Description of COPD

The hallmark of COPD is the evidence of a productive cough and a progressive decrease in the patient’s exercise tolerance. Three major diseases are part of COPD: asthma, emphysema, and chronic bronchitis.² All are characterized by airway obstruction. These diseases may have medically reversible components, such as bronchospasm, or they may have irreversible components, such as alveolar septal destruction. Some of the reversible components of asthma, such as retained secretions, bronchospasms, and infections, can be corrected with the interaction of the physician, nurse, physical therapist, and respiratory therapist. The treatment of asthma can include oxygen therapy, bronchodilators, chest physiotherapy, and proper hydration.

Chronic bronchitis is associated with chronic cigarette smoking. The nurse can contribute greatly to the patient’s future health with strong influences to refrain from smoking.³ Other therapy for the reversible components can include the use of bronchodilators, chest physiotherapy, and oxygen.

The patient with emphysema usually has airway destruction that is irreversible. As the alveolar septa are destroyed, insufficient alveolar ventilation ensues and eventually leads to hypercarbia. As the disease progresses, carbon dioxide cannot be expelled from the lungs and is retained there. The patient usually increases minute ventilation to try to compensate for the hypercarbia. Respiratory acidosis develops slowly as the various acid-base buffer systems try to neutralize the accumulated acid. In this compensated state, the patient usually has a near-normal pH, high plasma bicarbonate, low chloride concentration, and high total carbon dioxide levels. The PaCO₂ usually is low because some inspired oxygen is unable to cross into the blood from the lungs because of the decreased respiratory diffusion membrane surface area in the lungs. Pulmonary hypertension usually appears as the disease progresses. Cor pulmonale may develop, and because of the pulmonary venous engorgement, the right heart may begin to fail. The patient with emphysema who has irreversible destruction can be treated with chest physiotherapy, bronchodilators, and steroids.

Cigarette smoking as A precursor to the development of COPD

Cigarette smoking has been well established as one of the major precursors to chronic bronchitis and emphysema—two of the three disease components of COPD. Cigarette smoking affects the manner in which a patient recovers from an anesthetic.^4,5 The perianesthesia nurse should be aware of the diverse reactions that smoking can have on the patient who is emerging from an inhalation anesthetic. Studies on the relationship between smoking and its effects on anesthesia indicate an increase in the risk factor in the patient who smokes. Although the incidence rate of smoking is decreasing slowly, it continues to rise in the teenage population.

Surgical considerations

The incidence rate of pulmonary complications in patients who have undergone abdominal or thoracic surgery is high. Changes occur in the pulmonary status of the patient who undergoes anesthesia and surgery. In the postoperative phase, these changes are characterized by gradual or abrupt alveolar collapse. The patient with COPD, when subjected to surgery, then represents an even higher risk for postoperative complications. These patients must be given meticulous preoperative care so that they are in the best possible health when they enter surgery. This preoperative medical treatment usually includes hydration, nutrition, chest physiotherapy, bronchodilators, and prophylactic antibiotics if an infection is present. Serial pulmonary function tests and arterial blood gas determinations are used to monitor the progression of the preoperative treatment.⁷

When the patient’s pulmonary function reaches a peak before surgery (i.e., when the pulmonary function test and arterial blood gas test results no longer show continued improvement), surgery is considered because the patient has reached optimal pulmonary status.

Care of the COPD patient

Perianesthesia care focuses on prevention of complications. The modified stir-up regimen should include frequent cascade coughing, sustained maximal inspirations (SMIs), and repositioning of the patient (see Chapters 12 and 28). An appropriately implemented modified stir-up regimen is of great importance, especially in patients who are recovering from upper abdominal or thoracic operations. Surgery at these sites can cause decreased ventilatory effort and a complete absence of sighs by the patient. Given that the patient already has compromised respiratory function, the possibility of retained secretions and atelectasis is magnified. As a result, these patients represent a significant challenge to the perianesthesia nurse (Box 48-1).

When the patient is completely reactive from anesthesia, the use of the incentive spirometer may be helpful in reducing the incidence of atelectasis. Consequently, the perianesthesia nurse who is responsible for supportive measures should assist and encourage the patient in using the SMI with or without the incentive spirometer. On the basis of subjective research findings, if the perianesthesia nurse explains the rationale of the SMI maneuver and properly instructs the patient in the use of the technique before surgery, the patient is more likely to correctly use the SMI maneuver after surgery with or without coaching. The performance of the SMI maneuver, with or without mechanical devices, should be monitored by the nurse to ensure proper production of a sustained inspiration with a 3-second inspiratory hold. The perianesthesia nurse should also encourage and monitor the patient’s performance of the cascade cough to facilitate early secretion clearance.

Patients with COPD have some component of reactive airways disease. Consequently, the airway becomes compliant and can become compressed during a forced expiratory maneuver. This dynamic compression of the airways is a function of the equal pressure point theory, as discussed in Chapter 12. To reduce the amount of dynamic compression of the airway during exhalation, the patient should be encouraged to use pursed-lip breathing. Breathing through pursed lips during exhalation can be the same as adding 5 to 10 cm H₂O of positive end-expiratory pressure. Increasing the pressure inside the airway during exhalation reduces the amount of dynamic compression of the airways and decreases the amount of air trapping that commonly occurs in patients with COPD.

Audible wheezing will require the use of a fast-acting bronchodilator such as albuterol. Arterial blood gases may be ordered, and capnography may be used to monitor end-tidal CO₂.⁹

The cardiac status should be monitored meticulously because of the frequent involvement of the heart in the pathologic disorders of these patients. Kidney function should also be monitored because it may be altered, especially in patients with fluid retention and edema of the extremities.

The patient with severe COPD who has marked hypercarbia can present difficulties in the PACU. Patients who have severe emphysema usually fit into this category. Ventilatory effort in these patients is stimulated by the hypoxic drive, in which lack of oxygen stimulates ventilation. Hypoxia indirectly stimulates the respiratory center by means of chemoreceptors in the carotid bodies located at the bifurcation of the carotid artery. When the patient receives 100% oxygen to breathe in the PACU, oxygen tensions rise in the inspired gas; the carotid and aortic chemoreceptors cease to function; and the patient quickly becomes apneic. The patient’s respiratory status should be assessed carefully and the physician consulted before 100% oxygen is administered. Mist therapy after surgery aids in liquefying the secretions and helps in the all-important maintenance of a patent tracheobronchial tree. If excessive bronchial drainage is not removed, it provides a convenient avenue for bacteria and might also obstruct the airways, thus leading to insufficient alveolar ventilation and hypoxia.

The patient with COPD should be under constant surveillance for signs of cardiopulmonary decompensation, including shallow rapid gasping respirations, severe dyspnea, substernal retraction, and disorientation. Blood pressure may be elevated or low, but the patient usually has tachycardia, fever, and muscle rigidity. Cyanosis may be present.

Patients who are cigarette smokers have significant postanesthesia risks.⁶ Cigarette smokers who have smoked for a long period of time and have an FEV₁ less than 80% usually have an increased risk of pulmonary complications in comparison with nonsmokers. Patients who smoke more than two packs of cigarettes per day are especially prone to perianesthetic complications. In addition, patients who have had a long history of smoking (>20 pack years) and are presently in a nonsmoking situation still can have pulmonary complications. Many of these complications develop when cigarette smokers have a preexisting chronic respiratory disease, usually bronchitis. The major postoperative complications associated with smoking are infection, atelectasis, pleural effusion, pulmonary infarction, and bronchitis.

Complications associated with chronic cigarette smoking revolve around the inability of the patient to clear secretions. The goal of nursing care in the PACU centers on clearing the tracheobronchial tree, which necessitates frequent suctioning, cascade coughing, and the SMI maneuver. If rales and rhonchi are heard on auscultation, percussion and postural drainage should be initiated.

Because cardiovascular disease is associated with a long history of cigarette smoking, the patient should have continuous electrocardiographic monitoring. Arrhythmias, such as premature ventricular contractions, should be addressed because they may be the first signs of decreased myocardial oxygenation in the cigarette smoker.

Respiratory depressant drugs, such as opioids, should be given in low doses, or they should be avoided completely if the COPD is severe. Repositioning of the patient and splinting of the incision site, in addition to reducing the anxiety usually seen in these patients, reduces the need for opioids. Some form of regional analgesia may be beneficial for these patients.⁸

Care of the patient with myasthenia gravis

If a muscle relaxant is given during surgery, the patient has the neuromuscular blockade reversed. After reversal in the operating room, the patient must have a complete sustained return of skeletal muscle strength before extubation. If the patient does not meet the criteria for extubation, the endotracheal tube remains in place and the patient is taken to the PACU for ventilatory support. In patients with MG, the skeletal muscle strength may appear to be appropriate immediately after surgery, but may deteriorate a few hours thereafter.⁷

The patient with MG can have various difficulties because of an impaired respiratory system, possible poor nutrition, susceptibility to infection, altered psychiatric status, and possible altered response to drugs used during anesthesia. The patient should be placed in a quiet area, where no direct light shines in the eyes. The patient’s respiratory effort and exchange should be monitored continuously. Oxygen should be administered with humidification, and secretions should be removed with frequent suctioning and postural drainage. Oxygen saturation levels for these patients should be maintained at more than 96%. Any change in respiratory status should be reported to the physician immediately.

Because cardiac mechanisms may be responsible for some sudden deaths in this patient population, cardiac monitoring should be instituted for every patient with myasthenia in the PACU. Monitoring of the fluids administered to patients with MG is also important. Hypovolemia and hypervolemia must be avoided because of their deleterious effects on the already compromised heart and lungs.

The patient should be kept as pain free as possible to facilitate good respiratory exchange. Morphine and other opioids are often potentiated by anticholinesterases; therefore the initial opioid dose should be reduced to half the normal dose and then increased if necessary. If the patient is receiving continuous mechanical ventilation, the normal amount of medication can be given without compromising the patient’s respiratory status.

The PACU nurse should monitor for a myasthenic crisis, which is a severe exacerbation of the symptoms associated with MG. It can occur when an anticholinesterase is underdosed and does not reduce the amount of muscle weakness sufficiently. Alternatively, a cholinergic crisis can occur when too much anticholinesterase is administered, resulting in a surplus of acetylcholine at the myoneural junction and causing a depolarizing type block that leads to skeletal muscle weakness, which could be severe. For all the previous reasons, during PACU care of the patient with MG in the immediate postoperative phase, airway equipment must be kept at the patient’s bedside. Along with the skeletal muscle weakness, muscarinic side effects occur, such as abdominal cramping, miosis, bradycardia, salivation, and diarrhea. See Chapters 10, 11, and 23, which provide the reader an in-depth discussion of the myoneural junction and nicotinic and muscarinic effects.

The emotional status of the patient with myasthenia is of considerable importance. As few clinicians as possible should be responsible for this patient throughout the emergent phase, because the patient is likely to be distrustful of anyone he or she does not know. Communication is important, and the patient should be informed about any nursing procedure to be performed. If the patient with myasthenia has a tracheostomy, paper and pencil should be used to facilitate communication between nurse and patient.