Chronic Obstructive Pulmonary Disease (COPD) is a group of lungs diseases that includes emphysema, chronic bronchitis and chronic asthma (irreversible). Pathophysiology: presence of both component pulmonary (lungs) and systemic; hyperplasia of goblet cells enhances secretion of mucous, which accumulates in airways limiting the airflow. The cholinergic tone of smooth muscle and reduced elasticity due to existing lung conditions further reduces lungs ability to function. In all these conditions either the airway or the alveoli are compromised, leading to difficulty in gas exchange. 

The role of Nurses is to monitor patient vital observation, form a clinical judgement, prioritise care needs and take necessary steps based on clinical judgement, administer prescribed medication and supplemental oxygenation, perform non-invasive tests such as spirometry before and after medication administration, breathing exercise recommended by physiotherapists, physical exercise as tolerated, provide education and advocacy where needed.
NPS Medicinewise. (2022). The most common medicines used for COPD help to relieve symptoms such as coughing, wheezing and shortness of breath, making it easier for you to breathe. https://www.nps.org.au/consumers/medicines-for-copd#%C2%A0what-medicines-will-i-need?

Lakhna. (2019). What is the difference between Oxygenation and Ventilation. PEDIAA.  https://pediaa.com/what-is-the-difference-between-oxygenation-and-ventilation/#:~:text=The%20main%20difference%20between%20oxygenation%20and%20ventilation%20is,ventilation%20reduces%20the%20partial%20pressure%20of%20carbon%20dioxide.

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Discussion Post #1 - Manuel's Pain Medication

During this week’s workshop, the topic that piqued my attention the most was the clinical reasoning behind analgesia medication administration for Manuel. Manuel is an 89 year old male with an extensive history of COPD. My initial choice was per oral Oxycodone 5mg as I thought Paracetamol 1g was insufficient to address his pain. However upon checking with my groupmates, they had advised that Oxycodone would not be well tolerated by Manuel as he is vomiting. We had then decided to administer intramuscular Morphine 10mg as it will also assist him with his breathing.

I was initially conflicted with administering Morphine as I had remembered that one of its adverse effects was respiratory depression. Since Manuel already had COPD, I thought that it would be detrimental to his respiration. However, upon checking the evidence, respiratory depression rarely develops if opioids like morphine are carefully prescribed and monitored (Bryant et al., 2019). Moreover, Manuel does not have liver disease so using opioids at therapeutic doses can indeed help with his pain because renal disease can cause respiratory depression by extending the half-lives of opioids that are excreted in an active form (Bryant et al., 2019).

Finally, pain management for Manuel must be closely monitored during his entire stay in the hospital as a study of COPD patients with a median age of 72 years old found that low doses of extended-release morphine at 8 mg/d and 16 mg/d did not significantly reduce the intensity of the patient’s worst breathlessness after 1 week of treatment (Ekstroem et al., 2022).

 

Bryant, B., Knights, K., Darroch, S., & Rowland, A. (2019). Pharmacology for Health Professionals (5^th ed). Elsevier.

Ekström, M., Ferreira, D., Chang, S., Louw, S., Johnson, M., Eckert, D., Fazekas, B., Clark, K., Agar, M., & Currow, D. (2022). Effect of Regular, Low-Dose, Extended-release Morphine on Chronic Breathlessness in Chronic Obstructive Pulmonary Disease: The BEAMS Randomized Clinical Trial. JAMA: Journal of the American Medical Association, 328(20): 2022-2032. DOI: 10.1001/jama.2022.20206


INC 6 - Semester 1, 2023

Module 3

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 There is obstruction of normal airflow in COPD due to dysfunction in the alveoli, this not only leads to impaired oxygenation but also causes air hunger and increased work of breathing (Anzueto & Miravitles, 2017). Breathlessness is one of the major issues in advanced chronic obstructive pulmonary disease (COPD), especially among palliatives; breathlessness not only affects the physical ability to attend activities of daily living but is also distressful for other people to visualise (Verberkt et al., 2020). During an exacerbation or simple activity of daily living the chemoreceptors are stretched leading sensation of chest tightness, as well as shortness of breath can be a trigger to cause pain, especially chest pain and bronchospasm (Anzueto & Miravitles, 2017). Therefore, management of symptoms and/or prevention is better than cure. The use of low-dose Morphine regularly for 4 weeks has shown to be effective in advanced COPD and has improved quality of life and is cost-effective for individuals and the healthcare system (Verberkt et al., 2021).

 Morphine is also used for the management of moderate-severe pain. Therefore, administering morphine in low doses can not only help in the management of breathlessness and improve quality of life but also help manage pain symptoms.

Anzueto, A., & Miravitlles, M. (2017). Pathophysiology of dyspnea in COPD. Postgraduate Medicine, 129(3), 366–374. https://doi.org/10.1080/00325481.2017.1301190

 

Verberkt, C.A., van den Beuken-van Everdingen, M. H. J., Dirksen, C. D., Schols, J. M. G. A., Wouters, E. F. M., & Janssen, D. J. A. (2021). Cost-effectiveness of sustained-release morphine for refractory breathlessness in COPD: A randomized clinical trial. Respiratory Medicine, 179, 106330–106330. https://doi.org/10.1016/j.rmed.2021.106330

Verberkt, C. A., van den Beuken-van, M. H., Schols, J. M., Hameleers, N., Wouters, E. F., & Janssen, D. J. (2020). Effect of sustained-release morphine for refractory breathlessness in chronic obstructive pulmonary disease on health status: a randomized clinical trial. JAMA Internal Medicine, 180(10), 1306-1314. https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2769373

 

Reference

Bassi, G. L., Comaru, T., Marti, D., Xiol, E. A., Chiurazzi, C., Travierso, C., Carbonara, M., Ranzani, O. T., Amaro, R., Frigola, G., Fuster, C., Saco, M. A., Zanella, A., Rosa, F. D., Rigol, M., Fernandez, L., Luque, N., Ramirez, J., Blasi, F., Suen, J., & Torres, A. (2019). Recruitment manoeuvres dislodge mucus towards the distal airways in an experimental model of severe pneumonia. British Journal of Anaesthesia, 122(2), 269-276. https://doi.org/10.1016/j.bja.2018.07.039

Sorbo, L. D., Tonetti, T., & Ranieri, V. M. (2019). Alveolar recruitment in acute respiratory distress syndrome: Should we open the lung (no matter what) or may accept (part of) the lung closed?. Intensive Care Medicine, 45(10), 1436-1439. https://doi.org/10.1007/s00134-019-05734-7   

Xia, F., Pan, C., Wang, L., Liu, L., Liu, S., Guo, F., Yang, Y., & Huang, Y. (2020). Physiological effects of different recruitment maneuvers in a pig model of ARDS. BMC Anesthesiology, 20(1), 266-266. https://doi.org/10.1186/s12871-020-01164-x 

There is a high risk of atelectasis among people who undergo open-heart surgery, and post-operative pulmonary complications are prevalent after heart surgery, increasing the risk of mortality and morbidity among these populations (Costa Leme et al., 2017).  A randomised clinical trial done between two groups to see the effectiveness of intensive vs moderate alveolar recruitment in preventing postoperative pulmonary complications revealed that intensive alveolar recruitment was beneficial in people post cardiac surgery, these patients had fewer complications and fewer hospital stays (Costa Leme et al., 2017). However, this study was done in a small group, and other factors such as the use of analgesia, oxygen therapy, fluids management and other drugs were not included in the trial (Costa Leme et al., 2017).

Another trial done to investigate the effects of alveolar recruitment in acute respiratory distress syndrome (ARDS) revealed that the recruitment maneuvers using PEEP titration caused harm in the population suffering from pneumonia and the mortality rate was highest (Zampieri et al., 2019).

Costa Leme, A., Hajjar, L. A., Volpe, M. S., Fukushima, J. T., De Santis Santiago, R. R., Osawa, E. A., Pinheiro de Almeida, J., Gerent, A. M., Franco, R. A., Zanetti Feltrim, M. I., Nozawa, E., de Moraes Coimbra, V. R., de Moraes Ianotti, R., Hashizume, C. S., Kalil Filho, R., Auler, J. O. C., Jatene, F. B., Gomes Galas, F. R. B., & Amato, M. B. P. (2017). Effect of Intensive vs Moderate Alveolar Recruitment Strategies Added to Lung-Protective Ventilation on Postoperative Pulmonary Complications: A Randomized Clinical Trial. JAMA : the Journal of the American Medical Association, 317(14), 1422–1432. https://doi.org/10.1001/jama.2017.2297

Zampieri, F.G., Costa, E. L., Iwashyna, T. J., Carvalho, C. R. R., Damiani, L. P., Taniguchi, L. U., Amato, M. B. P., & Cavalcanti, A. B. (2019). Heterogeneous effects of alveolar recruitment in acute respiratory distress syndrome: a machine learning reanalysis of the Alveolar Recruitment for Acute Respiratory Distress Syndrome Trial. British Journal of Anaesthesia : BJA, 123(1), 88–95. https://doi.org/10.1016/j.bja.2019.02.026

Looking through the lens of a paediatric patient suffering from asthma, it not only affects them by missing out on school attendance, but it also places them at risk of lower academic achievement, risk of disability and emotional problems (Cicutto et al., as cited in Isik et al., 2019). From the parents’ perspective, they miss out on work as they must stay at home and look after their children (Engelke at al., as cited in Isik et al., 2019).

As future RN’s who may potentially work as a school nurse, a study has found that school-based asthma instructive interventions with topics such as “practical trainings on metered dose inhaler performances” are effective in promoting and maintaining health for school-age children who suffer from asthma (Suwannakeeree at al., as cited in Isik et al., 2019). This highlights the importance of patient education and is a practical and achievable project that we can undertake as RN’s in our future nursing practice.

Crisp, J., Douglas, C., Rebeiro, G., & Waters, D. (2021). Potter & Perry’s Fundamentals of Nursing Australia and New Zealand 6^th edition. Elsevier.

Isik, E., Fredland, N., & Freysteinson, W. (2019). School and Community-based Nurse-led Asthma Interventions for School-aged Children and Their Parents: A Systematic Literature Review. Journal of Pediatric Nursing, 44, 107-114. https://doi.org/10.1016/j.pedn.2018.11.007

References:

Zarmouh, A. (2019). Does clinic-based education have a sustainable impact on asthma patient awareness?. Libyan Journal of Medicine, 14(1). https://doi.org/10.1080/19932820.2019.1635843

Ahn, J. H., Chung, J. H., Shin, K., Jung, J. H., Jang, J. G., Lee, M. S., & Lee, K. H. (2020). The effects of repeated inhaler device handling education in COPD patients: a prospective cohort study. Scientific Reports (Nature Publisher Group), 10(1). https://doi.org/10.1038/s41598-020-76961-y

My goal for transition to practice is to improve communication and time management skills, as I believe these two components go hand in hand and are critical for clinical decisions making. As a new graduate transiting from student to working independently will require courage, practice and confidence, and to develop these attributes I will practice giving handovers following ISBAR, whilst receiving patient care I will question if unsure of terminologies, read progress notes from a multidisciplinary team and take note of plans for positive patient outcome. For time management I will stick to the shift planner to guide my task, however, will always prioritise things that are time critical and always come back to check the planner if missed anything.