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  1. Approximately 15.7 million Americans have been diagnosed with chronic obstructive pulmonary disease (COPD), and each one of them requires an individualized approach.1,2 It’s important to understand the different options when selecting an inhalation device for this complex patient population. On top of their breathing troubles, many patients may have other issues, such as cognitive and physical limitations.3,4 Remembering and following multiple steps, and coordinating a sequence of exhalations and inhalations, are some of the challenges these patients may face when operating their devices. In addition, maintaining an active lifestyle can be important for many patients struggling with COPD, so equipment and/or treatments with prolonged administration duration can be a challenge.5 A review of the different delivery options for COPD could help healthcare professionals choose the appropriate device for their patients.6 For many patients with COPD, adherence can be a major problem. Healthcare professionals can strive to mitigate adherence issues by considering their patients’ abilities and preferences and matching them to the appropriate inhalation device.6,7 Surveys suggest that there are opportunities for healthcare professionals to better connect with patients in terms of device training and technique. Approximately 25% of patients do not receive instructions for using their inhalation device, and 69% of patients report that their healthcare professionals have never watched them take their medication.8 COPD delivery options Metered-dose inhalers (MDIs)4,7,9-11 Compressed chemical propellant delivers medication in aerosol form Require coordination of breathing and actuation of device No drug preparation necessary, though shaking the device is required Administered in 1 or 2 breaths Slow-mist inhalers (SMIs)4,12,13 Use a Spring mechanism to create a mist Breath coordination is required Multiple steps for setup Administered in 1 or 2 breaths Dry-powder inhalers (DPIs)9,10,14-17 Breath actuated Proper breathing technique is required Minimal setup; patient may need to load capsule Administered in 1 or 2 breaths Jet nebulizers4,9,18 High-velocity air stream creates breathable mist Natural breathing administration Multiple steps for setup and maintenance Administration can take up to 20 minutes Vibrating membrane or mesh nebulizers4,13 Vibrating perforated material creates breathable mist Natural breathing administration Multiple steps for setup and maintenance Administration can take less than 5 minutes It is important to train patients on how to use their devices upon initiation and to regularly reassess and refresh them on proper technique. Knowing the pros and cons of different delivery options can help optimize treatments and deliver the best results for patients. When necessary, healthcare professionals should consider and advocate for alternative device options for appropriate patients.6 References: 1. Wheaton AG, Cunningham, TJ, Ford ES, Croft JB; Centers for Disease Control and Prevention. Employment and activity limitations among adults with chronic obstructive pulmonary disease—United States, 2013. MMWR Morb Mortal Wkly Rep. 2015;64(11):289-295. 2. Patel M, Steinberg K, Suarez-Barcelo M, et al. Chronic obstructive pulmonary disease in post-acute/long-term care settings: seizing opportunities to individualize treatment and device selection. J Am Med Dir Assoc. 2017:18(6):S53. e17-S53.e22. 3. Zarowitz BJ O’Shea T. Chronic obstructive pulmonary disease: prevalence, characteristics, and pharmacologic treatment in nursing home residents with cognitive impairment. J Manag Care Pharm. 2012;18(8):598-606. 4. Dhand R, Dolovich M, Chipps B, Myers TR, Restrepo R, Farrar JR. The role of nebulized therapy in the management of COPD: evidence and recommendations. COPD. 2012;9(1):58-72. 5. Amultiari HJ, Mussa CC, Lambert CT, Vines DL, Strickland SL. Perspectives from COPD subjects on portable longterm oxygen therapy devices. Respiratory Care. 2018;63(11):1321-1330. 6. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Global Initiative for Chronic Obstructive Lung Disease (GOLD). 2020:1-125. 7. Restrepo RD, Alvarez MT, Wittnebel LD, et al. Medication adherence issues in patients treated for COPD. Int J Chron Obstruct Pulmon Dis. 2008;3(3):371-384. 8. Cho-Reyes S, Celli BR, Dembek C, Yeh K, Navaie M. Inhalation technique errors with metered-dose inhalers among patients with obstructive lung diseases: a systematic review and meta-analysis of U.S. studies. Chronic Obstr Pulm Dis. 2019;6(3):267-280. 9. Dolovich MB, Ahrens RC, Hess Dr, et al. Device selection and outcomes of aerosol therapy: evidence-based guidelines: American College of Chest Physicians/American College of Asthma, Allergy, and Immunology. CHEST. 2005;127(1):335-371. 10. Pelegrin GM. Asthma inhalers? What you should know. Pharm Times. https://www.pharmacytimes.com/publications/ issue/2003/2003-05/2003-05-7182. Published May 1, 2018. Accessed March 30, 2020. 11. AZMACORT [prescribing information]. Kos Pharmaceuticals, Inc. 2007. 12. Anderson P. Use of Respimat® Soft MistTM Inhaler in COPD patients. Int J Chron Obstruct Pulmon Dis. 2006;1(3):251- 259. 13. Tashkin DP. A review of nebulized drug delivery in COPD. Int J Chron Obstruct Pulmon Dis. 2016;11:2585-2596. 14. Lavorini F, Magnan A, Dubus JC, et al. Effect of incorrect use of dry powder inhalers on management of patients with asthma and COPD. Respir Med. 2008;102(4):593-604. 15. Al-Showair RA, Tarsin WY, Assi KH, Pearson SB, Chrystyn H. Can all patients with COPD use the correct inhalation flow with all inhalers and does training help? Respir Med. 2007;101(11):2395-2401. 16. ADVAIR DISKUS [prescribing information]. GlaxoSmithKline: 2019. 17. SPRIVIA RESPIMAT [prescribing information]. Boehringer Ingelheim International GmbH: 2019. 18. Knoch M, Keller M. The customised electronic nebuliser: a new category of liquid aerosol drug delivery systems. Expert Opin Drug Deliv. 2005;2(2):377-390. SUNOVION is a registered trademark of Sumitomo Dainippon Pharma Co., Ltd. Sunovion Pharmaceuticals Inc. is a U.S. subsidiary of Sumitomo Dainippon Pharma Co., Ltd. ©2020 Sunovion Pharmaceuticals Inc. All rights reserved. 4/20 RESP-US-00039-20
  2. Chronic Obstructive Pulmonary Disease (COPD) Many patients with chronic obstructive pulmonary disease (COPD) struggle to use their inhalers properly.1 Though COPD is the fourth-leading cause of death in the United States, proper treatment can help many patients manage their condition.1,2 Unfortunately, the challenges presented by inhalation devices can place an additional burden on an already vulnerable patient population.1 It is critical that healthcare professionals work with patients to train them on inhalation techniques upon initiating treatment. In follow-up appointments, physicians and nurses should reassess and refresh patients on proper technique; and, when necessary, it may be important for healthcare professionals to consider and advocate for alternative device options for appropriate patients.1 A meta-analysis published in Chronic Obstructive Pulmonary Diseases in 2019 was a strong reminder of that basic tenet of treating patients with COPD: a large fraction of patients may not be getting adequate treatment because they are making errors with their inhalers. Metered-dose inhalers (MDIs) are the most commonly prescribed handheld device for treating COPD patients, but MDIs require hand–breath coordination that can be a barrier to proper administration. Some delivery devices, such as nebulizers, may be preferred by some patients. COPD treatments and devices vary and should be individualized to a patient's needs and abilities. Matching the proper delivery device to the correct patient can make a significant difference for patients struggling with their MDIs.1 How many patients are making errors with their MDIs? Eight in 10 patients who used an MDI made at least 1 error in taking their medication, according to the meta-analysis, which aggregated data for 1360 individuals across 10 published studies. Furthermore, the study showed that 7 in 10 patients performed ≥20% of their devices’ steps incorrectly.1 Though these numbers might seem high, the authors point out that they are in line with previous studies of MDI usage.1 The problem has been well documented by others looking at adherence and device usage in COPD. In other select reports, researchers have shown that ~25% of patients never receive instructions on how to use their device, and 69% report that their healthcare providers have never watched them try to take their medication.1 What kinds of errors are patients making? Coordinating breath, generating an adequate inspiratory force, and engaging the device by hand can be challenging, especially for a patient population plagued by comorbidities that include dementia and arthritis in addition to their breathing difficulties.1 The authors of the meta-analysis highlighted the following mistakes: 2 in 3 patients had trouble exhaling fully away from the MDI before inhalation (ie, failure to empty their lungs)1 2 in 5 patients failed to hold their breath after inhaling. This type of error can negatively impact treatment because of poor medication deposition1 1 in 3 patients failed to inhale slowly and deeply1 1 in 3 patients failed to shake the MDI1 What can be done? Clearly, nurses treating patients with COPD have significant challenges to overcome. More patient education and assessing and reassessing their patients’ technique with MDIs are crucial steps.1 Nurses should advocate for treatment options that suit their patients’ abilities and preferences, which may include nebulized therapies.1 SUNOVION is a registered trademark of Sumitomo Dainippon Pharma Co., Ltd. Sunovion Pharmaceuticals Inc. is a U.S. subsidiary of Sumitomo Dainippon Pharma Co., Ltd. ©2020 Sunovion Pharmaceuticals Inc. All rights reserved. 4/20 RESP-US-00039-20
  3. COPD by the numbers—let’s see how you do! Education and demonstration of device use can help offset some of the mistakes patients face, but it might not be enough.2 One device doesn’t fit all. It’s time to rethink how we treat COPD and use the right device for the right patient.2 References: Cho-Reyes S, Celli BR, Dembek C, Yeh K, Navaie M. Inhalation technique errors with metered-dose inhalers among patients with obstructive lung diseases: a systematic review and meta-analysis of U.S. studies. Chronic Obstr Pulm Dis. 2019;6(3):267-280. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Global Iniative for Chronic Obstructive Lung Disease. 2020:1-125. Amin A, Ganapathy V, Roughley A, Small M. Confidence incorrect inhaler technique and its association with treatment adherence and health status among US patients with chronic obstructive pulmonary disease. Patient Prefer Adherence. 2017;11:1205-1212. The more you know, the better equipped you are to help your patients with their COPD treatment! Continuing your education is the best way to provide optimal treatment for your patients. Share with a friend to see what they know about treating COPD.
  4. The sprays, wipes and liquids nurses frequently use to prevent infection could be harmful to lung health. A new study, published in JAMA Network Open found workplace exposure to cleaning chemicals significantly increases the risk in COPD among nurses. In the study, researchers used data from an on-going study of more than 116,000 registered female nurses, in 14 states, dating back to 1989. The study focused on women who were still nurses and without lung disease in 2009. The nurses completed questionnaires every other year to track work history and lung health from 2009 to 2015. Occupational Exposures and COPD COPD is not only the third leading cause of death worldwide, but a chronic condition that often can lead to long term disability. Cigarette smoking remains the major risk factor for COPD in the U.S. However, data suggests that 15% to 20% of cases are caused by occupational exposures. Workplace exposures can also contribute to the disease burden of someone with COPD. In the past, studies on occupational exposure and COPD have investigated broad categories of causal agents, such as vapors, dust, gases or fumes and only on a limited number of occupational settings. Significant Increase in Risk According to the study findings, nurses were between 25% and 36% more likely to develop COPD based on exposure to certain cleaning products. The percentages reported in the study were determined after accounting for whether the nurses were smokers or suffered from asthma. Researchers found weekly use of disinfectants to clean hospital surfaces increased COPD risk by 38%, while weekly use of chemical to clean medical instruments increased the risk by 31%. Women at Risk Although gender roles have changed over the past few decades, exposure to cleaning products at home and at work are more common in women. The majority of nurses are female, with males being only 13% of the nursing workforce. A 2014 survey by the US Bureau of Labor and Statistics found that women perform 55-70% of household cleaning, which is about 30% more than men. In the healthcare industry, exposure levels to cleaning products and disinfectants are particularly high. Irritation Causing Chemicals Orianne Dumas, lead study author and researcher with Inserm, states, “We found that exposure to several chemicals were associated with increased risk of developing COPD among nurses.” Glutaraldehyde and hydrogen peroxide, used to disinfect medical instruments were among the chemicals identified by Dumas. Glutaraldehyde exposure can cause throat, nasal and lung irritation, asthma and difficulty breathing, skin irritation, wheezing, burning eyes and conjunctivitis. Nurses were also regularly exposed to fumes from bleach, alcohol and quaternary ammonium compounds, which are used to clean surfaces and floors. All these chemicals are known to cause lung irritation and could lead to the development of COPD. However, Dumas states researchers only found an association in the study, not a cause-and-effect relationship. More Research Needed The study authors found further study is needed to determine how these cleaning products might cause COPD, and if they increase the risk of lung disease for workers in other professions. Findings also suggest the need for further research to determine exposure-reduction strategies that provide adequate infection control for healthcare settings. What Are the Alternatives? Hospitals could continue to protect nurses’ and patients’ health by using safer alternatives, such as ultraviolet light or steam for disinfecting equipment and surfaces. Another option is for hospitals to switch to “green” cleaning products that don’t emit harmful fumes. The key is finding a balance between safeguarding the health of nurses while maintaining the needed level of infection control. Additional Resources CDC Fact Sheet- Glutaraldehyde Cleaning Chemicals: Know the Risks
  5. tsm007

    COPD and O2 use, am I wrong?

    Going to give you background information and then want some feedback. I am new to med surg, been here about 2 months, been a nurse about a year. My preceptor has been a nurse a few months more than me, but all med surg experience. I go with the flow and don't really argue with my preceptor, but she's been wrong on another occasion. She's really nice and for the most part does a good job. She's just not always as knowledgable as the more experienced nurses on the floor. My patient was admitted for a fall, been stuck on the floor for a couple days before anyone found him. He's a heavy smoker with a history of sleep apnea. My preceptor kept saying he had COPD, but now in hindsite I don't recall seeing that in his chart or on in report. (However, can't look that up now so let's just say hypothetically that he does have COPD for this question.) First 2 days I took care of him he didn't sleep well and his O2 sats were 94-95ish. On the second day he got a little wheezy around 5am and his O2 sats dropped to 90-92%, but all during the dayshift and mostly through the night lung sounds were perfectly clear and O2 sats were good. Last night pt took xanax for anxiety which was a new med for him. I had a sneaking suspicion that his O2 sats would drop once he was all relaxed and sleeping. I know xanax doesn't have a side effect of low O2, but with a history of sleep anea and he was so sedated from it I wanted to check his O2 and vitals. Check O2 and vitals around 1am and Pulse Ox is 88%. I ask preceptor if I can put him on O2 and what the protocol is for starting O2. So we start him on 2L NC. This is the part that I have the question on. My preceptor then states that if his O2 gets above 92% I need to turn his O2 down because his baseline is probably this low all the time and he has COPD. Now how does that make any sense??? 1) If his baseline is that low all the time why am I putting him on O2? 2) His baseline hasn't been that low in the past 2 days I've been taking care of him. I know you don't want to give COPD people too much O2, but 2L should not be a problem and I thought the goal was to keep *above* 92% for most people (unless doctors make target goal lower). I just wouldn't see any reason to bump O2 down if it was above 92%. I mean if he's running 98% or something I can see bumping it back down because he might no need it any more, but I wouldn't think it would be harmful to him either. I eventually wound up calling RT and he wound up on a venti mask until morning. because his O2 sats dropped to 77-82% on RA (the nasal canula migrated from his nostrils) and the 2L wasn't budging him above the 88%. I know I'm being a brat and I appreciate anyone who read this book long post, but wanted thoughts on COPD and adjusting O2. Is there any reason you need to bump O2 down if their sats go above 92% on 2L? I know I wouldn't put them above 2L without getting doctor or RT involved.
  6. semester1kid

    End stage COPD clinical patient

    Last night we had an 88 y/o patient in clincal with end stage COPD...and she still smoked. We actually debated whether it was worth going through the motions with patient teaching regarding how unhealthy smoking was given her age and status. What do you think?
  7. You are a new graduate nurse on your second rotation in a 30-bed medical ward. It is 0800hrs during a morning shift, and you have been allocated the care of a 70-year-old female, who has been on your ward for the last week, recovering from an acute infective exacerbation of chronic obstructive pulmonary disease (copd). Past medical history: ischaemic heart disease (ihd) and severe copd (with type ii respiratory failure). When assisting the patient with breakfast you notice she has become increasingly breathless, only speaking in single words, and not interested in eating. A set of observations are taken: SAO2 88% on np at 2l/min bp 160/90, hr 144 resp rate 45 b/min, and Temperature 37.2. auscultation of the lung fields reveals wide spread expiratory wheeze bilaterally. lab results: abg uec's fbc ph 7.33 na 144mmol/l hb 155 g/l pa02 55 mmhg k 4.5 mmol/l wcc 11 x 109/l pac02 70 mmhg cl 109 mmol/l plt 400 x 109/l hc03 36 mmol/l urea 8 mmol/l creat 90 µmol/l Questions 1. Using the information given in the (above) case study start by prioritizing and justifying your immediate care of this patient? 2. You also need to interpret both clinical and lab results, and 3. what physiological processes may be responsible for the abnormal clinical or lab results?
  8. I am a first semester student who needs from guidance on this scenerio: How is a patient with COPD who has Carbon Monoxide Poisoning treated clinically?? Normally, you'd want to administer the highest amount of oxygen possible to that patient, using a Non-Rebreather, but in COPD, wouldnt this be definetly a problem because with devices that deliver a moderate to high FiO2 levels....wouldn't you knock out the hypoxic drive as well??
  9. SuesquatchRN

    Resident with End-Stage COPD

    Horribly anxious. Increasingly dependent with ADLs and losing continence, which is new. Obsessed with her bowel movements - it's hard for her to defecate 2o exhaustion. Very frail, arthritis, already on axiolytics and we started her on Vicodin yesterday for severe back pain. She has been in bed moaning, "Oh, dear, oh dear" and, while I feel great sympathy, she is driving me nuts while breaking my heart. Any suggestions? We have speech working with her on eating because she gobbles from fear of getting too tired to finish which, of courses, exhausts her.... it's a vicous circle.
  10. serenie222

    COPD pt sob

    I got ask this question....so you have a copd pt who is sob. Already on oxygen that is 2L. I know with cod pts they require a lower amount of oxygen than most people some only (85-89%) do u increase the level of oxygen or not...
  11. Zen Heath

    Warning Signs for People with COPD

    According to the Centers for Disease Control and Prevention, more than 15 million people in the United States are affected by chronic obstructive pulmonary disease (COPD), a lung condition that affects one's breathing and can develop into a life-threatening disease. In fact, a lot more people may already be living with COPD without their knowledge. One of the reasons COPD can be underdiagnosed is that its symptoms may be mistaken as natural signs of aging. This is why it is important to identify even the mildest symptoms to allow early diagnosis and treatment. This way, the condition is better managed or prevented. The earlier you are diagnosed with CPOD, the more chances you can prevent it from getting worst. Spot the early signs of COPD before it is too late. Shortness of Breath One of the most common COPD symptoms is the feeling of tightness in the chest and shortness of breath. According to pulmonologist Barry Make, MD, it is even a major warning sign to look out for. If you find yourself often feeling out of breath even when you're just doing simple everyday activities, you should consult a pulmonologist. Ongoing Cough A cough that's going on for too long is one of the initial signs of COPD. While coughing is the body's natural way of protecting the airways from inhaling irritants such as smoke and clearing the breathing passages of mucus, having a chronic cough is a warning sign that the lungs are not functioning well. If you have been coughing on a regular basis for a few weeks now, or if you are starting to wheeze, be sure to keep your health-care provider posted. Increase in Mucus With coughing comes the production of large quantities of mucus or phlegm. Naturally, the lungs produce mucus to trap irritants or to keep them out, but having lots of mucus come out from your lungs instead of the sinuses can be a red flag for COPD. If you feel the need to clear your throat from phlegm first thing in the morning, especially if it appears yellow or green or is tinged with blood, you may be experiencing a common COPD symptom. When to Call for Emergency Care Over time, initial symptoms may become severe, especially when no proper treatment or lifestyle adjustments have been done. With this, patients need to identify severe COPD symptoms that already call for medical attention. Seek emergency care right away if you find it difficult to catch your breath and to even speak more than a few phrases. One thing to watch out for also is cyanosis or the blue or grayish discoloration of the lips and fingernails. This can be a sign that your blood's oxygen level is dropping below normal. Once a low blood-oxygen saturation is confirmed by pulse oximetry, you may be given supplemental oxygen to keep your body functioning. Another serious COPD warning sign is a change in mental alertness and an increase in heartbeat. A COPD flare-up can put you in a potentially life-threatening state, which is why it is important that immediate action is taken once these symptoms surface. Avoiding COPD Flare-ups The main goal of COPD treatment is to enjoy a quality of life by keeping symptoms under control as much as possible. Aside from regularly keeping in touch with your doctor, you can keep COPD symptoms at bay by getting flu shots every year, washing your hands as often as you can, keeping yourself hydrated and well-rested, and ultimately living a healthy lifestyle. In the end, it is still up to you to take control of your condition.
  12. Hi Everyone, I used to be thankfulnurse2b here on allnurses and haven't posted in a while. I finally finished nursing school in December and passed my boards this week!! So, I am working now as an RN on a Med/Surg floor. My question is, what kind of advice can you all offer in how to provide comfort and to help decrease anxiety in a patient with severe end-stage COPD? I took care of this poor fellow last night, and all pharmacological remedies have been exhausted for him. We are basically offering palliative care, though he is still a full code. The story is quite sad; he is determined to stay alive to care for his sick wife at home. I taught him breathing techniques and tried to provide distraction. What else can you all think of to make him more comfortable?
  13. georgianurse16

    Please help me understand COPD!

    Hi, can somebody please help me understand the pathophysiology of COPD? I work in the ER and don't understand COPD in detail. I understand you shouldn't put a lot of supplemental O2 on a patient b/c it "kills their drive to breathe on their own" but I don't understand why. Is it safe to put a COPD patient on a non-rebreather for a little while if their sats are low enough? And when is it appropriate to use a venturi mask? I would appreciate any help!

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