COPD – Procedures and Guidelines for Evidence-Based Standardized Practice Essay

According to Hatipoğlu (2018) COPD is a global prevalent disease of the respiratory system and the 3^rd major cause of deaths in the US after cancer and heart disease. The global burden of COPD has decreased in the past two decades due to remarkable advances in researchers’ and clinicians’ understanding of the etiology, clinical presentation, related comorbidities, and management of COPD. COPD is primarily characterized by continuous and progressive airflow limitations, is initiated by a chronic airway and inflammatory response after exposure to noxious gases or particles. COPD – Procedures and Guidelines for Evidence-Based Standardized Practice Essay.

According to Plishka et al (2016), in the year 2009, COPD accounted for an estimated 1.5 million visits to EDs, 8 million visits to physicians, more than 133, 000 deaths and 715, 000 hospital admissions. In the year 2010, the US Department of Health spent more than $49.9 billion to manage COPD. Acute COPD exacerbations accounted for the highest mortalities and significant costs. In Canada, healthcare costs of severe and moderate COPD exacerbations were approximated to be more than $646 million annually and £800 million in the UK (Plishka et al, 2016).

To continue minimizing the global burden of COPD, GOLD (Global Initiative for Chronic Obstructive Lung Disease) in collaboration with organizations such as the ATS (American Thoracic Society) and the ERS (European Respiratory Society) provided guidelines on the identification, diagnosis, pharmacological and non-pharmacological management of COPD. These guidelines are based on high-level research evidence particularly systematic reviews of RCTs (randomized controlled trials) to guide healthcare providers (Mirza et al, 2018). Since nurse practitioners play a major role in diagnosing and managing COPD, knowledge of COPD guidelines is imperative to increase patient’s quality of life and decrease the utilization of healthcare.

Morbidity and Mortality

According to May & Li (2015), COPD initially ranked as the 5^th global burden of disease and the 3^rd cause of deaths across the globe by the year 2020.  On the contrary, COPD met this prediction in the US    by the year 2008 as the 3^rd leading cause of death. Globally, COPD accounted for more than 4 million deaths in the year 2008 when compared to stroke and cardiovascular illnesses and remains to be the major cause of deaths that is gradually increasing. Annually in the US, COPD accounts for more than 15 million visits to physicians’ offices, 726,000 hospital admissions, and 1.5 million visits to emergency departments (May & Li, 2015).  COPD – Procedures and Guidelines for Evidence-Based Standardized Practice Essay. Based on the estimates provided by the NHLBI (National Heart and Lung Blood Institute),  the number of people diagnosed with COPD by physicians is 14.8 million and those who remain undiagnosed are 12 million(Sullivan et al., 2018). Globally, the unadjusted   COPD mortality rate was 45.3 per 100,000 people in the year 2008.

Etiology

The main risk factor for COPD is tobacco. According to Mirza et al (2018),   tobacco smoking accounts for an estimated 40%-70% of COPD incidences and results in pathology by influencing a chronic inflammatory response,   dysfunction of cilia, and oxidative injury.  However, there are other potential etiologies such as occupational exposure to fumes, chemical agents and dust, air pollution, and burning biomass fuels indoors (Hatipoğlu, 2018). In patients with deficiency of alpha-1 antitrypsin, an imbalance of antiproteases and proteases and oxidative stress has a significant influence in the pathophysiology.

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Pathophysiology

Tobacco smoking remains the closest precipitating factor of COPD among smokers while exposure to chronic infections of the lower respiratory tract, fumes, dust, and biomass fuels are the precipitating pathophysiological factors among non-smokers. When inhaled, these particles initiate a chronic lung inflammatory response involving macrophages and neutrophils while in smokers, there is additional involvement of Tc1 lymphocytes and oxidative stress (O’Reilly, 2016).  Oxidative stress causes proteases to breakdown lung connective tissue resulting in emphysema. Emphysema causes trapping of air, airflow limitation, poor release, and absorption of respiratory gases.

Continuous scarring and inflammation of the airways contribute to obstructive bronchiolitis which causes an inability to breathe out. This happens when there is a decrease in the flow of air during expiration when chest pressure compresses the airways, trapping more air within the lungs resulting in hyperinflation. O’Reilly (2016) highlights that hyperinflation, a decrease in the desire to breathe, and obstruction of the airways that causes a poor exchange of respiratory gases can cause a ventilation-perfusion mismatch in COPD patients resulting in high levels of carbon (IV) oxide and low levels of oxygen. In the event of a COPD exacerbation, there is also an increase in the inflammation of the airways, a decrease in the expiratory flow of air and the transfer of gases worsens which ultimately impairs ventilation and the levels of oxygen in blood (O’Reilly, 2016). If the levels of oxygen in the blood continue to be persistently high, it can cause narrowing of the lung arteries while emphysema can result in a breakdown of lung capillaries. COPD – Procedures and Guidelines for Evidence-Based Standardized Practice Essay.  According to O’Reilly (2016), these pathological processes can lead to cor pulmonale which is characterized by increased pulmonary arterial blood pressure with subsequent right-sided failure.

Diagnostic Testing

GOLD guidelines recommend that healthcare providers should consider a diagnosis of COPD among patients presenting with symptoms of dyspnea, a productive cough, and an exposure history to potential risks of COPD. However, to make a definitive COPD diagnosis, spirometry is the main confirmatory test as it confirms airflow limitation expressed as FEV₁ (forced expiratory volume)/ FVC) (forced vital capacity) (Mirza et al, 2018). Based on the scores obtained, a provider can determine the extent of symptom severity by referring to the spirometry staging system.  The spirometry classification is the most useful method for predicting a patient’s health status, developing exacerbations, healthcare resource utilization, and COPD mortalities. GOLD proposed spirometry classification recommends that, patients with spirometry of FEV₁/FVC < 0.70, and spirometry ≥ 80% with symptoms of productive sputum and a chronic cough should be diagnosed with mild COPD (Stage 0).

Patients with FEV₁/FVC < 0.70 and spirometry 50%–80% with symptoms of productive sputum, cough, and shortness of breath on exertion be diagnosed with mild COPD (stage I). In moderate COPD (stage II), patients have an FEV₁/FVC < 0.70 and spirometry 30%–50% with symptoms of repeat exacerbations, greater shortness of breath, and a decreased exercise capacity (Mirza et al, 2018). In stage III (severe) COPD, the FEV1/FVC is < 0.70, spirometry is < 30%.  Lastly, in very severe COPD (stage IV), patients have FEV₁/FVC ≤ 0.7 and symptoms of respiratory failure which can also result in cor pulmonale (Mirza et al, 2018). The guidelines further recommend that healthcare providers should consider testing for the deficiency of α₁‐antitrypsin in patients with a familial history of COPD or those who present at an early age (40s or 50s) with airflow limitation.

Although spirometry is the major test in diagnosing COPD, guidelines by the American Academy Family of Physicians further recommend that clinicians should consider other tests to rule out concomitant diseases. For instance, clinicians should order for chest radiography to search for evidence of fibrotic changes, lung masses, and nodules (Stephens & Yew, 2008).   Clinicians should also order for a complete blood count to exclude polycythemia or anemia. For patients who present with signs of cor pulmonale, providers should consider ordering for an echocardiogram or an electrocardiogram as this may help to evaluate for pulmonary circulatory pressures (Stephens & Yew, 2008). To assess patients for supplemental oxygen therapy and hypoxemia, clinicians should consider pulse oximetry tests during sleep and with exertion. COPD – Procedures and Guidelines for Evidence-Based Standardized Practice Essay.

Clinical Presentation, Relevant Objective, and Subjective Findings

The major subjective findings of patients with COPD include the symptoms of dyspnea, an increase in the production of sputum, and a cough. These symptoms are particularly common among patients with a smoking history. Other patients may report wheezing and less commonly reported symptoms are increased night awakenings, edema, weight loss, and chest tightness (Qaseem et al. 2011). Providers can use the Medical Research Council dyspnea index to assess patients for the severity of COPD. Another accurate subjective finding in patients suspected of COPD is a positive familial history of COPD, occupational exposure to COPD risk factors and a history of cigarette smoking often expressed as pack years.

Although objective findings are not sensitive for initially diagnosing COPD since most patients have normal findings on examination. For patients with abnormal findings, clinicians are likely to note features of lung hyperinflation such as a wide anterior-posterior chest diameter. On percussion, the chest is hyper-resonant and on auscultation, there will be diminished breath sounds. When there is continuous damage to the pulmonary vasculature, patients might experience right-sided heart failure, commonly known as cor pulmonale. The objective findings of cor pulmonale include; peripheral edema, hepatomegaly, a heightened second heart sound, and jugular venous distension (Qaseem et al. 2011). Objective findings of pursed-lip breathing, respiratory distress may include an increase in the expiratory time, and auscultatory wheezing, breathing using accessory muscles, and paradoxical abdominal movement. The most significant findings that are occasionally related to COPD are cachexia and cyanosis.

Diagnostic Criteria and Management

Based on the latest guidelines provided by GOLD on diagnosing and managing COPD, the goal of COPD management should focus on reducing the severity of symptoms, improving life quality, and preventing COPD exacerbations. Management is highly dependent on a patient’s stage and the extent of the severity of symptoms. However, the overall management begins with avoidance of potential risk factors, vaccination, and smoking cessation.

• Patients with an FEV1 between 60%-80% (group A) should be managed with short-acting beta₂agonists such as levalbuterol and albuterol, or short-acting anticholinergics such as ipratropium to manage intermittent symptoms. These agents help to relax the smooth muscles of the airways and improve emptying in the lungs during tidal breathing (Mirza et al., 2018). This ultimately helps to delay the onset of hyperinflation during physical activity as well as to decrease the residual volume. Short-acting bronchodilators can influence an acute increase in tolerance to exercise and physical activity.
• Stable patients with FEV1 <60% and respiratory symptoms (group B) should be managed with long-acting beta₂agonists (formoterol, arformoterol, or salmeterol) or long-acting inhaled anticholinergics (tiotropium and aclidinium). The guidelines further recommend that, if a clinician prescribes tiotropium, the patient should immediately switch from ipratropium/albuterol or ipratropium to a short-acting drug such as albuterol (Qaseem et al, 2011).  Evidence suggests that long-acting beta 2 agonists decrease the risk of exacerbations and improve FEV₁. When compared to tiotropium, tiotropium decreases the risk of exacerbations and COPD-associated admissions but does not affect deaths. However, for patients who do not achieve symptom control with a long-acting beta₂ agonist or tiotropium alone, Mirza et al., (2018) recommend combining a long-acting beta₂ agonist and tiotropium for short-term outcomes.
• Patients with and FEV1 <60% who remain symptomatic (GOLD Group C) and symptomatic patients with FEV1<60% and stable COPD (Gold Group D) should be managed with monotherapy with either a long-acting inhaled β-agonists or a long-acting inhaled anticholinergics or a combination of long-acting beta₂agonist and an inhaled corticosteroid. COPD – Procedures and Guidelines for Evidence-Based Standardized Practice Essay. However, for patients with a history of poorly controlled symptoms, providers should consider starting them on a triple therapy of a long-acting beta₂ agonist, an inhaled corticosteroid, and a long-acting anticholinergic.
• Pulmonary rehabilitation is suitable in cases with FEV1 >50% or symptomatic patients with exercise limitations and an FEV1 >50%. It improves social support, exercise, and provides patients with tools to cope with COPD. It is suitable for patients who previously tried different pharmacological agents for COPD but still experience difficulties performing ADLs and have trouble breathing.
• COPD patients who present with hypoxemia (SPO₂≤88% or PAO₂ ≤55 mmHg) should be started on continuous oxygen therapy. Oxygen therapy is essential in improving cognitive performance, exercise, survival, and sleep in patients with hypoxemia. To determine a patient’s need for oxygen, providers should perform an ABG (arterial blood gas) assessment which also ascertains the arterial oxygen saturation as measured by pulse oximetry (SPO₂). According to Lee, Kim & Tagmazyan (2013), the goal of therapy should be to maintain the SPO₂ >90% during exertion, sleep, or rest. However, withdrawing oxygen when a patient’s PAO₂ improves and whose oxygen need was ascertained while stable may have significant effects.

Managing COPD Exacerbations

Patients with COPD may experience a change in the baseline sputum/cough, and dyspnea from the usual day to day variability warranting a change in the management approach. The management of exacerbations depends on the severity (mild, moderate, or severe) and clinical presentation. Wedzicha et al (2017) recommends that clinicians should begin with taking a comprehensive health history and present symptoms with spirometry, chest radiographs, and arterial blood gas measurements to evaluate lung function.  Patients can only be hospitalized under the following indications during an exacerbation;

• A significant increase in dyspnea
• Inadequate response to management as an outpatient
• An underlying high-risk comorbid condition such as heart failure, liver or renal failure, pneumonia, diabetes mellitus, and cardiac arrhythmias
• Change in mental status
• Worsening hypercapnia and hypoxemia
• Inadequate care at home
• A patient’s inability to care for him/herself

Patients with mild COPD exacerbations should be managed as outpatients as follows; patient education (assess patient’s inhalation technique), prescribe bronchodilators (a short-acting beta-agonist or ipratropium). Clinicians can also include a long-acting bronchodilator if the patient does not have one and a corticosteroid (prednisone 30-40mg orally for 10-14 days) (Wedzicha et al, 2017). Antibiotics such as macrolides amoxicillin or cephalosporins can only be prescribed in patients whose sputum characteristics have changed. COPD – Procedures and Guidelines for Evidence-Based Standardized Practice Essay.

In moderate COPD exacerbation, patients must be hospitalized and managed with supplemental oxygen (for O₂ saturation <90%), ipratropium MDI and a short-acting beta-agonist. If patients can tolerate oral intake, clinicians should also prescribe prednisone 30–40 mg PO for 10–14 days and prednisone IV to day 14 if they cannot tolerate oral intake(Wedzicha et al, 2017). The most recommended antibiotics to prescribe are respiratory fluoroquinolones and Amoxicillin/clavulanate but this is determined by local patterns of bacterial resistance.

Patients with severe COPD exacerbation need ICU or special care. The American Academy of Family Physicians recommends ventilator support, supplemental oxygen, ipratropium MDI 2 puffs after every 2-4 hours, and a short-acting beta 2-agonist (Wedzicha et al, 2017). If the patient can tolerate oral drugs, a provider should prescribe prednisone 30–40 mg PO for 10–14 days and antibiotics such as respiratory fluoroquinolones and Amoxicillin/clavulanate based on local patterns of bacterial resistance.

References

Hatipoğlu U. (2018). Chronic obstructive pulmonary disease: More than meets the eye. Annals of thoracic medicine, 13(1), 1–6. https://doi.org/10.4103/atm.ATM_193_17

Lee, H., Kim, J., & Tagmazyan, K. (2013). Treatment of stable chronic obstructive pulmonary disease: the GOLD guidelines. American family physician, 88(10), 655-663.

May, S. M., & Li, J. T. (2015). Burden of chronic obstructive pulmonary disease: healthcare costs and beyond. Allergy and asthma proceedings, 36(1), 4–10. https://doi.org/10.2500/aap.2015.36.3812

Mirza, S., Clay, R. D., Koslow, M. A., & Scanlon, P. D. (2018, October). COPD guidelines: a review of the 2018 GOLD report. In Mayo Clinic Proceedings (Vol. 93, No. 10, pp. 1488-1502). Elsevier.

O’Reilly S. (2016). Chronic Obstructive Pulmonary Disease. American journal of lifestyle medicine, 11(4), 296–302. https://doi.org/10.1177/1559827616656593

Plishka, C., Rotter, T., Kinsman, L., Hansia, M. R., Lawal, A., Goodridge, D., & Marciniuk, D. D. (2016). Effects of clinical pathways for chronic obstructive pulmonary disease (COPD) on patient, professional, and systems outcomes: protocol for a systematic review. Systematic reviews, 5(1), 135. COPD – Procedures and Guidelines for Evidence-Based Standardized Practice Essay.

Qaseem, A., Wilt, T. J., Weinberger, S. E., Hanania, N. A., Criner, G., van der Molen, T., … & Shekelle, P. (2011). Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Annals of internal medicine, 155(3), 179-191.

Stephens, M. B., & Yew, K. S. (2008). Diagnosis of chronic obstructive pulmonary disease. American family physician, 78(1), 87-92.

Sullivan, J., Pravosud, V., Mannino, D. M., Siegel, K., Choate, R., & Sullivan, T. (2018). National and state estimates of COPD morbidity and mortality—United States, 2014-2015. Chronic Obstructive Pulmonary Diseases: Journal of the COPD Foundation, 5(4), 324.

Wedzicha, J. A., Miravitlles, M., Hurst, J. R., Calverley, P. M., Albert, R. K., Anzueto, A., … & Krishnan, J. A. (2017). Management of COPD exacerbations: a European respiratory society/American thoracic society guideline. European Respiratory Journal, 49(3).

Assignment Content:

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Each state has its own requirements for advanced practice registered nurse (APRN) practice. Employers, likewise, may have additional limitations for APRN practice, such as standardized policies and procedures, chart review processes, supervising physician agreements, etc.

Use your findings from this week’s Standardized Policies and Procedures Research learning activity (SEE Instructions BELOW) for this assignment.

• Write a 2,200 -word evidence-based practice paper that you would consider submitting for publication on the evaluation, assessment, diagnosis, and treatment of the topic selected of COPD (Chronic obstructive pulmonary disease).

• Apply appropriate national guidelines and evidence-based practice guidelines (See BELOW for some referenced material …)

Include the following components:

1. • Introduction, morbidity and mortality, etiology, pathophysiology, and diagnostic testing
   • Clinical presentation, relevant objective and subjective findings
   • Diagnostic criteria and management, including clinical preventive services and treatment plan (treatment plans must follow evidence-based practice and national guidelines when available)COPD – Procedures and Guidelines for Evidence-Based Standardized Practice Essay.

Include a minimum of 10 references from the most current national guidelines from professional sites and sources including peer-reviewed  articles in the last 5 years.

Format your assignment according to APA guidelines.

National Guidelines and Evidence-Based Practice Guidelines

https://journal.copdfoundation.org/jcopdf/id/1209/National-and-State-Estimates-of-COPD-Morbidity-and-Mortality-United-States-2014-2015#:~:text=The%20total%20average%20number%20of,%2C%2045.7%20and%2039.7%2C%20respectively.

https://goldcopd.org/

https://www.cdc.gov/copd/for-clinicians.html

https://www.guidelinecentral.com/summaries/chronic-obstructive-pulmonary-disease/#section-society

https://emedicine.medscape.com/article/297664-guidelines 

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In ADDITION, These researched articles may be useful …

• Brandt, C. L. (2013). Study of Older Adults’ Use of Self‐Regulation for COPD Self‐Management Informs An Evidence‐Based Patient Teaching Plan. Rehabilitation Nursing, 38(1), 11-23. 

• Lodewijckx, C., Decramer, M., Sermeus, W., Panella, M., Deneckere, S., & Vanhaecht, K. (2012). Eight-step method to build the clinical content of an evidence-based care pathway: the case for COPD exacerbation. Trials, 13(1), 229. 

• Rennard, S., Thomashow, B., Crapo, J., Yawn, B., McIvor, A., Cerreta, S., … & Mannino, D. (2013). Introducing the COPD Foundation Guide for Diagnosis and Management of COPD, recommendations of the COPD Foundation. COPD: Journal of Chronic Obstructive Pulmonary Disease, 10(3), 378-389. COPD – Procedures and Guidelines for Evidence-Based Standardized Practice Essay. 

• Morgan, A. D., Zakeri, R., & Quint, J. K. (2018). Defining the relationship between COPD and CVD: what are the implications for clinical practice?. Therapeutic advances in respiratory disease, 12, 1753465817750524.

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Learning Activity

• Standardized Policies and Procedures Research Locate and download the board of registered nursing sample template for standardized policies and procedures for your state of practice FLORIDA.

Please follow the grading criteria (See Below), when writing this paper.

Grading Criteria:

COPD – Procedures and Guidelines for Evidence-Based Standardized Practice Essay