Respiratory Disorders

COPD
Bronchial Asthma

Prepared by:
Ben Ryan J. Sauce MN, RN,RM,EMT
Lecturer
 Learning Objectives
After the discussion, learners
will be able to:

Define and describe COPD

and its pathophysiology

Define and describe B.A

and its pathophysiology

Utilize and apply NCP as a

blueprint in the provision of
care to patient with COPD
and B.A
Chronic Obstructive Pulmonary Disease
A slowly progressive
obstruction of the
airways
Airflow obstruction
diseases such as:
1. Emphysema
2. Chronic bronchitis
Asthma is now
considered a
separate disorder
but can coexist with
COPD.
 COPD versus B.A
COPD: a disease state in
which airflow is obstructed
The obstruction is usually
progressive and irreversible
Asthma: is primarily a
reversible inflammatory
airway condition
Yet, asthma and COPD in
some cases may be
reversible or irreversible
 Chronic Obstructive Pulmonary Disease
(COPD)
is a broad , non specific term
describing a group go
pulmonary disorders with
symptoms of chronic cough,
expectoration, dyspnea, and
impaired expiratory flow.

C.B,emphysema, atelectasis,
bronchiectasis
Chronic Obstructive Lung
Disease (COLD)
Chronic Lower Respiratory
Disease (CLRD)
 Chronic Bronchitis
is a prolonged or
extended inflammation
of the bronchi with chronic
cough and excessive mucus for
at-least 3 months each year for
2 consecutive years
 Pathophysiology and Etiology
characterized by hyper-secretion
of mucus and recurrent or
chronic RTI
As the infectious progresses, cilia
lining the airway can not
propel secretion upward
Secretions remain in the lungs
and form plugs in smaller
bronchi, plugs are areas for
bacterial growth and chronic
infection
Increase mucus secretion and
causing areas of focal tissue
death
Airway obstruction result from
bronchial inflammation
Pathophysiology and Etiology
Development of C.B may be
insidious (gradual) or follow by a
long history of B.A or Acute
RTI such as influenza and pneumonia
Air pollutions and smoking are
significant factors
C.B may develop at any time , but
appears most commonly in middle
age after years of untreated low
grade bronchitis
duration of the symptoms, how
disease process began, and
history of occupational health
hazards, pulmonary disease,
smoking form the basis for
DIAGNOSIS
Pathophysiology 1. Mucus-producing glands deep within the lining of
the airways become enlarged (hypertrophy) and
and Etiology increase in number (hyperplasia), and the
number of surface cells that produce mucus
(goblet cells) increases, resulting in excessive
secretion of mucus in the lungs. The resulting chronic
cough and expectoration
2. Secretions remain in the lungs and form plugs in
smaller bronchi, plugs are areas for bacterial growth and
chronic infection.
3. The hyperplasia and hypertrophy of the sub
mucosal glands (mucus-producing glands deep within
bronchial walls) thicken the airway walls
4. The resulting increased volume of mucus that
occurs plugs the airways.
5. Columnar cells (cells that line the surface of the
airways) undergo changes that result in
the destruction of cilia—delicate hairlike structures
on columnar cells lining the airways that sweep mucus
with offending agents up and out of the lungs.
6. The loss of cilia and the inability to clear
bacteria predispose the patient to lung infections.
Increase mucus secretion and causing areas of
focal tissue death
Pathophysiology and Etiology
V/Q mismatch: The physiologic response leads to a drop in ventilation
and compensation with the rise in CO. Increased perfusion in the
areas of poor ventilation takes place eventually causing hypoxia and
secondary polycythemia.
Severe hypoxia and hypercarbia: Chronic V/Q mismatch leads to
decreased oxygenation/deoxygenation of the blood resulting in hypoxemia
and increased CO2 retention (Respiratory Acidosis).
Hypoxia refers to a state in which oxygen supply is insufficient,
whereas hypoxemia and anoxemia refer specifically to states that
have low or zero arterial oxygen supply.

Pulmonary hypertension and cor pulmonale: Chronic hypercapnia and

respiratory acidosis lead to arterial vasoconstriction in the lungs. With
the retrograde pressure build-up, the right ventricular pressures continue to
rise and eventually causing RV failure. Otherwise, known as cor
pulmonale.
 Assessment Findings
Development of C.B may be
insidious (gradual) or follow by a
long history of B.A or Acute
RTI such as influenza and pneumonia
Air pollutions and smoking are
significant factors
C.B may develop at any time , but
appears most commonly in middle
age after years of untreated low
grade bronchitis
duration of the symptoms, how
disease process began, and
history of occupational health
hazards, pulmonary disease,
smoking form the basis for
DIAGNOSIS
 Assessment Findings
Chronic cough productive of white, thick mucus (Earliest Symptom)- sputum
may become copious, yellow, purulent and blood streak after paroxysms of cough
during acute infection- High amount of sputum produced by the goblet cells,
Cough: Irritation of the cough receptors, by the mucous, in the smaller and the
large airways.
Bronchospasm may occur during severe attack of coughing
Expiration is prolonged due to obstructed airway passages (wheezing and crackles)
Cyanosis due to hypoxemia and hypercapnia
Dyspnea begins with exertion but later with minimal activity and then at rest
RSHF (Col Pulmonale) due to tachycardia in response to hypoxemia, leading to
edema in the extremities (peripheral edema)
Pulmonary HTN due to vasoconstriction due to hypoxemia
Col Pulmonale due Chronic Pulmonary HTN
Secondary Polycythemia due to hypoxemia (Elevated erythropoietin, RBC, hgb,
Hematocrit)
 Diagnostic Findings
Chest Xray - Increased broncho-
vascular lungs markings(signs of
fluid overload and consolidation-
lung tissue that has filled with liquid)

as RSHF develops Enlarged Heart

 Diagnostic Findings
Pulmonary Function Test Forced Vital Capacity (FVC)
measures the amount of air
Decreased Vital Capacity you can breathe out in one
and forced expiratory volume complete breath
Increased residual volume A decrease in the FEV may
and total lung capacity mean there is blockage to the flow
of air out from the lungs
Residual volume, the
volume of air left in the Vital capacity (VC) is the
lungs maximum amount of air a
person can expel from the
Total Lung Capacity gas that still lungs after a maximum
remains in the chest even after inhalation
the patient makes his/her effort
to fully "empty" the lungs
 Medical Management
Goal of treatment are to:

Prevent recurrent irritation of bronchial mucosa by

infection or chemical agent

Maintain function of the bronchioles

Assist in removal of secretions

 Medical Management
Bronchodilator Medications — Inhaled as aerosol
sprays or taken orally, bronchodilator medications may
help to relieve symptoms of chronic bronchitis by
relaxing and opening the air passages in the lungs.
 Medical Management
Steroids — Inhaled as an aerosol spray, steroids can help relieve symptoms of
chronic bronchitis (anti-inflammatory) which suppress inflammation
and immunity
 Medical Management
Antibiotics — Antibiotics may be used to help fight
respiratory infections common in people with chronic
bronchitis.
Vaccines — Patients with chronic bronchitis should receive
a flu shot annually and pneumonia shot every five to seven
years to prevent infections.
Oxygen Therapy — As a patient's disease progresses, they
may find it increasingly difficult to breathe on their own and
may require supplemental oxygen. Oxygen comes in various
forms and may be delivered with different devices, including
those you can use at home.
 Medical Management
Surgery — Lung volume reduction surgery, during which
small wedges of damaged lung tissue are removed, may
be recommended for some patients with chronic
bronchitis.
Medical Management
Pulmonary Rehabilitation
Education
Nutrition counseling
Learning special breathing
techniques
Help with quitting smoking
Starting an exercise regimen.
Because people with chronic
bronchitis are often physically
limited, they may avoid any kind
of physical activity. However,
regular physical activity can
actually improve a patient's
health and wellbeing.
 Pulmonary Emphysema
Chronic disease characterized by
abnormal distention of the alveoli
The alveolar wall and capillary beds
also show marked destruction.
Damage to the lungs usually
permanent
Impaired gas exchange
due to destruction of the
walls of over-distended
alveoli
loss of elasticity of lung
tissue is caused by
destruction of elastin &
collagen fibers
Pathophysiology and Etiology
Alveoli loss elasticity
Trapping air the client
normally expire
Alveoli wall have broken
down, forming one large
sac (bullae, bleb) instead of
multiple, small air spaces
Capillary beds previously
located within alveolar walls
are destroyed and formed
fibrous scarring
Decreased inability to oxygenate
the blood.The body has to
compensate by hyperventilation
(the "puffer" part).  Their arterial
blood gases (ABGs) actually are relatively
Normal or dec PCO2 because of
this compensatory
hyperventilation.
Eventually, because of the low
cardiac output, people afflicted
with this disease develop muscle
wasting and weight loss. 
They actually have less hypoxemia
(compared to blue bloaters) and
appear to have a "pink" complexion
and hence "pink puffer".
Some of the pink appearance may
also be due to the work (use of neck
and chest muscles) these folks put into
just drawing a breath. 
 Normally healthy lungs has a balance between
protease and anti protease
Emphysema is the cause of imbalance between
protease and anti protease
Smoking cause inflammation in the airways
Neutrophils and other immune cell are recruited to the
small airways, releasing proteases from Neutrophil
(elastase) and alveolar macrophages
(mataloprotease)
Neutrophil (elastase) and alveolar macrophages
(mataloprotease) Break down or destroy the
elastic fiber and damage cell that normally
contributes to the elastic recoil during expiration of
bronchioles and alveoli
Alpha 1 Antitrypsin (anti protease) is a protease
inhibitor that keeps elastase in check , to keep the
balance and prevent further cell damage
Alpha 1 antitrypsin is the best known genetic
predisposition to empysema because there is no anti
 Normally healthy lungs has a balance
between protease and anti protease
Emphysema is the cause of imbalance
between protease and anti protease
Smoking cause inflammation in the airways
Neutrophils and other immune cell are
recruited to the small airways, releasing
proteases from Neutrophil (elastase) and
alveolar macrophages (mataloprotease)
Neutrophil (elastase) and alveolar
macrophages (mataloprotease) Break
down or destroy the elastic fiber and
damage cell that normally contributes to the
elastic recoil during expiration of bronchioles
and alveoli
Alpha 1 Antitrypsin (anti protease) is a
protease inhibitor that keeps elastase in
check , to keep the balance and prevent
further cell damage
Alpha 1 antitrypsin is the best known genetic
predisposition to empysema because there is no
anti protease activity
 Emphysema Types:
Acinus -
1.Centrilobular (centriacinar) small sac-
Proximal and central part of the acinus is like cavity
expanded
Affect upper lobes in a gland
Cigarette smoking
2.Panacinar (Panlobular)
Involves entire respiratory acinus, from
respiratory bronchiole to alveoli is expanded.
Common in lower zones
Alpha1- antitrypsin deficiency

3.Paraseptal (Distal Acinar) Distal near

pleura and septae In areas of fibrosis and
scarring Bullae formation
4. Irregular or mixed( Paracicatritial
emphysema)
Combination
No particular relationship to the acinus .
 Assessment Findings
Non cyanotic (“pink”): Matched
V:Q defect; no hypoxemia.
Diminished breath sounds on
auscultation: Hyperinflation of
alveoli and destruction of
alveolar architecture causes
decreased airway resistance.
Low cardiac output, people
afflicted with this disease develop
muscle wasting and weight
loss. 
Thin/cachexia: Loss of skeletal
muscle and subcutaneous fat due
to inadequate oral intake as well
as high levels of inflammatory
cytokines that cause such wasting.
Severe constant dyspnea/
tachypnea (“puffing”) related to
increasing end-expiratory volume
(decreased recoil), making each
breath less efficient.
Patients use accessory muscles
(tripod position) and breath faster
(hyperventilation) to compensate
for feeling of inadequate
ventilation.
Dyspnea is also related to
respiratory muscle fatigue from
increased use as well as the
flattening of the diaphragm
which impairs its function.
 The term "barrel
chest" describes a
rounded, bulging
chest that
resembles the shape
of a barrel. Barrel
chest isn't a disease,
but it may indicate
an underlying
condition.

Chronically
overinflated with air, so
Hyperinflation of lungs the rib cage stays
› Low diaphragmatic position partially expanded all
› Decreased intensity of heart and the time.
breath sounds Inspiration is
› AP = Transverse diameter (barrel difficult because of the
chest) rigid chest
› Costal angle greater than 90 degrees
 accessory breathing muscles
(muscles in the neck, upper
chest, and between the ribs)
When you exhale with your lips
pursed, there is increased
resistance in your airways, which
helps them stay open during
exhalation.
Pursed-lip breathing also helps calm
you down and slows your breathing.
Practice this technique by inhaling
through your nose, making sure to
keep your mouth closed.

CO2 Narcosis -
Co2 in the blood increased and
reach the toxic level dec LOC to coma
 Diagnostic Findings
Pulmonary Function Test Forced Vital Capacity (FVC)
Decreased Vital Capacity measures the amount of air
and forced expiratory you can breathe out in one
volume complete breath
Increased residual volume A decrease in the FEV may
and total lung capacity mean there is blockage to the flow
of air out from the lungs
Residual volume, the volume
of air left in the lungs Vital capacity (VC) is the
maximum amount of air a
Total Lung Capacity gas that still person can expel from the
remains in the chest even after lungs after a maximum
the patient makes his/her effort inhalation
to fully "empty" the lungs Hypoxemia & R. Acidosis
 Medical Management
Goal of treatment are to:

Improving the quality of life

Slowing the disease progression

Treating obstructed airways

 Medical Management
Bronchodilator Medications — Inhaled as aerosol
sprays or taken orally, bronchodilator medications may
help to relieve symptoms of chronic bronchitis by
relaxing and opening the air passages in the lungs.
 Medical Management
Steroids — Inhaled as an aerosol spray, steroids can help relieve symptoms of
chronic bronchitis (anti-inflammatory) which suppress inflammation
and immunity
 Medical Management
Antibiotics — Antibiotics may be used to help fight
respiratory infections common in people with chronic
bronchitis.
Oxygen Therapy
In a normally functioning patient, the respiratory drive is
largely directed by PaCO2 levels in the brain since H+ readily
crossed the blood brain barrier
In this patient, PaCO2 becomes chronically elevated, and thus
the body shifts its respiratory controllers to become more
responsive to PaO2 levels.
Chronic emphysema patient with oxygen increased the blood
oxygen levels too rapidly. This may result in knocking out
his hypoxic drive, causing further depression of the
respiratory drive.
 Medical Management
Therapy
Oxygen given at or above 32% by mask or any means,
hypoxic drive to breath is lost and respiratory drops, leading to
further retentions of co2, apnea and death
Safest method NC @ 2-3 LPM

Therapy
Pulmonary rehabilitation.
teach you breathing exercises and techniques that may help reduce your
breathlessness and improve your ability to exercise.
Nutrition therapy. You'll also receive advice about proper nutrition. In the early
stages of emphysema, many people need to lose weight, while people with late-
stage emphysema often need to gain weight.
 Medical Management
Surgery

Depending on the severity of your emphysema, your doctor may

suggest one or more different types of surgery, including:

Lung volume reduction surgery. In this procedure, surgeons remove

small wedges of damaged lung tissue. Removing the diseased tissue
helps the remaining lung tissue expand and work more efficiently
and helps improve breathing.

Lung transplant. Lung transplantation is an option if you have

severe emphysema and other options have failed.
Nursing Care Process
COPD
Bronchial Asthma
 Nursing Diagnosis
Ineffective Airway Clearance: Inability to clear secretions or
obstructions from the respiratory tract to maintain a clear airway.
Possibly evidenced by
May be related to Statement of difficulty breathing
Bronchospasm Changes in depth/rate of respirations, use of
accessory muscles
Increased production of Abnormal breath sounds, e.g., wheezes, rhonchi,
secretions; retained crackles
secretions; thick, viscous Cough (persistent), with/without sputum
secretions production

Allergic airways Desired Outcomes

Hyperplasia of Maintain airway patency with breath sounds
clear/clearing.
bronchial walls
Demonstrate behaviors to improve airway
Decreased energy/ clearance, e.g., cough effectively and
fatigue expectorate secretions.
 Nursing Diagnosis
Impaired Gas Exchange: Excess or deficit in oxygenation and/
or carbon dioxide elimination at the alveolar-capillary membrane.
May be related to Possibly evidenced by
Dyspnea
Altered oxygen Abnormal breathing
supply (obstruction Confusion, restlessness
of airways by Inability to move secretions
secretions, Abnormal ABG values (hypoxia and hypercapnia)
Changes in vital signs
bronchospasm; air- Reduced tolerance for activity
trapping) Desired Outcomes
Alveoli destruction Demonstrate improved ventilation and adequate
Alveolar-capillary oxygenation of tissues by ABGs within patient’s
normal range and be free of symptoms of respiratory
membrane changes distress.
Participate in treatment regimen within level of
ability/situation.
 Nursing Diagnosis
Ineffective Breathing Pattern: Inspiration and/or
expiration that does not provide adequate ventilation.
May be related to Possibly evidenced by
Alteration of patient’s Dyspnea
usual O2/CO2 ratio Wheezes/crackles on auscultation on the BLF
Anxiety Subcostal retraction
Decreased energy Nasal flaring
Decreased lung expansion Presence of non-productive cough
Fatigue Increase RR above normal range
Hypoxia
Inflammatory process: Desired Outcomes
viral or bacterial
Tracheobronchial
Patient will improve breathing pattern.
obstruction Patient will maintain a respiratory rate
Retained Secretions within normal limits.
 Nursing Diagnosis
Imbalanced Nutrition: Less Than Body Requirements - Dyspnea;
sputum production, anorexia, nausea/vomiting, Fatigue

Risk for Infection- Inadequate primary defenses (decreased ciliary action, stasis of
secretions), Inadequate acquired immunity (tissue destruction, increased environmental
exposure), Chronic disease process, Malnutrition

Deficient Knowledge - Lack of information/unfamiliarity with information

resources, Information misinterpretation, Lack of recall/cognitive limitation

Self-Care deficit, specify—Intolerance to activity, decreased strength/ endurance,

depression, severe anxiety.

Home Maintenance, ineffective—Dntolerance to activity, inadequate support

system, insufficient finances, unfamiliarity with neighborhood resources.

Infection, risk for—Decreased ciliary action, stasis of secretions, tissue destruction,

increased environmental exposure,chronic disease process, malnutrition.
 Nursing Intervention
Nursing Interventions Rationale
Assess and monitor respirations and
breath sounds, noting rate and sounds
(tachypnea, stridor, crackles, wheezes).
Note inspiratory and expiratory ratio.
Assist patient to assume position of
comfort (elevate head of bed, have
patient lean on over-bed table or sit
on edge of bed).
Tachypnea is usually present to some
degree and may be pronounced on
admission or during stress or
concurrent acute infectious process.
Respirations may be shallow and
rapid, with prolonged expiration in
comparison to inspiration.
Elevation of the head of the bed facilitates
respiratory function by use of gravity;
however, patient in severe distress will seek
the position that most eases breathing.
Supporting arms and legs with table, pillows,
and so on helps reduce muscle fatigue and
can aid chest expansion.
 Nursing Intervention
Nursing Interventions Rationale
Keep environmental pollution to a
Precipitators of allergic type of
minimum such as dust, smoke, and
respiratory reactions that can trigger
feather pillows, according to
or exacerbate onset of acute episode.
individual situation.

Provides patient with some means to

Encourage abdominal or pursed-lip
cope with or control dyspnea and
breathing exercises.
reduce air-trapping.

Increase fluid intake to 3000 mL per
day within cardiac tolerance. Provide
warm or tepid liquids. Recommend
intake of fluids between, instead of
during, meals.
Hydration helps decrease the viscosity
of secretions, facilitating expectoration.
Using warm liquids may decrease
bronchospasm. Fluids during meals can
increase gastric distention and pressure
on the diaphragm.
 Nursing Intervention
Nursing Interventions Rationale
Position head midline with flexion on
To gain or maintain open airway
appropriate for age/condition
To decrease pressure on the
Elevate HOB
diaphragm and enhancing drainage
Observe S/Sx of infections To identify infectious process
Demonstrate chest physiotherapy, These techniques will prevent possible
such as bronchial tapping when in aspirations and prevent any untoward
cough, proper postural drainage. complications

More aggressive measures to maintain

Administer Medications if prescribed.
airway patency.
 Nursing Intervention
Nursing Interventions Rationale
Thick, tenacious, copious secretions are a
major source of impaired gas exchange in
Encourage expectoration of sputum;
small airways. Deep suctioning may be
suction when indicated. required when cough is ineffective for
expectoration of secretions.
Decrease of vibratory tremors suggests
Palpate for fremitus.
fluid collection or air-trapping.
Restlessness and anxiety are common
manifestations of hypoxia. Worsening
Monitor level of consciousness and
ABGs accompanied by confusion/
mental status. Investigate changes. somnolence are indicative of cerebral
dysfunction due to hypoxemia.
Tachycardia, dysrhythmias, and changes in
Monitor vital signs and cardiac
BP can reflect effect of systemic hypoxemia
rhythm. on cardiac function.
 Nursing Intervention
Nursing Interventions Rationale
Evaluate level of activity tolerance. Provide
calm, quiet environment. Limit patient’s
activity or encourage bed or chair rest during
acute phase. Have patient resume activity
gradually and increase as individually
tolerated.
Assess and routinely monitor skin and
mucous membrane color.
Auscultate breath sounds, noting
areas of decreased airflow and
adventitious sounds.
During severe, acute or refractory respiratory distress,
patient may be totally unable to perform basic self-care
activities because of hypoxemia and dyspnea. Rest
interspersed with care activities remains an important
part of treatment regimen. An exercise program is
aimed at increasing endurance and strength without
causing severe dyspnea and can enhance sense of well-
being.
Cyanosis may be peripheral (noted in nailbeds) or
central (noted around lips/or earlobes). Duskiness
and central cyanosis indicate advanced hypoxemia.
Breath sounds may be faint because of
decreased airflow or areas of consolidation.
Presence of wheezes may indicate
bronchospasm or retained secretions.
Scattered moist crackles may indicate
interstitial fluid or cardiac decompensation.
 Nursing Intervention
Nursing Interventions Rationale

Establishes baseline for monitoring progression

or regression of disease process an complications.
Note: Pulse oximetry readings detect changes in
Monitor and graph serial ABGs, pulse saturation as they are happening, helping to
oximetry, chest x-ray. identify trends before patient is symptomatic.
However, studies have shown that the accuracy
of pulse oximetry may be questioned if patient
has severe peripheral vasoconstriction.

Place patient in semi-fowlers position To have a maximum lung expansion

Provide respiratory support. Oxygen
To aid in relieving patient from
inhalation is provided per doctor’s
dyspnea
order
To facilitate secretion mov’t and
Change position every 2 hours
drainage
 Nursing Intervention
Nursing Interventions Rationale
Administer supplemental oxygen Decreases dyspnea and increases energy for
during meals as indicated. eating, enhancing intake.

Extremes in temperature can

Avoid very hot or very cold foods. precipitate or aggravate coughing
spasms.
Odorous, yellow, or greenish secretions
Observe color, character, odor of
suggest the presence of pulmonary
sputum.
infection.

Explain and reinforce explanations of Decreases anxiety and can lead to

individual disease process. Encourage improved participation in treatment
patient and SO to ask questions. plan.
 Nursing Intervention
Nursing Interventions Rationale
Instruct and reinforce rationale for
breathing exercises, coughing
effectively, and general conditioning
exercises.
Review the harmful effects of
smoking, and advise cessation of
smoking by patient and SO.
Demonstrate technique for using a metered-dose
inhaler (MDI), such as how to hold it, taking 2–5
min between puffs, cleaning the inhaler.
Pursed-lip and abdominal or diaphragmatic
breathing exercises strengthen muscles of
respiration, help minimize collapse of small
airways, and provide the individual with means
to control dyspnea. General conditioning
exercises increase activity tolerance, muscle
strength, and sense of well-being.
Cessation of smoking may slow or halt
progression of COPD. Even when patient
wants to stop smoking, support groups and
medical monitoring may be needed. Note:
Research studies suggest that “side-stream” or
“second-hand” smoke can be as detrimental as
actually smoking.
Proper administration of drug enhances
delivery and effectiveness.
Thank You
 References
http://nurseslabs.com/chronic-obstructive-pulmonary-disease-copd-
nursing-care-plans/6/

Smeltzer, S. C. O., Hinkle, J. L. ., Cheever, K. H. ., & Bare, B. G..

(2010). Brunner & Suddarth's textbook of medical-surgical nursing
(12th, North American Edition, Combined Volume edition.).
Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Dudek, S. G. (2010). Nutrition essentials for nursing practice.

Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

https://www.youtube.com/watch?v=WiPMZ4GmfD0

https://www.youtube.com/watch?v=ChlSfDBHLvg