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Pathophysiology of Dyspnea in COPD

Question-1- (a) The above shown ECG strip reflects on supraventricular tachycardia of the patient. Supraventricular tachycardia is a type of abnormal heart rhythm, which is mainly created due to abnormality in the upper chambers of the heart, also commonly known as atria (Page, 2016). Supraventricular tachycardia is generally represented with an absence of “P-wave” in the ECG strip and a prolonged “QRS-complex”. These cardiac arrhythmias are mainly observed to be in four types as follow:

  1. Atrial fibrillation
  2. Paroxysmal supraventricular tachycardia
  3. Atrial flutter
  4. Wolff-Parkinson-White syndrome.

The conduction mainly starts at atria and increases rapidly. As the heart rate increases abnormally, there is a reduced contraction of the atria, leading to the missing “P-wave” formation in the ECG strip. This is a direct reflection of abnormality in the atria chambers of the heart (Al-Zaiti, 2020). The patient might experience the symptoms like chest palpitations, feeling of faintness, shortness of breath, sweating and so on.

(b) There are multiple reasons for development of supraventricular tachycardia. Three of the main attributing reasons can be as enlisted below:

  • Age- The chances and incidences of development of supraventricular tachycardia is observed more in people who are either middle aged or older in age (Shkolnikova, 2020). The same is thus, observed in our patient, Mrs. Graham, as she is 78-years-old. Thus, due to underlying vulnerability she might have developed the condition.
  • Having a history of coronary artery disease or any chronic respiratory condition- The patient given in the case study is having a set diagnosis of Chronic Obstructive Pulmonary Disease. COPD condition is also found to be directly associated with the cardiac conditions. Over the due course of time, as the condition progresses, it leads to put additional load on the body to compensate for the respiratory loss. Due to over work of the heart arteries, in order to supply for the oxygenated blood, they tend to get narrow with time. This can also lead to the development of cardiomyopathy in the patient and thus, increasing the risk of developing ECG abnormality such as supraventricular tachycardia (Matera, 2016).
  • Drug-related effects- There are certain medications which are prescribed for the treatment and management of cough and cols. These medications are also found to have a direct impact in causing and episodic event of supraventricular tachycardia.

(c) The treatment options of supraventricular tachycardia depend on the severity of the symptoms. The treatment can be as follow:

  • Vagal maneuvers- In case of acute symptoms, the doctor can give the patient vagal massage. The symptoms can be managed by the method of placing down an ice-cold wet towel on the face of the patient. The patient is kept in a bearing down position while doing the same. The patient is instructed to breathe out through the abdominal muscles and not letting air in through the means of nose or mouth. These actions are to be performed while the patient is lying down. If and when this method does not work, the patient should be admitted to the emergency department for further management of the condition (Ceylan, 2019).
  • Medical management- Medication management for cardiac arrhythmia is mainly done by help of beta-blockers, calcium-channel blockers or with the help of antiarrhythmic medication (Brubaker, 2018). It is more commonly used in patients who experience recurrent episodes of cardiac arrhythmias. However, these medications can also have a side effect on the patient.
  • Cardioversion- It is given in the form of an electric shock to the heart. It is generally used in severe cases of supraventricular tachycardia. This is also the treatment choice for patients on whom there is no positive effect of medication or vagal maneuver method. Many patients with supraventricular tachycardia also undergo the process of cardiac ablation for the treatment of the same (Chen, 2020). This electrical procedure helps in developing an extra electrical pathway to the heart, which helps in identifying the cause of heart rate and thus, destroying the same. Ablation procedure, however, comes with its own risks and implications on the patient.

Question-2 (a) The ABG of the patient with given readings indicate respiratory acidosis. Respiratory acidosis is a condition where the lungs are not efficient enough to remove excess carbon dioxide from the body. This increase in the levels of carbon dioxide brings about a decrease in the level of pH and other body fluids as well, making them acidic in nature (Pompey, 2019). Acidosis is generally observed when the pH .value in arterial blood gas analysis is reflected at a value below the reading of 7.35. Respiratory acidosis is an underlying condition which is mainly manifested in the patient due to severe respiratory failure or ventilator failure. Normally the lungs help in the ventilation process by taking in the oxygen and exhaling our carbon dioxide. Oxygen is circulated through the lungs in the blood, whereas, carbon dioxide passes from the blood to the lungs. Due to respiratory insufficiency, the lungs are not able to filter out enough carbon dioxide from the lungs (Pompey, 2019). This can also be caused due to decreased movement of air with in the lung passage, due to other underlying factors such as age, physiological changes and so on.

(b) Chronic Obstructive Pulmonary Disease (COPD) is characterized by the feature of poor and irreversible airflow obstruction. It is brought about by an abnormal inflammatory response in the lungs. Long term exposure to pollutants and genetic abnormalities can also result in the development of COPD in the patients (Anzueto, 2017). Due to increase mucous production and its hypersecretion, there is constant tissue damage in the lungs. The destruction starts from smaller passages of the lung spaces known as bronchioles and extending further into the further branches of lungs spaces. This progressive deformation and inflammation of the lung passages lead a patient to develop Chronic Obstructive Pulmonary Disease.

(c) The treatment of patient having COPD history and having respiratory acidosis can be divided into surgical management and medical management. The medical management of these patients can be done in the following manner:

  • With the help of Noninvasive positive-pressure ventilation- This type of ventilation can be administered with the help of two devices, commonly known as CPAP (continuous positive airway pressure) or Bi-PAP (Bilevel positive airway pressure). This method of treatment is generally delivered to the patient by the means of pressurized air facemask that covers the mouth and nose of the patient. This device helps in exerting additional pressure on the lungs, in sync with the patients breathing pattern and thus, helping him to easily expel out residual carbon dioxide. This method is also deemed quite effective in reducing the chances of intubation in patients and avoiding him being placed on ventilation (Kuklisova, 2017).
  • Oxygen therapy- The patient can also be treated with the help of supplement oxygen. In the given case study, the blood oxygen level is also observed to be low. The same is reflected both by the low percentage of oxygen saturation as well as in terms of partial oxygen pressure reflected in the arterial blood gas analysis. Whenever, there is low blood oxygen levels detected, additional oxygen therapy can be given to compensate for the loss (Murphy, 2017). It is one of the most common modalities of treatment options opted in such cases of COPD with respiratory failure. However, the concentration of oxygen should be kept in low amount enabling smooth expelling out of carbon dioxide from the body and avoiding oxygen toxicity in the lung spaces. This oxygen toxicity can also increase the amount of carbon dioxide in the lungs and affect the cells.
  • Bronchodilators- The patient can also be prescribed bronchodilators or corticosteroids. This drug class helps in reversing the effect of airway obstruction and promoting bronchodilation. This is very helpful in promoting smooth ventilation of lung in chronic conditions like COPD, leading to the development of respiratory insufficiency in the patients (Calzetta, 2016).
  • Other pharmacology treatment- Some of the other drug classes that can be used in the treatment of COPD can include, alpha1-antitrypsin augmentation drugs therapy, antibiotic agent, vasodilators, antitussive drugs therapy and so on (López, 2020).

The surgical management of the condition can be done in the following ways:

  • Intubation- The saturation rate of the patient in the given case study can be observed to be alarmingly low in concentration. The patient can also be observed to be having severe breathing difficulty. Intubating the patient can be helpful in clearing the obstruction in the airway passage and thus, promoting smooth facilitation of ventilation of air through these lung passages. The patient can also be connected to the ventilator and once normal ventilation is restored; she can be extubated from the same.
  • Bullectomy- This is a surgical procedure through which bullous emphysema can be removed. This method can help in lowering the dyspnea considerably and thus, improving the lung functions by multiple folds (Hou, 2016).

Question-3 (a) Before getting a secondary assessment survey done for the patient, it is generally considered that any life-threatening condition which was observed in the patient, was dully detected and corrected as on time. The main focus of this assessment method is to identify a specific condition the patient may be having. For this assessment purpose, a full set of vital signs, giving comfort and history of the patient from head to toe is taken, including the inspection of the posterior part of the body as well. The components of secondary survey are as follow:

  • Full set of vital signs- This part not only comprises of taking vitals such as heart rate, respiratory rate, blood pressure etc. rather includes details of further investigations done as well. This can include taking urine sample, monitoring ABG, monitoring ECG and so on (James, 2020).
  • Give comfort- Generally the pain intensity defined by the patient can be quite subjective. So before administering analgesics medications a sound clinical judgement is required. It should not only be based on the subjective information provided by the patient, rather should be delivered after proper consultation with the team members as well. Good clinical judgement is also required to administer the right kind of drug and avoid any drug adversity. Providing comfort should also be inclusive of developing a therapeutic relation with the patients as well as their family members. Anxiety of the patient should also be managed.
  • History taking- The process of history taking is done by the method of AMPLE pneumonic (Mohamed, 2019). A stand for noting down the allergies, M stands for medication history, P stands for past medical history, L stands for last meal taken, E stands for noting the events surrounding the injury.
  • Head to toe assessment- This includes assessing various body parts from top to bottom. Different parts of the body are assessed for abnormal signs and symptoms.
  1. Head/neck/face- It can be observed for stiffness around the neck or accessory muscle breathing.
  2. Chest- The chest can be observed for the respiratory pattern such as abdominal breathing pattern or abnormal chest movements.
  3. Abdomen- It can be auscultated for abnormal breath sounds and additional abdominal movement as compensation during respiration.
  4. Extremities- They can be checked for peripheral pulses. The skin can also be assessed for appearance and capillary filling.
  • Inspection of posterior surfaces- The posterior surface can be inspected for any skin laceration or open wound which might lead to the development of infection in the person.

(b) The three common respiratory signs that are observed in patients of COPD are as follow:

  • Shortness of breath- This is caused by airflow obstruction, brought by progressive inflammation if the air passages over the due course of time. The air passages lose their elasticity and stops to recoil resulting in further airflow restriction and lung parenchymal tissue damage.
  • Wheezing- Due to inflammation of the lung passages they tend to narrow down. So, whenever the air passes through these narrow spaces, it resonates creating a wheezing sound, observed especially during expiration (Miravitlles, 2017).
  • Use of accessory muscles- Due to respiratory insufficiency the patient tends to make use of accessory muscles to help with the ventilation of the patient. This is usually observed during episodes of acute exacerbation of COPD (Ko, 2016).

The patient can be monitored for these abnormal signs through physical examination as well as vital and lab monitoring. The patient can be assessed through the means of periodic auscultation to evaluate for the air flow entry. Vitals such as respiratory rate, heart rate, saturation and blood pressure can be monitored for the any deviation. Arterial blood gas analysis can also be helpful in keeping a track on the percentage of oxygen and carbon dioxide saturation in blood.

References for Mrs. Graham Case Study

Al-Zaiti, S. S., Faramand, Z., Kozik, T. M., Pelter, M. M., & Carey, M. G. (2020). Arrhythmia diagnosis and the 12-lead electrocardiogram: Seeing the whole picture. American Journal of Critical Care29(3), 237-238. https://doi.org/10.4037/ajcc2020555

Anzueto, A., & Miravitlles, M. (2017). Pathophysiology of dyspnea in COPD. Postgraduate Medicine129(3), 366-374. https://doi.org/10.1080/00325481.2017.1301190

Brubaker, S., Long, B., & Koyfman, A. (2018). Alternative treatment options for atrioventricular-nodal-reentry tachycardia: An emergency medicine review. The Journal of Emergency Medicine54(2), 198-206. https://doi.org/10.1016/j.jemermed.2017.10.003

Calzetta, L., Rogliani, P., Matera, M. G., & Cazzola, M. (2016). A systematic review with meta-analysis of dual bronchodilation with LAMA/LABA for the treatment of stable COPD. Chest149(5), 1181-1196. https://doi.org/10.1016/j.chest.2016.02.646

Ceylan, E., Ozpolat, C., Onur, O., Akoglu, H., & Denizbasi, A. (2019). Initial and sustained response effects of 3 vagal maneuvers in supraventricular tachycardia: A randomized, clinical trial. The Journal of Emergency Medicine57(3), 299-305. https://doi.org/10.1016/j.jemermed.2019.06.008

Chen, C., Tam, T. K., Sun, S., Guo, Y., Teng, P., Jin, D., ... & Liu, X. (2020). A multicenter randomized controlled trial of a modified Valsalva maneuver for cardioversion of supraventricular tachycardias. The American Journal of Emergency Medicine38(6), 1077-1081. https://doi.org/10.1016/j.ajem.2019.158371

Hou, G., Wang, W., Wang, Q. Y., & Kang, J. (2016). Bronchoscopic bullectomy with a one‐way endobronchial valve to treat a giant bulla in an emphysematic lung: A case report. The Clinical Respiratory Journal10(5), 657-660. https://doi.org/10.1111/crj.12257

James, N., Marwaha, S., Brough, S., & John, T. T. (2020). Impact of single sign-on adoption in an assessment triage unit: A hospital's journey to higher efficiency. JONA: The Journal of Nursing Administration50(3), 159-164. 10.1097/NNA.0000000000000860

Ko, F. W., Chan, K. P., Hui, D. S., Goddard, J. R., Shaw, J. G., Reid, D. W., & Yang, I. A. (2016). Acute exacerbation of COPD. Respirology21(7), 1152-1165. https://doi.org/10.1111/resp.12780

Kuklisova, Z., Tkacova, R., Joppa, P., Wouters, E., & Sastry, M. (2017). Severity of nocturnal hypoxia and daytime hypercapnia predicts CPAP failure in patients with COPD and obstructive sleep apnea overlap syndrome. Sleep Medicine30, 139-145. https://doi.org/10.1016/j.sleep.2016.02.012

López-Campos, J. L., Carrasco Hernandez, L., & Caballero Eraso, C. (2020). Implications of a change of paradigm in alpha1 antitrypsin deficiency augmentation therapy: From biochemical to clinical efficacy. Journal of Clinical Medicine9(8), 2526. https://doi.org/10.3390/jcm9082526

Matera, M. G., Rogliani, P., Calzetta, L., & Cazzola, M. (2016). Safety considerations with dual bronchodilator therapy in COPD: An update. Drug Safety39(6), 501-508. https://doi.org/10.1007/s40264-016-0402-4

Miravitlles, M., & Ribera, A. (2017). Understanding the impact of symptoms on the burden of COPD. Respiratory Research18(1), 67. https://doi.org/10.1186/s12931-017-0548-3

Mohamed, Z. S., Ahmed, N. G., & Mahmoud, A. M. (2019). Tertiary trauma survey: nurses' performance and poly-trauma patients outcome. Evidence-Based Nursing Research1(1), 13-13.

Murphy, P. B., Rehal, S., Arbane, G., Bourke, S., Calverley, P. M., Crook, A. M., ... & Hurst, J. R. (2017). Effect of home noninvasive ventilation with oxygen therapy vs oxygen therapy alone on hospital readmission or death after an acute COPD exacerbation: A randomized clinical trial. Jama317(21), 2177-2186. https://doi.org/10.1001/jama.2017.4451.

Page, R. L., Joglar, J. A., Caldwell, M. A., Calkins, H., Conti, J. B., Deal, B. J., ... & Indik, J. H. (2016). 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia: executive summary: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines and the Heart Rhythm Society. Circulation133(14), 471-505. https://doi.org/10.1161/CIR.0000000000000310

Pompey, J., & Abraham-Settles, B. (2019). Clarifying the confusion of arterial blood gas analysis: Is it compensation or combination?. AJN The American Journal of Nursing119(3), 52-56. https://doi.org/10.1097/01.NAJ.0000554035.74335.59

Shkolnikova, M. A., Jdanov, D. A., Ildarova, R. A., Shcherbakova, N. V., Polyakova, E. B., Mikhaylov, E. N., ... & Shkolnikov, V. M. (2020). Atrial fibrillation among Russian men and women aged 55 years and older: Prevalence, mortality, and associations with biomarkers in a population-based study. Journal of Geriatric Cardiology: JGC17(2), 74. https://dx.doi.org/10.11909%2Fj.issn.1671-5411.2020.02.002

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