59 years old woman presented in the ER with complain of:
History of presenting complaint:
According to the patient, she was in her usual state of health one month back when she experienced severe bouts of cough with sputum, white and non-foul smelling and difficulty in breathing. She had difficulty in climbing stairs. She experienced frequent episodes of wheezing. She has already been on albuterol inhaler for months and on and off antibiotic use. Her cough and difficulty in breathing has increased over the past one month despite these medications.
She had several attacks of cough with sputum annually since the past 10 years. Her condition started to worsen 3 years back when she started experiencing difficulty in breathing as well. She sought medical advice and was prescribed antibiotic course, albuterol inhaler when needed. She had wheezing which was relieved temporarily relieved by inhalers. She has been smoking since 40 years, approximately 1.5 pack per day. She was also advised to quit smoking. (Tashkin, 2011). Her symptoms have worsened over the time.
She is married with 3 off springs, alive. Eldest son suffers from Asthma. Her past medical history includes the history of depression due to her poor quality of life and joint pains, frequent headache. Her past surgical history includes removal of the uterus, appendix and gall bladder. Her family history is unavailable because she was an adopted child.
A woman of average build and height with no signs of distress lying on the bed. Her vitals are heart rate: 85/minute, respiratory rate: 20/minute, SaO2: 90 %
Systemic examination reveals audible first and second heart sounds with no murmur and normal volume pulses. Chest expands equally with each breath but shows increased anteroposterior diameter and decreased breath sounds bilaterally. There is no wheezing. The rest of the examination is unremarkable.
Initial impression and work up required:
The patient seems to suffer from COPD. Her symptoms of chronic productive cough and wheezing along with the history of smoking strongly favor this diagnosis. The patient needs further workup (Spirometry) to confirm the diagnosis of COPD, escalation of the treatment she is receiving, advice to quit smoking and regular follow-up with a physician.
Pulmonary function tests: FEV1: 0.95 L (47%), FVC: 1.83L (67%), FEV1/FVC: 52%, TLC: 120%, RV: 160%, RV/TLC: 53%
Diagnosis and treatment advised:
Chronic obstructive pulmonary disease (COPD) of moderate to severe variety (Gary T. Ferguson,2003). Bronchodilator (ipratropium with albuterol) four times daily. Stop smoking, and follow up visits.
COPD is a clinical diagnosis in a patient who presents with productive cough, difficulty in breathing and has a history of cigarette smoking. It can be confirmed by Spirometry. If the ratio of FEV1 (forced expiratory volume in 1 sec) and FVC (forced vital capacity is less than 0.7, the diagnosis is confirmed.
Signs and symptoms include a productive cough, dyspnea at a late stage, bluish discoloration (cyanosis) of the skin and mucosa, obesity, expiratory wheezing (whistling sound on auscultation), cor pulmonale.
COPD can be classified on the basis of severity in 4 grades; GOLD 1 mild (FEV1 > 80%), moderate (FEV1 50%-80%), severe (FEV1 30%-50%) and GOLD 4 very severe (FEV1 < 30%)
The investigations for COPD include X-ray chest which shows a horizontal heart and increased bronchial markings in the lung field. Arterial blood gases show respiratory acidosis and pulmonary function tests (spirometry) confirms the diagnosis.
The patients with COPD can easily be managed in the hospital according to the severity of their symptoms and discharged on oral or inhaled medicines.
Preventive Management Strategies:
COPD can be prevented by caseation of smoking. Both active and passive smoking should be avoided. Avoiding the exposure to dust and chemicals also reduces the risk for COPD. The environment should be kept clean by the public and organizations to provide safe breathing.
The management of COPD includes:
a) Reduction of symptoms (increase exercise tolerance, alleviate the symptoms) (Qaseem, 2011).
b) Reducing the risk of disease progression (avoiding exacerbation of symptoms, decreasing mortality)
Non Pharmacologic intervention:
1. Keep the patient in an upright position
2. Oxygen through face mask.
Bronchodilators: These include anticholinergic medicines and beta2 agonists. They can be used in combination as well. The inhaled formulations provide quick relief from the symptoms than the oral medication.
Corticosteroids: They are effective in severe and very severe disease and in conditions where beta2 agonists have a limited role. They are effective as inhaled medication in combination with beta2 agonists. The patients who are on inhaled corticosteroids need to be monitored for oral thrush and bruising. Those on oral steroids, especially old female patients also need to undergo periodic bone density scans.
Phosphodiesterase-4 inhibitor: It is also used for severe disease to control acute attack of breathlessness.
In the above-mentioned case study, the patient was experiencing the symptoms of cough with sputum and wheezing, not relieved with the occasional use of albuterol inhaler. She was diagnosed as a case of COPD after spirometry, and her medicines were increased She responded well to the treatment given by improvement in PaO2 on follow-up visits and decreased episodes of cough. She can benefit by caseation of smoking and adhere to the treatment prescribed.
Qaseem, A., Wilt, T. J., Weinberger, S. E., Hanania, N. A., Criner, G., Van der Molen, T., & Shekelle, P. (2011). Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Annals of internal medicine, 155(3), 179-191.
Tashkin, D. P., Rennard, S., Hays, J. T., Ma, W., Lawrence, D., & Lee, T. C. (2011). Effects of varenicline on smoking cessation in patients with mild to moderate COPD: a randomized controlled trial. Chest Journal, 139(3), 591-599.
(n.d.). Retrieved July 1, 2015, from http://www.jhasim.com/files/articlefiles/pdf/288-290(V3-4B).pdf
(n.d.). Retrieved July 1, 2015, from http://www.goldcopd.org/uploads/users/files/GOLD_AtAGlance_2011_Jan18.pdf