Introduction
This essay critically appraises the current best evidence for nursing care of older persons with chronic obstructive pulmonary disease (COPD), focusing on a case study of Mr. Robert Langley, an 84-year-old man presenting with an acute exacerbation of COPD (AECOPD). COPD is a significant health concern among the elderly, contributing to substantial morbidity and mortality globally. The purpose of this assessment is to explore the pathophysiology of AECOPD, identify one actual and one potential complication relevant to Mr. Langley’s scenario, and discuss two evidence-based nursing interventions with their rationales. By examining these elements, the essay aims to highlight the complexities of managing COPD in older adults, particularly in the context of comorbidities, social isolation, and non-compliance with treatment. The discussion will draw on peer-reviewed literature and authoritative guidelines to ensure a robust evidence base.
Pathophysiology of Acute Exacerbation of COPD
COPD is a progressive respiratory condition characterised by airflow limitation due to chronic inflammation, primarily caused by long-term exposure to noxious particles or gases, such as tobacco smoke (Global Initiative for Chronic Obstructive Lung Disease [GOLD], 2023). In an acute exacerbation, as seen in Mr. Langley’s case, there is a sudden worsening of respiratory symptoms beyond normal day-to-day variations, often triggered by respiratory infections or environmental factors. The pathophysiology involves increased airway inflammation and mucus production, leading to further airflow obstruction, gas trapping, and hyperinflation of the lungs (Wedzicha & Seemungal, 2007). This is evident in Mr. Langley’s clinical presentation, with increased sputum production (green and thick), dyspnoea, and wheezing, alongside chest X-ray findings of hyperinflated lungs.
Moreover, during an AECOPD, there is impaired gas exchange, resulting in hypoxaemia and hypercapnia, as reflected in Mr. Langley’s arterial blood gas results (PaO₂ 60 mmHg, PaCO₂ 56 mmHg). The increased work of breathing, demonstrated by his respiratory rate of 30 breaths per minute and use of accessory muscles, further exacerbates energy expenditure, contributing to fatigue and weight loss (BMI 19.3). Indeed, the combination of these factors underpins the severity of his current condition and necessitates urgent intervention.
Complications of AECOPD: Actual and Potential
Actual Complication: Respiratory Infection/Pneumonia
One actual complication evident in Mr. Langley’s case is a likely respiratory infection, potentially pneumonia, as suggested by his elevated white cell count (14.2 × 10⁹/L), raised C-reactive protein (88 mg/L), fever (38.3°C), and bilateral basal infiltrates on chest X-ray. Respiratory infections are common during AECOPD, particularly in older adults with compromised immune responses and pre-existing lung damage (Sethi & Murphy, 2008). Such infections can worsen gas exchange, increase systemic inflammation, and elevate the risk of respiratory failure if not promptly managed. This complication aligns with his history of increased sputum production and malaise, indicating the need for targeted antimicrobial therapy alongside supportive care.
Potential Complication: Respiratory Failure
A potential complication for Mr. Langley is respiratory failure, particularly Type 2 (hypercapnic) respiratory failure, given his elevated PaCO₂ (56 mmHg) and borderline pH (7.30). Respiratory failure occurs when the lungs fail to maintain adequate oxygenation or carbon dioxide elimination, often during severe AECOPD, especially in patients with GOLD stage III disease (GOLD, 2023). Factors such as his advanced age, reduced respiratory reserve, and comorbidities like ischaemic heart disease increase this risk. If untreated, this could progress to life-threatening acidosis and necessitate mechanical ventilation. Therefore, close monitoring and timely interventions are critical to prevent this outcome.
Nursing Interventions for Mr. Langley
Intervention 1: Oxygen Therapy with Monitoring
The first nursing intervention for Mr. Langley is the administration of controlled oxygen therapy with regular monitoring of oxygen saturation (SpO₂) and arterial blood gases. Given his SpO₂ of 85% on room air, improving to 91% on 2L nasal prongs, oxygen therapy is essential to correct hypoxaemia. However, as COPD patients are at risk of hypercapnia due to oxygen-induced suppression of hypoxic drive, oxygen must be titrated cautiously to maintain SpO₂ between 88-92%, as recommended by the British Thoracic Society (BTS) guidelines (O’Driscoll et al., 2017). Nurses should monitor for signs of drowsiness or worsening hypercapnia, adjusting oxygen flow as needed and ensuring interdisciplinary collaboration with respiratory teams for potential non-invasive ventilation if deterioration occurs.
Intervention 2: Patient Education and Support for Medication Adherence
The second nursing intervention involves patient education and support to improve medication adherence, addressing Mr. Langley’s non-compliance and lapse in salbutamol use. Nurses can provide tailored education on the importance of regular inhaler use (e.g., tiotropium and salbutamol) and develop strategies such as medication reminders or involving community support services in his retirement village. Additionally, addressing his feelings of hopelessness through empathetic communication and referral to psychological support can improve his motivation to adhere to treatment. This intervention aligns with National Institute for Health and Care Excellence (NICE) guidelines, which emphasise personalised education to enhance self-management in COPD patients (NICE, 2018).
Evidence-Based Rationale for Nursing Interventions
The rationale for oxygen therapy is grounded in evidence demonstrating its role in reducing mortality and improving outcomes in hypoxaemic AECOPD patients. A systematic review by Austin et al. (2010) found that titrated oxygen therapy significantly reduces the risk of hypercapnia compared to high-flow oxygen, supporting the BTS target of 88-92% SpO₂. Regular monitoring, as part of nursing care, ensures early detection of respiratory deterioration, enabling timely escalation of treatment. This is particularly relevant for Mr. Langley, whose atrial fibrillation and rapid ventricular response (HR 110 bpm) indicate cardiovascular strain, which could worsen with uncontrolled hypoxaemia.
The rationale for patient education and adherence support is supported by studies highlighting the impact of non-compliance on exacerbation frequency and hospital readmissions. A study by Vestbo et al. (2014) reported that adherence to inhaled therapies in COPD reduces exacerbation rates by up to 30%, underscoring the importance of addressing barriers such as forgetfulness and depression in older adults like Mr. Langley. Furthermore, integrating psychosocial support aligns with holistic nursing principles and NICE recommendations, ensuring that emotional and social factors are considered in care delivery (NICE, 2018). This dual approach not only addresses immediate needs but also promotes long-term management.
Conclusion
In conclusion, the management of AECOPD in older adults like Mr. Langley requires a comprehensive understanding of the underlying pathophysiology, recognition of complications such as respiratory infection and potential respiratory failure, and the implementation of evidence-based nursing interventions. Controlled oxygen therapy with monitoring addresses immediate hypoxaemia while minimising risks of hypercapnia, and patient education with adherence support tackles long-term challenges of non-compliance and psychosocial distress. These interventions, supported by robust evidence from guidelines and research, underscore the critical role of nurses in optimising outcomes for elderly COPD patients. Arguably, the integration of clinical and psychosocial care is paramount in addressing the multifaceted needs of this population, with implications for reducing hospital readmissions and enhancing quality of life. Future nursing practice should continue to prioritise individualised, evidence-based approaches to meet the complex demands of managing chronic conditions in ageing populations.
References
- Austin, M. A., Wills, K. E., Blizzard, L., Walters, E. H., & Wood-Baker, R. (2010) Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: Randomised controlled trial. British Medical Journal, 341, c5462.
- Global Initiative for Chronic Obstructive Lung Disease [GOLD]. (2023) Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. GOLD Report.
- National Institute for Health and Care Excellence [NICE]. (2018) Chronic obstructive pulmonary disease in over 16s: Diagnosis and management. NICE Guideline [NG115].
- O’Driscoll, B. R., Howard, L. S., Earis, J., & Mak, V. (2017) BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax, 72(Suppl 1), i1-i90.
- Sethi, S., & Murphy, T. F. (2008) Infection in the pathogenesis and course of chronic obstructive pulmonary disease. New England Journal of Medicine, 359(22), 2355-2365.
- Vestbo, J., Anderson, J. A., Calverley, P. M., Celli, B., Ferguson, G. T., Jenkins, C., … & Yates, J. C. (2014) Adherence to inhaled therapy, mortality and hospital admission in COPD. Thorax, 69(10), 939-943.
- Wedzicha, J. A., & Seemungal, T. A. (2007) COPD exacerbations: Defining their cause and prevention. The Lancet, 370(9589), 786-796.
