequate tidal volume? One quick thing you can do to help is to position the patient to facilitate the muscular work of breathing. Sit them up so they can lean forward over a pillow placed on a bedside table. Don't expect this patient to lie on his back fully supine. (Also, these patients can be so air hungry, they can't stand to have an O2 mask on. Nasal cannulas may be more comfortable, if the patient's condition permits. And remember that too much O2 can be hazardous to chronic bronchitics.)

Then I think of circulation: Is there any evidence of systemic hypoxia, hypercapnea: Obviously blood gasses are the gold standard here, but bedside assessment is important too. Cyanosis and a plethoric (swollen) look may be "normal" for some COPD patients. I always look at the organ systems that use the most oxygen, the heart and the brain. Is the patient showing increased ectopy, for example. What is the patient's level of consciousness and is it changing for the worse?

One general nursing goal for these patients is to reduce the demand for oxygen. This includes doing everything you can to make them comfortable to trying to reduce their anxiety. (Don't let tons of family, or squads of medical students go willy nilly into the room to try to talk with the patient. Organize care so that it's as efficient as possible. No t-bone steaks for meals, calories in a readily accessible form. These patients are sometimes trying so hard to breathe that they can't chew and swallow.)

Ventilators: One of the main problems with vents and COPD patients is that weening off is sometimes really difficult. (I've been out of the loop for a few years, maybe more current nurses can add to or correct me.)

A principle problem with vents is what they do to circulation. When you and I inhale, we create a negative pressure in our thorax. This, in turn, facilitates blood returning to the right atrium then to the right ventricle. When a pt. is on a vent, this situation is reversed. Inspiration produces positive pressure that impairs blood return. So be mindful of the fact that putting a pt. on a vent can improve gas exchange in the lung's alveoli, but impair delivery of that oxygenated blood to the rest of the body. This situation is made worse if the patient requires PEEP.

And obviously, another problem with vents is that the pressures they impose on lungs that are already hyper-inflated, is that tissues can tear. The patients can suffer barotrauma. So you're always assessing for any sudden changes in the patient and the vent. Chest tubes might be needed in a hurry. Know how to set them up.

Whew! Big long reply. Sorry about that. But it's a big area of study and something that you'll see a lot of on medical floors and ICU's.

Thanks for the fabulous explaination you gave!! Very helpful!!