This assignment will discuss the changes of normal social, physical, biochemical and physiological functions of a disease process of chronic obstructive pulmonary disease (COPD). This is a term used for a number of conditions; including chronic bronchitis and emphysema. COPD leads to damaged airways in the lungs, causing them to become narrower and making it harder for air to get in and out of the lungs. The word ‘chronic’ means that the problem is long-term. COPD is a condition which mainly affects people over the age of 40, and COPD has a higher prevalence occurring among women than men (NHS-Choices, 2008).
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COPD is also a condition that is long term and incurable that can have a serious affects on health and quality of life, its not fully understood why COPD develops. (Marieb, 2003). The student will also incorporate local and national health and social policies, including frameworks that are in place in relation to the patient’s illness. The student identified a patient named Mrs J. She was admitted to hospital due to exacerbation of COPD. Her primary diagnosis is Osteoarthritis of the Hip but also had symptoms of emphysema. Mrs J is a 55 year old woman and is married, Mrs J also has an older child of 34 whom she has become quite dependant on and felt like she had impacted on her child’s life and had become a hindrances. Mrs J has become more breathless as her condition develops over time and more so while she was lying in bed unable to carry out her daily activities such as doing the housework, leisure activities, also looking after her appearance as she normally would have done at home.
COPD is becoming one of the fastest leading causes of disability (NHS choices, 2008). According to British Lung Foundation, (2010) a recent survey, 83% of COPD patients said their COPD slows them down, 79% said they had to cut down their activities and 56% said their condition has a great affect on their families. COPD is the most common respiratory conditions in adults in the developed world and poses an enormous burden to society both in terms of direct cost to the healthcare services and indirect costs to society through loss of productivity. Recent analysis estimated that National Health Service (NHS) spends £818 million annually in the United Kingdom (UK). (British Thoracic Society, 2006). However 50% of the cost is accounted for by poorly managed exacerbations resulting in frequent re-admissions to hospital (Coakley & Ruston, 2001).
COPD is a chronic inflammatory condition of the lungs that causes the respiratory passages to be swollen and irritated, increases the mucus production and damaging the lungs. (Marieb, 2003).
COPD develops when irritants are breathed into the airway and down the bronchial tubes. Normally, oxygen is passed through the bronchioles into the alveoli, tiny hollow sack-like structures in the lungs where oxygen is absorbed in to the bloodstream. When air is mixed with smoke or irritants, it will damage the lungs and the ability to take enough oxygen in (NHS-Choices, 2008).
Mrs J condition would of been triggered by her heavy smoking, the toxins from her cigarettes has made her bronchioles (airway and lungs) become inflamed and narrowing the airway, this will lead to irreversible damage to the respiratory system by obstructing the bronchial airflow and hindering gaseous exchange within the alveoli (Munden, J, 2007). Mrs J suffers from many symptoms due to her smoking these include shortness of breath, a persistent cough, yellowish green sputum, signs of cyanosis to her lips, also Mrs J has continued to smoke as she thinks the damage has already been done so her condition. The vast majority of COPD patients are smokers. By stopping smoking patients can slow the rate of decline in lung function and thus improve the patient’s prospects in terms of symptoms and survival.
The NICE guidance recommends that short-acting bronchodilators should be used for the initial treatment for breathlessness and exercise limitation and goes on to say that, if this isn’t having an effect then the treatment should be intensified using either a long-acting bronchodilator or a combined therapy with a short acting beta2-agonist and a short-acting anticholinergic.
The respiratory system is the major part for gases exchange to take place, it allows takes the air that enters are bodies when we inhale and travels through the respiratory system, exchanging oxygen for carbon dioxide and expels carbon dioxide when we exhale (munden, J, 2007).
Mrs J has been smoking now for 45 years and on an average day having up to 40 cigarettes a day and is not prepared to quit as she feels the damage is already done. Mrs J smokes for comfort and feels that its all for her pleasure, she has become very isolated, her chronic bronchitis makes her breathless when doing actives and is not able to do her daily activities therefore is becoming depressed. Do this having a huge impact on her mental and social parts of her life.
Patients like Mrs J with airflow limitation clinically they have become known as ‘pink puffers’ and ‘blue bloaters’ (Kleinschmidt, 2008). Patients with COPD have traditionally been divided into pink puffers and blue bloaters based on their physiological response to abnormal blood gases. The former work hard to maintain a normal pO2 which is why they puff away. They tend to have a barrel-shaped, hyper inflated chest and breathe through pursed lips. The latter are blue because of hypoxia and polycythaemia. They are often obese and have water retention. This is why they are bloated. The blue bloaters are dependent upon hypoxia for their respiratory drive and to give oxygen and deprive them of this will lead to significant hypercapnia and acid base imbalance. (MedicineNet, 1996 – 2010)
Mrs J falls under the term ‘blue bloaters’ as she linked to chronic bronchitis due to cyanosis which causes a blue tinge to the lips, which occurs from poor gas exchange. Airway Smooth Muscle in Asthma and COPD: Biology and Pharmacology by Prof. Kian Fan Chung
‘pink puffers’ has been linked to emphysema as the patients may be showing signs of weight loss, using their accessory muscles with pursed lips giving them a reddish complexion, they may also adopt the tripod sitting position (Kleinschmidt, 2008). Although these conditions separate the patient may present with slight variations of them both, however they do differentiate through their underlying process, signs and symptoms (Bellamy & Booker, 2004).
The respiratory system can be separated into a conducting and a respiratory portion. The conducting portion consists of the air-transmitting passages of the nose, nasopharynx, larynx, trachea, bronchi and bronchioles. This part of the respiratory system serves to filter, warm and humidify air on its way to the lungs. Principles of Anatomy and Physiology by Gerard J. Tortora, and Bryan H.
Specialized portions of the conducting system also serve other functions, e.g., the nose in the sense of smell, the pharynx in alimentation, and the larynx in phonation. The actual exchange of gases occurs in the respiratory portion which consists of the respiratory bronchioles, alveolar ducts and sacs and alveoli. Ross and Wilson Anatomy and Physiology in Health and Illness.
Principles of Anatomy and Physiology by Gerard J. Tortora, and Bryan H. Derrickson
There are two separate arterial systems in the lungs, the pulmonary arteries which carry deoxygenated blood, follow the respiratory passages and end in capillaries in alveolar walls, and the bronchial arteries which carry oxygenated blood. (Ross and Wilson,2009).
The lungs are richly supplied with lymphatic vessels, which are organized into two sets a deep set that accompanies the pulmonary vessels and airways and a superficial set that lies beneath the visceral and parietal pleura. Little or no anatomises occurs between the two plexus except in the region of the hilum. (SUNY Downstate Medical Center, 2008)
The lung is the organ for gas exchange; it transfers oxygen from the air into the blood and carbon dioxide from the blood into the air. To accomplish gas exchange the lung has two components, airways and alveoli. The airways are branching, tubular passages like the branches of a tree that allow air to move in and out of the lungs. The wider segments of the airways are the trachea and the two bronchi. The smaller segments are called bronchioles. At the ends of the bronchioles are the alveoli, thin-walled sacs. Small blood vessels (capillaries) run in the walls of the alveoli, and it is across the thin walls of the alveoli where gas exchange between air and blood takes place. 1996-2010 MedicineNet, http://www.medicinenet.com/chronic_obstructive_pulmonary_disease_copd/article.htm
Airways and air sacs within the lungs are elasticised, with the air we breathe the lungs will change shape with inhalation they expand and return to the normal shape after they have been stretched with full of air.
With in the Lining the of the nasal cavity is a mucous membrane full of blood vessels, with the many blood vessels this enable the nose to warm and humidify the incoming air quickly. Cells in the mucous membrane produce mucus and have tiny hair like projections (cilia). Usually, the mucus traps incoming dirt particles, which are then moved by the cilia toward the front of the nose or down the throat to be removed from the airway. This action helps clean the air before it goes to the lungs.
Ciliated Columnar Epithelium which contains goblet cells and cilia, the goblet cells are responsible for secreting mucus which is able to trap the finer particles from inspired air and the cilia which are fine hairs to trap particles from going into the respiratory track. The cilia carry’s the particles by a sweeping the mouth or nose where it can then be swallowed, coughed or sneezed out of the body (Munden, 2007).
The two major sources of mucus secretion in the respiratory tract are the surface epithelial goblet cells and mucous cells. In lungs, goblet cells are present in the large bronchi, becoming increasingly thin toward the bronchioles. The sub mucosal glands are in the airways with the thickness decreasing with airway quality. With COPD, sub mucosal glands increase in size (hypertrophy), and the number of goblet cells will increased (hyperplasia) (Rogers, Jackson, 2001). The increased of goblet cells to ciliated cells will cause thickness in the bronchioles, this then impairs clearance of mucus.
Patients affected by COPD also show the presence of edema, which can further reduce airway size and compromise the lung function. (Postma and Kerstjens, 1998). In clinical studies, these inflammatory parameters have been shown to correlate with a reduction lung function and an exaggerated bronchoconstriction (Postma and Kerstjens, 1998).
The goblet cells are replaced within the small airways (bronchi) with Clara cells they are another form of secreting cell that are form ciliated cells and to help renew the bronchiolar epithelium, they produce hypophase component and a protease inhibitor these help protect the lungs by clearing foreign bodys from the airway (Stokley et al, 2006)
Gasses exchange in the lung takes places in the airway with in the alveoli, The largest airway is the windpipe (trachea), this then branches into two smaller airways; the left and right bronchi, At the end of each bronchiole are thousands of small air sacs (alveoli) the walls are a thick network of tiny blood vessels called capillaries. The thin barrier between air and capillaries allows oxygen to move from the alveoli to the blood and allows carbon dioxide to move from the blood to the capillaries into the alveoli (Matterporth & Matfin, 2009).
Mr J has a poor respiratory drive due to having poor ventilation on the lungs. Hypoxemia and hypercapnia can take place due to the poor ventilation, hypoxia in Patients with COPD like Mrs J have raised CO2 levels and depend on a deficiency of oxygen (hypoxia) to encourage respiration. They will develop increased CO2 retention, respiratory acidosis and subsequently will require mechanical ventilation (oxygen). It also causes the kidneys to produce erthpoietin which stimulates excessive red blood cell production as Mrs J has poor ventilation intake the blood cells are not fully oxygenated there for cyanosis can occurs (Munden, J, 2007).This has lead to hypercapnia due to raised carbon dioxide levels resulting from suppression of hypoxic ventilation drive. However, this understanding does not account for the many factors that contribute to the control of breathing in patients, and has resulted in oxygen being withheld inappropriately from some patients with acute respiratory failure. (Brooker & Nicol, 2004). Mrs J has lent to live in hypoxic drive as she has made adjustments in her life and has lived like this for 4 years now and has become normal to her. Mrs J has sensitivity to falling oxygen levels rather than raised carbon dioxide (Brooker & Nicol, 2004). A higher level of oxygen within Mrs J’s system reduces the stimulus to breath therefore inducing carbon dioxide maintenance (Walsh & Crumbie, 2007).
Emphysema occurs when the air sacs at the ends of your bronchioles gradually gets destroyed, smoking is the leading cause of emphysema. Resulting in the air sacs (alveoli), in the lungs becoming over stretched making their thin walls tear, there for losing the lung tissue and elasticity. The lungs cannot expand or contract fully, and so become less efficient when breathing. (McCance & Huether, 2006) As the condition worsens, emphysema turns the air sacs which are like a bunch of grapes to become enlarged, irregular pockets with gaping holes in their inner walls; this reduces the number of air sacs and keeps some oxygen entering the lungs from reaching the bloodstream (Munden, J, 2007). This makes you try and breathe harder as insufficient oxygen is not getting into our airways. Our bodies compensates by lowering cardiac output and we then begin to hyperventilate, which then results in limited blood flow through fairly well oxygenated lungs this is in contrast to chronic bronchitis (Brooker & Nicol, 2004). Due to low cardiac output in Mrs J’s body it will tend to suffer from tissue hypoxia leading to weight loss or muscle wasting (McClance & Huether, 2006).
Mrs J’s chronic bronchitis is a Type 2 respiratory failure; this refers to hypercapnoea, which is a presence of an abnormally high level of carbon dioxide in the blood steam, which can occur with or without hypoxia. This type of respiratory failure is caused by a decline the amount of gas inhaled and exhaled (Higgins,D., Guest,J, 2008). Respiratory failure occurs when alveolar ventilation is ineffective to expel carbon dioxide in the body. Poor ventilation is due to reduced ventilation effort, it affects the lung as a whole, there for carbon dioxide accumulates in the lungs this could deadly if it is not treated (Partridge, 2006). This process is seen in patients such as Mrs J with COPD and can be made more aggressive by an illness (Higgins,D., Guest,J, 2008).
Mrs J views her quality of life as poor and hates getting up in the mornings, this is because Mrs J becoming breathless and not being able to fulfil her daily activities.
COPD can leave patients feeling anxious and suffering from panic attacks (Christen & Antoni, 2000). Mrs J feels frightened becoming breathless as she has had frequent admissions of exacerbation with long stays in hospital, exacerbations is a increased case of breathlessness and sputum experience and very distressing for patients and disruptive to their lives (Alaxander,Fawcett & Runciman, 2006).
Because of Mrs J being short of breath she feels very lonely and isolated, Mrs J has now got a low self esteem and self confidence this has been induced by her affects of the disease, any activities such as washing, dressing and shopping has become quite dependant on her family in these tasks and feels helpless and a burden to them. The psychological affects of living with COPD can be overwhelming the anxiety and panic levels are very high as Mrs J is living in constant fear and frustration each day of the affects of the illness.
COPD patients tend to have a high prevalence rate of clinical depression (N, Haynes, 2000). Depression is very common in COPD patients, around 40% are affected by severe depressive symptoms or clinical depression (Henriksen,A, 2008).
Since Mrs J has been diagnosed she has had to make some psychological adjustments, she has some challenges ahead of her such as maintaining her ADL’s i.e. self image and personal hygiene. Mrs J feels weak and drained on any activities she does due to breathlessness, most of the time she has to rely on her husband and family to meet these needs and has become dependant upon them; this can lead to activation of negative self image which has lasting changes to the patient (Christen & Antoni, 2000). Mrs J feels that dealing with her chronic illness she has had to challenge her own self worth, her own sense of vulnerability and to think of what the future has in hold for her (N, Haynes, 2000). COPD may also adversely affect Mrs J self image which is negatively stigmatised her self inflicted this illness on her self due to smoking (Gore et al, 2000).
Stigma has had a huge impact on Mrs J’s low self esteem as she has smoked most of her life and has caused her condition to progress, so she only has herself to blame. Having low self esteem can be very difficult for some patients to handle as is plays a role in their lives (Christen & Antoni, 2000). The more inactive Mrs J will becomes it will decrease her self esteem and can have an impact on her well being (Haynes, 2000). Mrs J also thinks that she has become depressed due to her condition which has had a huge impact on her quality of life with has lead to isolation and dependant on family and friends (Barnett, 2008).
COPD patients are being stigmatized in today’s society, this disabling condition has been linked to poor lifestyle changes and people that have smoked (Bartolame, Berger, 2009).
Patients with COPD feel stigmatised due to medical profession as they have been labelled under ‘pink puffers’ and ‘blue bloaters’ this can have a negative impact on their image (Johnson et al, 2007). Mrs J feels that the main reason that she has become isolated is that she is embarrassed by her visible side affect due to poor mobility and breathlessness. COPD research has mainly focused on the medical side rather than the social impact of the disease. This neglect is seen as patients are not prepared for wider social attitudes of smoking related to their illness and has been looked at as self infliction and avoidable conditions creating stigma which is attached to the disease (Johnson et al, 2007).
The National Clinical Strategy for COPD is currently being developed by the Department of Health. This was previously known as the National Service Framework (NSF). Following the Darzi report which stated that ‘high quality for all’ this was based upon ways to reshape and improve the NHS. The National Clinical Strategy will address the lack of awareness of COPD and also focus on the undiagnosed or inaccurately and also making clear pathways for those diagnosed. (NICE, 2004). NICE guidelines on COPD Cover a full range of care that should be available from the NHS to adults like Mrs J who has this illness and to have the appropriate support and treatments this includes smoking cessation, pulmonary rehabilitation and management of exacerbations and to have easy access to these services (NICE, 2008).
COPD has had a huge negative impact on Mrs J’s life she has had to overcome challenges due to her COPD such as her basic day to day activities, by making some adjustments to meet these tasks. With Mrs J disabling disease this has lead to loss of function, low self confidence and has become socially isolated in her own home due to her clinical depression (Brooker, 2005).
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