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Desired Outcomes For a Patient Diagnosed With COPD Essay
Write a 5 page research paper about Chronic Obstructive Pulmonary Disease (COPD). Include:
– What it is including pathophysiology
– Treatments (Desired outcomes for a patient diagnosed with COPD). Pharmacological and non pharmacological treatments
– Risk factors
In this nursing care plan guide are seven (7) nursing diagnosis for Chronic Obstructive Pulmonary Disease (COPD). Get to know the nursing interventions, goals and outcomes, assessment tips, and related factors for COPD.
What is Chronic Obstructive Pulmonary Disease (COPD)?
Chronic Obstructive Pulmonary Disease (COPD) is defined as “a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients. Its pulmonary component is characterized by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases.” (Global Initiative for Chronic Obstructive Lung Disease or GOLD)Desired Outcomes For a Patient Diagnosed With COPD Essay
Any respiratory disease that persistently obstructs bronchial airflow fall under the broad classification of COPD, also known as chronic airflow limitations (CAL). Chronic Obstructive Pulmonary Disease (COPD) is a condition of chronic dyspnea with expiratory airflow limitation that does not significantly fluctuate. Within that broad category, the primary cause of the obstruction may vary; examples include airway inflammation, mucous plugging, narrowed airway lumina, or airway destruction.
The term COPD mainly involves two related diseases — chronic bronchitis and emphysema. Although asthma also involves airway inflammation and periodic narrowing of the airway lumina (hyperreactivity), the condition is the result of an individual response to a wide variety of stimuli/triggers and is therefore episodic in nature with fluctuations/exacerbations of symptoms. COPD is also called chronic obstructive lung disease (COLD).Desired Outcomes For a Patient Diagnosed With COPD Essay
Asthma: Also known as chronic reactive airway disease, asthma is characterized by reversible inflammation and constriction of bronchial smooth muscle, hypersecretion of mucus, and edema. Precipitating factors include allergens, emotional upheaval, cold weather, exercise, chemicals, medications, and viral infections.
Chronic bronchitis: Widespread inflammation of airways with narrowing or blocking of airways, increased production of mucoid sputum and marked cyanosis.
Emphysema: Most severe form of COPD, characterized by recurrent inflammation that damages and eventually destroys alveolar walls to create large blebs or bullae (air spaces) and collapsed bronchioles on expiration (air-trapping).
Nursing Care Plans
Nursing care planning for patients with COPD involves the introduction of a treatment regimen to relieve symptoms and prevent complications. Most patients with COPD receive outpatient treatment, the nurse should develop a teaching plan to help them comply with the therapy and understand the nature of this chronic disease.Desired Outcomes For a Patient Diagnosed With COPD Essay
Assessment of patients with chronic obstructive pulmonary disease (COPD) is important to establish an accurate diagnosis, assist in making therapeutic decisions, measuring outcomes for clinical and research purposes, and determining prognosis. Chest computed tomography (CT) scans are useful in patients who present with airflow limitation and clinical features suggestive of COPD but in whom other diagnoses are being considered. In such cases, a chest CT may indicate another diagnosis. The amount and distribution of emphysema can identify outcomes from lung volume reduction surgery, and chest CT scans are mandatory in assessment of patients for this surgery. Quantitative parameters from chest CT scans have been used to define longitudinal progression of disease. Assessment of patients with COPD for both clinical and research purposes should incorporate a variety of different outcomes. There are outcome measures that have been successfully incorporated in large clinical trials, and the design and outcomes of these trials can be used to plan future clinical investigations in COPD.Desired Outcomes For a Patient Diagnosed With COPD Essay
A variety of procedures, tests, and questionnaires can be used to evaluate patients with chronic obstructive pulmonary disease (COPD) for clinical and research purposes. Appropriate assessment of patients with COPD can be used to
Make an accurate diagnosis,
Assist in making decisions and choices of the most appropriate therapeutic interventions,
Measure outcomes in response to interventions in clinical settings and in research investigations, and
Provide information about prognosis.
This article will discuss the use of chest computed tomography (CT) scans to assess patients with COPD and review the use of other measures in COPD studies. Because of its size and the large number of outcomes assessed, the National Emphysema Treatment Trial (NETT) will be used to highlight the use of outcome measures in clinical trials Desired Outcomes For a Patient Diagnosed With COPD Essay
The most widely used current definitions of COPD are provided by two current clinical practice guidelines: he Global Initiative on Obstructive Lung Disease (GOLD) consensus guideline, and the joint statement by the American Thoracic Society and European Respiratory Society. A review of the definitions in these guidelines indicates that the major components are similar:Desired Outcomes For a Patient Diagnosed With COPD Essay
Chronic Obstructive Pulmonary Disease (COPD) is a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients. Its pulmonary component is characterized by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases. Desired Outcomes For a Patient Diagnosed With COPD Essay
Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease state characterized by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and is associated with an abnormal inflammatory response of the lungs to noxious particles or gases, primarily caused by cigarette smoking. Although COPD affects the lungs, it also produces significant systemic consequences.Desired Outcomes For a Patient Diagnosed With COPD Essay
There is only one criterion required for the diagnosis of COPD: the presence of airflow limitation after an inhaled bronchodilator.
Although not specifically embodied in the definitions nor discussed in detail in the COPD guidelines, optimal clinical practice would dictate that the diagnosis of COPD should only be made after other disorders that are associated with airflow limitation are excluded. History and physical examination may be helpful in excluding other diagnoses and can guide the use of other tests in patients in whom the differential diagnosis includes disorders other than COPD. In addition, the use of chest imaging, particularly chest CT scans, is an important and often overlooked diagnostic tool in COPD when there is a need to exclude other conditions.Desired Outcomes For a Patient Diagnosed With COPD Essay
When should a chest CT scan be considered by a clinician making a diagnosis of COPD? One group has recently prospectively examined a cohort of patients with COPD to generate a phenotypic definition based on clinical, functional, and chest radiographic criteria; high-resolution CT (HRCT) was subsequently obtained in a subset of subjects (6). Patients could be separated into airway- versus emphysema-predominant phenotypes. Another study segregated 85 patients with COPD using qualitative assessment of HRCT into four groups based on assessment of emphysema and airway disease: (1) without emphysema without bronchial wall thickening (n = 11), (2) without emphysema with bronchial wall thickening (n = 11), (3) emphysema without bronchial wall thickening (n = 30), and (4) emphysema with bronchial wall thickening (n = 31) (7). A prospective evaluation of the role of CT scans in the evaluation of all patients presenting with nonreversible limitation and a clinical diagnosis of COPD would be provide useful information to guide clinicians. Such a study would provide information on the utility of CT scans in excluding other conditions. However, we are unaware of such a report.Desired Outcomes For a Patient Diagnosed With COPD Essay
Good clinical practice would suggest that a chest CT scan be considered in two distinct clinical scenarios: (1) when the clinician’s differential diagnosis suggests there may be a diagnosis other than COPD, and (2) in patients presenting with nonreversible airflow limitation without a history of sufficient environmental or occupational respiratory exposures known to cause COPD. The ATS/ERS COPD statement notes that a chest X-ray is useful in differential diagnosis, and the GOLD guidelines indicate that a chest CT scan may be helpful in differential diagnosis (4, 5). Health care practitioners should carefully consider what type of imaging study would provide the most robust information to assist in their clinical differential diagnosis. Disorders that may be included in the differential diagnosis of patients with nonreversible airflow limitation include bronchiolitis, bronchiectasis, panbronchiolitis, chronic respiratory infections or their sequellae, hypersensitivity pneumonitis, asthma, congestive heart failure, lung cancer, lymphangioleiomyomatosis, sarcoidosis, and tracheobronchomalacia (4, 5). In many of these conditions (particularly bronchiolitis, bronchiectasis, panbronchiolitis, chronic respiratory infections and their sequellae, hypersensitivity pneumonitis, lung cancer, lymphangioleiomyomatosis [8, 9], sarcoidosis, and tracheobronchomalacia [10, 11]) chest CT scanning may suggest a diagnosis or even be diagnostic of a condition other than COPD. This is particularly evident in diffuse parenchymal conditions associated with cystic lung disease (12). Interstitial lung disease may also co-exist with COPD, and chest CT scanning is diagnostic of combined disease (13). Since the management of these many of these other disorders differs markedly from the management of patients with COPD, clinicians should be sure they are not overlooking a condition that would result in a different therapeutic approach.
Recent studies suggest that 15% of patients with COPD do not have a history of cigarette smoking (14–16). Since most patients with COPD most commonly have a history of exposure to cigarette smoke, an argument could be made that most if not all patients with nonreversible airflow limitation who are nonsmokers or do not have an occupational or environmental exposure known to cause COPD should have a chest CT scan to exclude other disorders. However, the utility of this algorithm in clinical practice has not been tested.Desired Outcomes For a Patient Diagnosed With COPD Essay
THERAPEUTIC DECISION-MAKING IN COPD
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There are two surgical therapies (bullectomy and lung volume reduction surgery) that mandate the use of a chest CT scan to select appropriate patients. While a chest X-ray may suggest the presence of bullae, the presence and extent of such lesions can only accurately be assessed with chest CT scans (17). Similarly, the presence, extent, and distribution of emphysema can most precisely be determined with a chest CT scan.
Early reports of lung volume reduction surgery (LVRS) suggested benefit in patients with upper lobe emphysema (18). The National Emphysema Treatment Trial (NETT) extended these observations, and the results of the NETT form the basis for current selection criteria for LVRS (2, 3, 19). In NETT, there were two parameters that determined differential response to treatment: emphysema distribution and exercise capacity.Desired Outcomes For a Patient Diagnosed With COPD Essay
A chest CT scan is an important tool to determine patients who should not undergo LVRS (19). In NETT, LVRS was associated with a high risk of death (16% with LVRS compared with 0% in subjects treated medically) at 30 days in two types of subjects with emphysema: (1) those with FEV1 of less than or equal to 20% of predicted and non–upper lobe–predominant disease, and (2) subjects with FEV1 of less than or equal to 20% of predicted and a diffusing capacity less than or equal to 20% of predicted. At 6 months, survivors of LVRS compared with medically treated subjects had improvements in walk distance and FEV1, but no improvement in health-related quality of life or exercise capacity. Although there is great interest in quantitative assessment of emphysema using computer scoring systems, CT scan interpretation of emphysema distribution by trained radiologists in NETT was an important outcome marker.Desired Outcomes For a Patient Diagnosed With COPD Essay
Similarly, the distribution of emphysema on chest CT scan is a marker of the response to LVRS. Subgroups of subjects with emphysema in NETT had differential responses to LVRS. The subgroups were based on radiologist scoring of the distribution of emphysema and exercise capacity (maximum work assessed on an incremental cycle ergometer test). Emphysema distribution was categorized as either upper lobe–predominant or non–upper lobe–predominant; exercise capacity was categorized as high (greater than 40 watts in males and 25 watts in females) or low based on post hoc analyses. The four subgroups with differential outcomes were: (1) upper lobe emphysema and low exercise capacity who had the best outcomes, including improved survival with LVRS; (2) upper lobe emphysema and high exercise capacity who had improved exercise capacity and health-related quality of life with LVRS; (3) non–upper lobe emphysema and low exercise capacity who had improved health-related quality of life and exercise capacity with LVRS; and (4) non–upper lobe emphysema and high exercise capacity who had increased mortality with LVRS .Desired Outcomes For a Patient Diagnosed With COPD Essay
Given the importance of CT scanning in assessing patients with COPD for potential lung volume reduction surgery that may lead to improved survival, when is a CT scan indicated in patients with COPD? As a starting point, physicians might consider a CT scan in patients with COPD who have an FEV1 of less than or equal to 45% of predicted. Based on the NETT, clinicians should consider performing a chest CT scan on patients who (1) are clinically suspected of having emphysema, (2) meet NETT inclusion criteria outlined below, and (3) do not have any exclusion criteria for LVRS. Only with the information provided by a chest CT scan, can clinicians evaluate the role of LVRS and have meaningful discussions with their patients about potential surgical intervention.
Chest CT scans have become an integral part of the evaluation of patients for lung transplantation, as they appear to alter the surgical approach to lung transplantation in selected patients. Kazerooni and colleagues noted that chest CT prompted a change in the determination of which lung was more severely diseased in 27 of 169 patients; of the 45 patients who subsequently underwent transplantation, CT prompted a change in the determination of which side to perform SLT in four (20). Subsequently this group identified pulmonary nodules, suspicious for malignancy, in 8 of 190 patients evaluated for lung transplantation (21). As an active malignancy precludes transplantation, such a finding would clearly alter the candidacy of a patient for lung transplantation. Finally, the presence of unsuspected bronchiectasis could alter the decision to perform DLT in contrast to SLT.Desired Outcomes For a Patient Diagnosed With COPD Essay
The cost of CT scans should also be considered when making recommendations on the performing the test. The “costs” of CT scans include radiation exposure, time of the patient, and use of medical resources. Medicare reimbursement for a chest CT scan is about $400. The costs of performing a chest CT scan on all the 12 million patients in the United States with diagnosed COPD would be about $4.8 billion, and based on current evidence could not be justified.
Clinician use of CT scanning in COPD has not been reported. In an effort to evaluate pulmonary specialists’ perceptions of the use of CT scans, one of the authors (B.J.M.) surveyed clinicians in his university affiliated medical centers. Two questions were posed: (1) “In what percentage of patients with COPD do you think a chest CT scan should be performed for clinical purposes”? and (2) “In what percentage of patients with COPD and an FEV1 of less than 50% of predicted do you think a chest CT scan should be performed for clinical purposes”? Responses that could be chosen were 25%, 50%, 75%, and “nearly all.” Surveyed pulmonary clinicians responded that 50% (± 31%) of all patients with COPD should have a chest CT scan. In response to the second question, pulmonary physicians indicated that 83% (± 28%) of patients with COPD and an FEV1 of less than 50% of predicted should have a chest CT scan.Desired Outcomes For a Patient Diagnosed With COPD Essay
OUTCOME ASSESSMENT IN COPD
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PROGNOSIS IN COPD
CT scan–derived data, such as the extent of emphysema and airway disease, can serve as a primary outcome of future clinical trials in COPD. However, in such studies it would also be important to simultaneously assess other outcomes that are clinically relevant, have valid measurement tools that are commonly used, have been employed in previous COPD investigations, and are familiar to health care practitioners. Not all outcome measures meet all these criteria. For example, the FEV1 is commonly used as a lung function outcome in COPD studies and is well known to pulmonary specialists, but is not widely recognized as important to patients. While the FEV1 can be expected to improve with therapies that target lung function, it may not be a relevant outcome marker for other novel therapies with different targets. In addition, although spirometry testing is well standardized, the minimal clinical important difference has not been rigorously evaluated (22, 23). For example, exercise capacity was chosen by the NETT investigators as a key outcome because of its importance to patient overall function (1). Inspiratory capacity is better correlated with changes in exercise capacity than FEV1 and in clinical trials has been shown to be improved in response to currently available medications (24–27).Desired Outcomes For a Patient Diagnosed With COPD Essay
A variety of constructs can be assessed in response to therapies in COPD, including not only lung function but also physical function, patient-reported outcomes such as health-related quality of life and respiratory symptoms, exacerbation frequency and severity, the course of the disease, systemic consequences, and others. Table 1 provides categorizes outcomes that are important in COPD. It may not be realistic to measure all these outcomes in all clinical trials in COPD. However, the study design should consider assessing multiple outcomes based on the purpose of the study, the nature of the intervention (if any), and the importance of these outcomes to patients with COPD, health care providers, payers of health care costs, and society. A recent ATS/ERS statement made recommendations on the outcomes that should be considered in pharmacologic trials in patients with COPD; those outcomes recommended by the ATS/ERS Desired Outcomes For a Patient Diagnosed With COPD Essay