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Pathophysiology of COPD

Discuss about the Efficacy And Safety Of Oral Solithromycin Versus.

COPD or chronic obstructive pulmonary disorder is a life-threatening respiratory disorder which can be considered as an umbrella terms that encompasses to key diseases, chronic bronchitis and emphysema. Emphysema is the abnormal permanent enlargement of the alveoli t facilitated by the destruction of alveolar wall without Fibrosis. The damage to the alveolar walls leads to lack of elasticity of the wall fibers of alveoli and destroys the exhalation stability of the patient leading to chronic emphysema (Agusti, 2014). Chronic Bronchitis can be characterized by inflammation of the bronchial tubes and facilitated by hypersecretion of mucus. In order to better understand the pathophysiology of this particular disease the most prevailing contributing factor has to be discussed. According to the case study, Robert had developed chronic obstructive pulmonary disorder 18 months before having the acute exacerbation and being admitted to the ICU. His past medical history reveals that he has been active chain-smoker for the past 40 years of his life. According to the Albert et al. (2011), COPD is a progressive and eventually debilitating lung disease and tobacco addiction is one of the most prominent triggers leading to manifestation and exacerbation of this disease. Smoke triggers damage and breakdown of the alveolar wall fibres and heightens the risk of chronic obstructive pulmonary disorder and bronchitis, several folds. The smoke stiffness the air sacs seconds and destroys the alveolar walls actresses over secretion of mucus as well due to prolonged exposure (Bischoff et al., 2011). Hence for Robert, the COPD can be considered to be manifested largely due to the smoking and as he had not stopped smoking even after being diagnosed with this particular respiratory disorder it also facilitated to the exacerbation. Robert had been working in his own chicken farm, the prolonged occupational exposure to poultry dust could also have contributed to damaging his respiratory system and facilitating the COPD (Almagro et al., 2012).

An exacerbation can be defined as the event that causes deteriorating changes in the disease progression threatening the life and safety of the patient going through the disease. In case of COPD, acute exacerbation can be caused by many factors such as a secondary infection, environmental pollutant triggers, etc (Erb-Downward et al., 2011). The clinical manifestation of acute exacerbation of chronic obstructive pulmonary disorders includes excessive and severe wheezing, severe and prolonged episodes of shortness of breath or dyspnea, changes in the quantity and colour of the sputum. Considering the case study, the most important contributing factor to the exacerbation that the patient suffers from can be the community acquired pneumonia. According to the Han et al. (2010), infection leads to 75% of the acute exacerbations of CPD and it is the leading cause for fatalities associated with this respiratory disorder as well. In case of Robert as well,  the infection provoked the over secretion of mucus further and contributed to further blocking of the airways which eventually let two acute exacerbation and resulted in accessories in acute shortness of breath in the patient. The prolonged effect of smoking cannot be ignored in this scenario as well.  It has to be mentioned that the patient had been an active smoker for the past 40 years and he had made 5 attempts to quit already but had not been successful. Continuing to smoke even after being diagnosed with chronic obstructive pulmonary disorder 18 months ago can also be a constituting factor to the acute exacerbation Robert suffered from in the case scenario (Giske & Hedlund, 2010).

Exacerbation of the COPD

Pneumonia is infectious disease caused by Streptococcus pneumoniae that results in inflammation of the alveolar sac and triggers overproduction of mucus for the blocking the airways of the patient. The manifestation of the disease is facilitated by the entry of pathogens through the aspiration procedure after which the pathogen in which the lung parenchyma and causes inflammation in the alveolar sac (Johansson, Kalin, Tiveljung-Lindell, Giske & Hedlund, 2010). On the more elaborative note, as soon as the pathogen reaches the alveolar sac of the patients the innate immunity of the patient is compromised and the pathogen can easily manifest and multiplicative this point leading to overgrowth and targeting over secretion of mucus (Kaptein, Fischer & Scharloo, 2014).

Now pneumonia can be of three different types based on the transmission. The first type is called the community acquired pneumonia, which can be caused by more than a hundred different types of pathogens and is not associated with the health care facility at all. The most frequently observed transmission route is via the microaspiration of the oropharyngal secretions through which the pathogen reaches the lung parenchyma.  The pathogen easily overcomes the alveolar macrophage and multiplies at a rapid rate spreading further and blocking the airways. On the other hand, hospital or health care associated pneumonia is facilitated by patient staying more than 48 to 72 hours in Healthcare facility for accepting the signs and symptoms of the pneumonia (Musher & Thorner, 2014). The major difference includes the pathogen origin where as for the Healthcare associated or Hospital associated pneumonia the origin of infection is bacterial rather than being viral and the microbial strain is often antibiotic resistant. Similarly in case of healthcare associated pneumonia, the infection is facilitated by staying for a program time of period in a community care in patient setting where the transmission on it is also antibiotic resistant strains (Martin-Loeches et al., 2010).

This is a beta 2 andrenergic receptor stimulator which performs bronchodilation in COPD. The mechanism of action is by activating the adenylyl cyclase channel of the patient that triggers overproduction of cyclic AMP. The increase in the concentration of cyclic AMP activates the protein kinase which relaxes the bronchial tube and facilitates better air passage through the airways and reduces airway resistance. The contraindication includes hypersensitivity reactions such as urticaria, angioedema, rash and preexisting cardiac tachyarrhythmias as well. The side effects are fine tremor, enhanced nervousness, palpitations, tachycardia, headache, muscle cramps, hyperkalemia, and paradoxical bronchospasms. The nursing consideration for Robert while administering salbutamol should be checking if he has any hypersensitivity to the medication or if there are any tremors or palpitation. The nurse will have to be conscious about arrhythmia, hypertension, hypothyroidism, convulsive disorders, and if the patient has been taking any tricyclic antidepressants as well. The patient will have to be educated regarding the side effects of this medication and regarding the dosage (Postma et al., 2015).

Pathophysiology of pneumonia

It is the combination of two active components, budesonide which is a corticosteroid and formoterol fumarate dihydrate which is a selective Beta 2 agonist. The mechanism of action of this medication is by reducing the inflammation of the airways of Robert and relaxing the bronchial tubes. The contraindications include any allergic hypersensitivity reaction probability in the patient and this particular medication it is not useful or beneficial in case of acute exacerbation event. Side effects include body pain, cough, difficulty breathing, fever, headache, muscle ache, chills, sneezing, sore throat, fatigue, stuffy or runny nose, and tightness of the chest. In case of Robert the two nursing considerations for administration of this medication will include hypersensitivity reaction and possibility of secondary infection requiring intensive measures where this medication can resolve to decrement ill effects rather than positive effects. Patient education for this medication will be the possible side effects and not to take this particular medication in case of acute bronchospasm events. This medication also leads to exceeding wheezing, the patient will also be educated to seek medical attention immediately in case of acute asthmatic attack (File et al., 2010).

It is a long acting 24 hour anticholinergic, a very common medication used in chronic obstructive pulmonary disorder. This is a muscarinic receptor agonist, which targets mainly M3 muscarinic receptors that are located in the bronchial airways and facilitate smooth muscle relaxation and causes a bronchodilatory effect. The side effects are dry mouth and dizziness along with renal problem such as difficulty in union eating and painful urination. This medication is contraindicated for patients with closed angle glaucoma, blockage of urinary bladder, enlarged prostate, chronic kidney diseases, anticholinergic quaternary allergies, and allergies to ipratorium analogues (Barrera et al., 2016). The nursing consideration is halting administration in case of angioedema and monitoring for anticholinergic effects in the patient. Patient education for this medication includes educating the patient not to let the medication contact the eyes, educating him regarding this medication being once daily maintenance treatment, withholding the drug and seeking immediate medical attention in case of swelling around the face mouth or neck.

The physician has replaced budesonamide injection with tiotropium because researchers are of the opinion that budosonamide leads to secondary infection of pneumonia and it is not very useful for severe exercise session of chronic obstructive pulmonary disorders. As Robert have already been suffering with community acquired pneumonia continuing this would have been extremely harmful for him hence the doctor changed it for a much more effective bronchodilator tiotropium.

Pharmacology

It is a quinolone antibiotic, a very common antibiotic used for community acquired pneumonia only of bacterial origin. The mechanism of action is facilitated by its bacteriocidal activity that inhibits the growth of bacteria. The side effects of this medication include nausea, diarrhea, headache, dizziness, lightheadedness, and sleeping problems (Musher & Thorner, 2014). The contraindications include hypersensitivity reaction, diabetes, and renal disorders. While administering the medication the nurse will have to run medication should very slowly to avoid any stinging that Robert may feel. The patient will have to be educated about possible side effects of this medication and the patient should also be encouraged to take vitamin supplements while taking this particular antibiotic as it can lead to nutrition deficiency and weakness.

It is another common antibiotic used to treat community acquired pneumonia and the mechanism of action of this medication is facilitated by bacteriocidal activity. It is also a quilonone antibiotic. The side effects of this kind of medication are also nausea, diarrhea, dizziness, lightheadedness, headache, weakness, and insomnia. This medication is contraindicated against any hypersensitivity reaction to quilonone derivatives, and this medication is also contraindicated against diabetes cardiac problems hepatic diseases depression nervous system diseases convulsions and seizures (Davydow, Hough, Levine, Langa & Iwashyna, 2013). The nursing consideration for this medication will be to check if Robert has any hypersensitivity reaction to quilonone derivatives and if patient has had a history of taking blood thinners and Strontium until recently. Patient education will be for side effects of this medication and possible drug interactions.

This particular medication is a cefalosporine which is a very common medication used for elderly patients like Robert to treat bacterial infection such as pneumonia and its mechanism of action is also bactericidal. Possible Side Effects that Robert may experience after taking his medication includes bronchospasm, diarrhoea, nausea and vomiting (Barrera et al., 2016). This medication is contraindicated for calcium ceftriaxone interaction or any hypersensitivity or allergic reaction to it. While administering this medication the nurse will have to ensure that Robert does not have bronchospasm or sudden shortness of breath and he does not develop any allergic reaction. He will need to be educated regarding the possible precautions to take and the possible side effects and along with that Robert will also needed to be educated to seek attention if any adverse reaction develops.

Elderly patient population with chronic disorders have been reported to be twice as likely to suffer from depression in psychiatric impairments. In this case Robert had been suffering from two chronic health conditions, COPD and pneumonia and these health conditions are associated with various restrictions and suffering which could have a negative impact at his psyche (Davydow, Hough, Levine, Langa & Iwashyna, 2013). Robert has stated that he is anxious about how his prolonged hospitalization would affect his wife as she would be left all alone and devastated to see him suffering. Hence, the anxiety and stress can also lead to detrimental impact on the psychological state of the patient.

Salbutamol

In this case, the nursing professional will have to establish and therapeutic relationship with the patient and engage him effective communication to help him feel better and understand the depth of the psychological troubles he might have. According to the NMBA practice standards, therapeutic relationship provides the patient with communicational comfort and a sense of being valued which enhances their emotional and spiritual health and helps them share their grievances effectively. The nurse will have to commence the patient on psychotherapies like cognitive behavioral therapy and mindfulness based therapies with collaboration with psychotherapists to help him cope with stress, anxiety and depression (Hynninen, Bjerke, Pallesen, Bakke & Nordhus, 2010). His wife must be included in the entire care planning procedure so that she is not anxious and so that Robert is not distressed with thoughts of how his wife is coping.

References:

Agusti, A. (2014). The path to personalised medicine in COPD. Thorax, vol 69(9), pp 857-864. doi: 10.1136/thoraxjnl-2014-205507

Agustí, A., Edwards, L. D., Rennard, S. I., MacNee, W., Tal-Singer, R., Miller, B. E., ... & Crim, C. (2012). Persistent systemic inflammation is associated with poor clinical outcomes in COPD: a novel phenotype. PloS one, vol 7(5), e37483. Retrieved from https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0037483

Albert, R. K., Connett, J., Bailey, W. C., Casaburi, R., Cooper Jr, J. A. D., Criner, G. J., ... & Make, B. (2011). Azithromycin for prevention of exacerbations of COPD. New England Journal of Medicine, 365(8), pp 689-698. doi: 10.1056/NEJMoa1104623.

Almagro, P., Cabrera, F. J., Diez, J., Boixeda, R., Ortiz, M. B. A., Murio, C., & Soriano, J. B. (2012). Comorbidities and short-term prognosis in patients hospitalized for acute exacerbation of COPD: the EPOC en Servicios de medicina interna (ESMI) study. Chest, vol 142(5), pp 1126-1133. Retrieved from https://journal.chestnet.org/article/S0012-3692(12)60613-8/abstract

Barrera, C. M., Mykietiuk, A., Metev, H., Nitu, M. F., Karimjee, N., Doreski, P. A., ... & Van Rensburg, D. J. (2016). Efficacy and safety of oral solithromycin versus oral moxifloxacin for treatment of community-acquired bacterial pneumonia: a global, double-blind, multicentre, randomised, active-controlled, non-inferiority trial (SOLITAIRE-ORAL). The Lancet Infectious Diseases, 16(4), 421-430. doi.org/10.1016/S1473-3099(16)00017-7

Bischoff, E. W., Hamd, D. H., Sedeno, M., Benedetti, A., Schermer, T. R., Bernard, S., ... & Bourbeau, J. (2011). Effects of written action plan adherence on COPD exacerbation recovery. Thorax, vol 66(1), pp 26-31. Retrieved from https://journal.chestnet.org/article/S0012-3692(12)60613-8/abstract

Davydow, D. S., Hough, C. L., Levine, D. A., Langa, K. M., & Iwashyna, T. J. (2013). Functional disability, cognitive impairment, and depression after hospitalization for pneumonia. The American journal of medicine, 126(7), 615-624. doi: 10.1016/j.amjmed.2012.12.006

Erb-Downward, J. R., Thompson, D. L., Han, M. K., Freeman, C. M., McCloskey, L., Schmidt, L. A., ... & Martinez, F. J. (2011). Analysis of the lung microbiome in the “healthy” smoker and in COPD. PloS one, vol 6(2), e16384. Retrieved from https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0016384

File Jr, T. M., Low, D. E., Eckburg, P. B., Talbot, G. H., Friedland, H. D., Lee, J., ... & Thye, D. (2010). Integrated analysis of FOCUS 1 and FOCUS 2: randomized, doubled-blinded, multicenter phase 3 trials of the efficacy and safety of ceftaroline fosamil versus ceftriaxone in patients with community-acquired pneumonia. Clinical infectious diseases, 51(12), 1395-1405. doi: 10.1086/657313

Han, M. K., Agusti, A., Calverley, P. M., Celli, B. R., Criner, G., Curtis, J. L., ... & Make, B. J. (2010). Chronic obstructive pulmonary disease phenotypes: the future of COPD. American journal of respiratory and critical care medicine, vol 182(5), pp 598-604. doi: 10.1056/NEJMoa1406330

Hynninen, M. J., Bjerke, N., Pallesen, S., Bakke, P. S., & Nordhus, I. H. (2010). A randomized controlled trial of cognitive behavioral therapy for anxiety and depression in COPD. Respiratory medicine, 104(7), 986-994. doi: 10.1016/j.rmed.2010.02.020

Johansson, N., Kalin, M., Tiveljung-Lindell, A., Giske, C. G., & Hedlund, J. (2010). Etiology of community-acquired pneumonia: increased microbiological yield with new diagnostic methods. Clinical Infectious Diseases, vol 50(2), pp 202-209. doi.org/10.1086/648678

Kaptein, A. A., Fischer, M. J., & Scharloo, M. (2014). Self-management in patients with COPD: theoretical context, content, outcomes, and integration into clinical care. International journal of chronic obstructive pulmonary disease, vol 9, pp 907. doi:  10.2147/COPD.S49622

Martin-Loeches, I., Lisboa, T., Rodriguez, A., Putensen, C., Annane, D., Garnacho-Montero, J., ... & Rello, J. (2010). Combination antibiotic therapy with macrolides improves survival in intubated patients with community-acquired pneumonia. Intensive care medicine, vol 36(4), pp 612-620. doi: 10.1007/s00134-009-1730-y

Musher, D. M., & Thorner, A. R. (2014). Community-acquired pneumonia. New England Journal of Medicine, vol 371(17), pp 1619-1628. doi: 10.1056/NEJMra1312885

Postma, D. F., Van Werkhoven, C. H., Van Elden, L. J., Thijsen, S. F., Hoepelman, A. I., Kluytmans, J. A., ... & Oosterheert, J. J. (2015). Antibiotic treatment strategies for community-acquired pneumonia in adults. New England Journal of Medicine, vol 372(14), pp 1312-1323. doi: 10.1056/NEJMoa1406330

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