Emphysema: Signs and Symptoms (Nursing)

00:00 Now, the patient will start noticing they're usually dyspneic at first with exertion. So, seated they're not short of breath. Because remember dyspnea, dys means difficulty with whatever comes after dys. Dyspnea refers to breathing. So, they usually only have this unusual dyspnea or difficulty with breathing at first when they exert themselves. ___ sitting down no problem but they get up and start walking around, moving around they kind of get short of breath but as the disease progresses and the lungs get more difficult and distended it's going to get worse and so at the end of this disease process they have dyspnea or shortness of breath sometimes sitting still. So, the level of dyspnea or difficulty breathing will be a clue to you as a nurse as to how advanced this disease is. If they have to move around in order to get short of breath, then that's a clue that okay it's progressing but it's not as severe as we see in the end stages. Now we often describe people with emphysema as having a barrel chest.

01:10 We've got a picture there for you to see, kind of seem what looks like a barrel. Let me describe it to you. Normally, people are twice as wide as they are deep. That's the normal shape of a chest wall. But in extensive COPD like this patient has had chronic COPD for a long period of time, the lungs become hyperinflated because of all that air are getting trapped in there.

01:34 So they have chronic air trapping and the lung gets more and more inflated. So that's why their chest looks like that. The chest becomes round like a barrel, it's just as wide as it is deep.

01:47 So we are the same, wide as it is deep and that's why they get the term barrel-chested. So that's a great graphic for you to see, a chest without COPD and the chest and late stages of COPD. That's why it gets the name barrel chest. Okay now pursed lip breathing is something that emphysema patients learn to almost do on their own, but if they aren't aware of this technique you can teach them. Normally, I breathe in and out the same length of time. So, in, out, in, out. Okay I don't usually do that through my mouth in public but we're just doing that to show you. So normally you breathe in and out the same length of time but remember what challenge emphysema patients have. They have that air trapping. So you teach them to purse their lips. They about they're trying to blow the candle, that's a good way to explain it to patients when we say pursed lip breathing. You make your lips like you're ready to blow the candle. Okay. Or you know duck lips if you're on Instagram. Alright, so you're going to blow out that candle and you breathe out slowly, twice as long as your inhaled breath. So if I breathe in like this, I breathe out like this. Okay, the pursed lip helps you take a longer period of time with a greater force to help deal with that air trapping. So it's a way to prolong the expiratory phase. That's what pursed lip breathing does. So just doing this isn't going to fix it. You want to make sure they know that they need a longer time breathing so when they become short of breath, they don't have to breathe like this all the time but when they notice having increased dyspnea they're probably having increased air trapping. If they'll use pursed lip breathing, that will help them try to re-establish a balance in their lungs. Now tripod positioning is another position that patients would probably do just naturally, but if they don't you'll notice when you go into COPD patient's room, you can help them be more comfortable. Now if you look at our picture you see that he has got a bedside table and he has got pillows over that. Now the patient sits upright and they lean forward with their weight resting on their hands or their elbows like that on furniture or their knees. Let me show you what that does. Take your body and do this with me. If you sit up straight and you put your arms up like this, what happens to your ribcage? Well, as you notice, things __ thin and get bigger. That gives you more room.

04:33 Remember, they're already barrel chested and stuff is blown up in here. So when they're really having trouble, you'll see them sit like that in the tripod position, that's what we call it. So that can help them facilitate their breathing. So when they're not doing well, this is usually how they'll sit. So you'll see them tripod positioning in, pursed lip breathing. That's a sign to you if you see a patient doing that. They're probably not doing really well. You need to take some extra time, listen to their lungs, ask them how they're feeling, look what their pulse ox is, really do some further investigation to see if there's something you need to follow up on.

05:12 Now if you see a patient using their accessory muscles, we're talking about usually the diaphragm and the intercostal muscles are what drive respiration. Right? My abs are involved too, you have to have good strong abs for coughing; my diaphragm, which is a thin skeletal muscle that divides my chest from my gut. If I notice that usually that's not enough for me to breathe then I start to use the accessory muscles. Okay, so this isn't a good sign. My diaphragm, intercostal muscles, and my abs should be enough to help me breathe and cough.

05:47 When they are getting tired out, I'm really getting in distress, I start using the accessory muscles of respiration. That's these other muscles in here that aren't the diaphragm, the abs, or using the intercostal muscles. Now this is when the patient is under high metabolic demand.

06:04 That means they are really having to work hard. This is causing them to exert themselves.

06:09 They're having some significant respiratory difficulty. So one of the signs of a patient in distress is when their normal muscles, diaphragm, intercostals, abs are not enough to help them breathe and drive respirations, then they're using every other muscle that they can recruit to try to help them breathe. Now, we've listed the muscles for you there; for inhalation, for exhalation, every one of these has a very specific role in what they do and what they can perform for breathing. It is fascinating. I wouldn't recommend that you memorize these, just having the concept in mind, knowing that each one of these muscles has a very specialized role. It's amazing what they do. Now remember it takes action for me to inhale and then just kind of relaxing. Is what happens is more passive with exhaling. So spend some time, look at those muscles and really get a feel for the different roles that each of them plays in respiration.