Emphysema

WHAT WENT WRONG?
Chronic inflammation reduces the flexibility of the walls of alveoli, resulting in
over-distention of the alveolar walls. This causes air to be trapped in the lungs,
impeding gas exchange. Smoking is often linked to development of emphysema.
A less frequent cause is an inherited alpha1-antitrypsan deficiency.

PROGNOSIS
Symptoms often begin insidiously and are progressive. Shortness of breath is ini-
tially associated with exertion, then presents at rest. These patients are more sus-
ceptible to lung infections. Supplemental oxygen becomes necessary at first for
exacerbations, then for daily use. Periodic exacerbations requiring hospitalization
are not unusual.

SIGNS AND SYMPTOMS

• Difficulty breathing (dyspnea) due to air trapping, which retains carbon
dioxide and reduces alveolar gas exchange.
• Barrel chest develops over time as more air is trapped within the distal air-
ways. The anteroposterior diameter (distance between front and back of the
chest) increases, giving the chest a more barrel-like appearance.
• Use of accessory muscles to breathe as the respiratory effort increases. The
number of muscles used to inhale will increase in an effort to get enough
oxygen into the body.
• Loss of weight as extra calories are needed to maintain respiration. Increased
effort of breathing also detracts from eating.
• Patients prefer a seated position which allows for greater chest expansion.

TEST RESULTS
• Increased residual volume shown in pulmonary function test due to air
trapping.
• Decreased oxygen and increased carbon dioxide in arterial blood gas as gas
exchange is impaired due to air trapping; more pronounced as disease pro-
gresses.

TREATMENT

Treatment will vary depending on the stage of the emphysema. As the disease pro-
gresses the treatment will change. Medications to control symptoms and keep air-
ways open, use of supplemental oxygen, and smoking cessation are the mainstays
of treatment.
• Administer beta2-agonists to bronchodilate by inhaler or nebulizer:
• terbutaline, albuterol, levalbuterol
• Administer long-acting bronchodilating medications by metered dose inhaler
or dry powder inhaler:
• formoterol, salmeterol
• Administer anticholinergics which allow for relaxation of bronchial smooth
muscle:
• ipratropium, tiotropium inhaler
• Administer methylxanthines to dilate the bronchi. These are typically used
in conjunction with other medications, not for acute effect:
• aminophylline
• theophylline
• Administer steroids to decrease inflammation within the airways:
• hydrocortisone, methylprednisolone systemically
• beclomethasone, triamcinolone, fluticasone, budesonide, flunisolide in-
halers
• prednisolone, prednisone orally
• Chest x-ray shows overinflation of lungs and flattening of the diaphragm.

• Administer antacid, H2 blocker, or proton pump inhibitor to decrease the
amount of acid in stomach, reducing possible ulcer formation due to stress
of the disease or medication effects:
• antacids: aluminum hydroxide/magnesium hydroxide, calcium carbonate
• H2 blockers: ranitidine, famotidine, nizatidine, cimetidine
• Proton pump inhibitors: omeprazole, lansoprazole, esomeprazole, rabepra-
zole, pantoprazole
• Administer expectorant—to loosen secretions:
• guaifenesin
• Administer diuretics to decrease fluid retention in patients that are develop-
ing right-sided heart failure secondary to lung disease:
• furosemide, bumetanide
• Administer vaccines—to prevent respiratory infections:
• influenza
• pneumonia
• Administer antibiotics:
• selected based on results of culture and sensitivity study or given empirically
• Administer alpha1-antitrypsin therapy for patients with deficiency.
• Administer oxygen, 2 liters per minute, to help meet body’s oxygen needs
while avoiding CO2 retention.
• Give patient 3 liters of fluids per day to help liquefy secretions.
• Nocturnal negative pressure ventilation for hypercapnic (elevated CO2 levels)
patients.
• Teach patient how to use:
• the incentive spirometer to encourage deep breathing and enhance cough-
ing and expelling of mucous.
• the flutter valve to increase expiration force.

NURSING DIAGNOSES

• Impaired gas exchange
• Fatigue
• Risk for infection

NURSING INTERVENTION

• Monitor the patient’s sputum for color, amount, or changes in characteristics,
which may indicate infection.
• Place patient in high Fowler’s position, which eases respiratory effort.
• Administer low-flow oxygen, which increases oxygen delivered to patient
without compromising respiratory drive.
• Monitor intake and output fluids.
• Explain to the patient:
• The importance of turning, coughing, and deep-breathing exercises.
• How to administer oxygen therapy.
• Avoid exposure to irritants and people with infections.