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A CASE PRESENTATION ON

CHRONIC OBSTRUCTIVE RUMELLE B. REYES


POST GRADUATE INTERN

PULMONARY DISEASE
OBJECTIVES:
ToThis
be case
a presentation
To aims to:

3
1

4
discuss To be able To be able
able to the to know to present
present a etiology, the the
case of a risk pathogene manageme
patient with factors, sis and nt of
COPD. clinical diagnose a COPD.
manifestati patient with
ons of COPD.
COPD.
DATE AND
INFORMAN RELIABILIT
TIME OF
T Y
HISTORY
AUGUS
PATIEN
T 15, 98 %
T
2018
WIDOW
DOB:
10/04/1941
76/M
SAN
C.B ROMAN
CATHOLIC
SEBASTIAN
SAMAR
FILIPINO ADMITTED FOR THE
1ST
TIME AT OUR
CENTER
DOA: AUGUST 12, 2018
TOA: 11:05 AM
CHIEF COMPLAINT
DIFFICULTY
OF
BREATHING
HISTORY OF PRESENT
ILLNESS
1 • Dyspnea
• Easy fatigability
MONT • Relieved by rest
H • Productive cough to a whitish
PTA sputum
NO FEVER, CHEST
PAIN, ABDOMINAL
PAIN, DYSURIA
• CBC
• NA, K,
SOUGHT BLOOD
CONSUL CHEMIST
RY
T AS • SPIROME
OPD TRY
• 12-L ECG
SOUGHT
CONSULT AS OPD
OPD (07/03/18)
HEMOGLOBI 142
N
SPIROME
CBC
TRY
HEMATOCRIT 0.40
WBC COUNT 6.1
NA, K 12-L ECG PLATELET CT 260
NEUTROPHIL 54
S
BLOOD LYMPHOCYT 32
CHEMIST E
RY
MONOCYTE 3
SOUGHT OPD
CONSULT AS (07/03/18)
OPD
GLUCOSE 4.9

LDL 3.51
SPIROME
CBC
TRY VLDL 0.64

CHOLESTEROL 5.0

TRIGLYCERIDE 1.40
NA, K 12-L ECG S
DIRECT HDLC 0.9

BLOOD ALBUMIN 37
CHEMIST ALT 35
RY
SOUGHT
CONSULT AS
OPD OPD
(07/03/18
)
SPIROME
CBC NA 140.9
TRY
K 4.51
NA, K 12-L ECG BUN 5.4
CREATININ 83
BLOOD E
CHEMIST
RY
SOUGHT
CONSULT AS
OPD SPIROMETRY
VERY SEVERE
CBC SPIROMETRY
OBSTRUCTIVE TYPE OF
DEFECT WITH GOOD
RESPONSE TO
BRONCHODILATOR.
NA, K 12-L ECG PLEASE CORRELATE
CLINICALLY.

BLOOD
CHEMISTRY
SOUGHT
CONSULT AS
OPD
12-L ECG
CBC
SPIROME SINUS
TRY
TACHYCARDIA,
LEFT AXIS
NA, K 12-L ECG
DEVIATION,
BLOOD
ANTEROSEPTAL
CHEMIST WALL ISCHEMIA
RY
LEVOCETIRIZINE +
N-ACETYLCYSTEINE
MONTELEUKAST DOXOFYLLINE
600 mg, 1 tab in ½
10/5 mg, 1 tab 200 mg, 1 tab BID
glass of water OD
OD

IPRATROPIUM + ROSUVASTATIN
TRIMETAZIDINE
SALBUTAMOL 20 mg, 1 tab
neb 35 mg, 1 tab BID
ODHS

CARVEDILOL
ASPIRIN
6.25 mg, ½ tablet
80 mg, 1 tab OD
BID
ON INTERIM…
NO
RELIEVED BY
FOLLOW UP
NEBULIZATION OF
SALBUTAMOL +
CONSULT
PERSISTENCE OF THE IPRATROPIUM EVERY DONE.
MENTIONED 8 HOURS
SYMPTOMS WERE • MAINTENANCE
NOTED. MEDICATIONS TAKEN
WITH GOOD
• OCCASIONAL DYSPNEA COMPLIANCE
• EASY FATIGABILITY
• PRODUCTIVE COUGH
HISTORY OF PRESENT ILLNESS

1 • (+) exertional dyspnea


DAY • Productive cough
• Easy fatigability
PTA • Slightly relieved by rest
PERSISTENCE OF THE SALBUTAMOL +
PROMPTING
MENTIONED IPRATROPIUM 2.5 ML
CONSULT
SYMPTOMS NEB X 1 DOSE

WORSENING OF
PROVIDING NO
THE DIFFICULTY HENCE,
RELIEF OF THE
OF BREATHING ADMITTED.
DYSPNEA
EVEN AT REST

OCCASIONAL
DYSPNEA, EASY

HOURS PTA
FATIGABILITY,
PRODUCTIVE
COUGH
PAST MEDICAL HISTORY
HYPERTENSION
Losartan 50 Carvedilol 6.25
mg/tablet, 1 tablet
• 10 YEARS OD – poor mg/tablet, 1
compliance tablet BID
• HIGHEST BP
RECORDED: 170/80 MAINTENANCE Trimetazidine Rosuvastatin
mmHg MEDICATIONS:
35mg/tablet, 1
tablet BID 20mg/tablet, 1
tablet OD
NO OTHER Aspirin
Doxofylline,
80mg/tablet, 1
COMORBIDITIES tablet OD 200mg/tablet,
NOTED. 1 tablet BID

• (-) DM
• (-) ASTHMA
PAST MEDICAL HISTORY
PREVIOUS
SURGERY ALLERGY
HOSPITALIZATION

MAY 2018 at
Tacloban Doctors
due to chest tightness NONE NONE
and productive
cough. Patient was
admitted for 7 days
and was discharged
improved.
MOTHER WIFE
Died at the Died at 74 due to an
unknown lung disease
age of 84 due but was known to be a
to a fire chronic smoker
smoking 1 pack per
incident day.

FATHER
Died at 71 NO OTHER
HEREDOFAMILIAL
(+) Hypertension
FAMILY DISEASES NOTED

HISTOR
Y
PERSONAL SOCIAL HISTORY
ALCOHOLIC
EDUCATIONAL ATTAINMENT:
COLLEGE GRADUATE SMOKER BEVERAGE DRINKER

Occupation:
Duration: 51 years Duration: 55 years
Elementary Teacher

Drug/Herbal Number of Pack Frequency: once a


Medication Use: None Years: 26 pack years week

Quit: 2013 Quit: 2017

Amount/Type: 2
glasses per session
REVIEW OF SYSTEMS
•(-) weight loss; afebrile; (+) body
GENERAL malaise; (-) weight gain, (+) easy
fatigability, (+) loss of appetite

•(-) Rash, (-) Itchiness, (-) Lesions, (-)


SKIN Pallor

•(-) Eye discharge, (-) Ear discharge, (-


HEENT ) Nasal Discharge, (-) Epistaxis, (-)
Sore throat
•(+) dyspnea, (+) productive
RESPIRATORY cough; (-) hemoptysis

CARDIO •(-) chest pain; (-) palpitations,


VASCULAR (+) 2 pillow orthopnea, (-) PND

GASTRO •(-) Vomiting, (-) Abdominal Pain,


INTESTINAL (-) Diarrhea, (-) Constipation
•(-) Hematuria, (-) Oliguria,
URINARY
(-) Dysuria

REPRODUCTIVE •(-) Discharge, (-) Itching

MUSCULO • (+) joint stiffness and


pains (-)Tremors, (-)
SKELETAL Limitation of Movement
• (-) Polyphagia, (-) Heat
ENDOCRINE Intolerance

PSYCHIATRIC • (-) Tantrums, (-) Suicidal ideations

• (-) Seizures, (-) LOC, (-) Change in


NEUROLOGIC sleep patterns, (-) Change in
personality
PHYSICAL EXAMINATION
GENERAL AWAKE, CONSCIOUS, COHERENT

BP: 90/60 mmHg SPO2:100 %


HR: 66 bpm WEIGHT: 55.5 kg
RR: 23 cpm HEIGHT: 155 cm
TEMP: 36.3 C BMI: 23.10

INTEGUMENT
• Skin: Dry, warm, no scars
• Nails: Good capillary refill, no clubbing, pinkish nail
HEAD

• Scalp: No tenderness, no scars, no active lesions


• Skull: Atraumatic

EYES

• Eyebrows: symmetrical, fine, black, intact, no scars, nor active


lesions
• Eyelashes: fine, black, oriented outwards
• Eyelids: no edema, no ptosis, no lidlag, no inflammation
• Conjunctiva: pinkish palpebral conjunctiva, no hemorrhage
• Sclera: anicteric, no hemorrhage
• Cornea; no ulcerations, no scars, no opacities
• Pupils: symmetrical, 3 mm in diameter, equally round and reactive
to light and accommodation.
• EOM: intact upward, downward, medial and lateral movements
NOSE

•pinkish nasal mucosa, no septal


deviation

MOUTH/THROAT

• Pale, dry lips, pinkish buccal mucosa,


gums no bleeding/swelling
•Tongue: pinkish, smooth
NECK

• trachea midline, no palpable lymph nodes, no neck


vein engorgement

CHEST/LUNGS

• Inspection: truncal in shape, no bulging, no


retraction of subcostal and intercostal muscles
• Palpation: symmetrical lung expansion, with normal
tactile fremitus, no masses
• Percussion: resonant in all lung fields
• Auscultation: (+) rales mid-basal in both lung fields,
(+) wheeze all over the lung fields
HEART

• Inspection: no bulging of precordium, no mass


• Palpation: PMI palpable at 5th ICS left MCL, no thrills, no
heaves
• Auscultation: normal rate, regular rhythm, synchronous
with the pulse, no murmurs, no pericardial friction rub

ABDOMEN

• Inspection: flat, symmetrical, no engorged veins, no


hypo/hyperpigmentation,
• Palpation: liver, spleen and kidney are not palpable
• Percussion: tympanitic on all other quadrants
• Auscultation: normoactive bowel sounds
GENITOURINARY

•no discharges, no lesions, no redness, no


hematuria

EXTREMITIES

•Full equal pulses, proportional in length,


no noticeable deformities, no active
lesions, grade 1 bipedal pitting edema,
no cyanosis, no atrophy
SALIENT PAST MEDICAL HISTORY
• Hypertensive
FEATURES • Admitted last May 2018
due to cough, dyspnea
PERSONAL SOCIAL
and chest tightness
HISTORY
ROS
• A known smoker; 26
• 2-PILLOW pack years
ORTHOPNEA
• Exposed to second
hand smoking

PHYSICAL EXAMINATION

76
HISTORY
• NO NVE
• EASY FATIGABILITY
• CHEST AND LUNGS: MID

MALE
• PRODUCTIVE COUGH TO BASAL RALES, (+)
• EXERTIONAL WHEEZING
DYSPNEA • GRADE 1 BIPEDAL PITTING
EDEMA
DIFFERENTIAL DIAGNOSIS
RULE IN RULE OUT
√ Fatigue No neck vein engorgement
CHF √ Exertional Dyspnea
√ 2- pillow orthopnea
√ Rales
√ Wheezing
√ Grade 1 bipedal edema CANNOT
√ Alcoholic beverage drinker TOTALLY RULE
FRAMMINGHAM DIAGNOSTIC CRITERIA OUT
MAJOR MINOR
ORTHOPNEA DYSPNEA ON
RALES EXERTION
CARDIOMEGALY
RULE IN RULE OUT
√ Age Fever
COMMUNITY √ Tachypnea Pleuritic chest pain
ACQUIRED √ Rales
√ Wheezing
PNUEMONIA – √ Productive cough
MODERATE RISK
CANNOT
C: No confusion of new onset
U: 14.0 mmol/L TOTALLY RULE
R: 23 cpm
B: 90/60 mmHg
OUT
65: Patient is 76 years old

INTERPRETATION: 2
RULE IN RULE OUT

TUBERCULOSIS √ Dyspnea (-) WEIGHT LOSS


√ Productive Cough For 3 (-) LOW GRADE FEVER
Months (-) NIGHT SWEATS
√ Smoker (-) Exposure to TB
√ Exposure To Second
Hand Smoking
CANNOT
TOTALLY RULE
OUT
RULE IN RULE OUT
MYOCARDIAL √ Exertional dyspnea No chest pain
√ History of previous MI No diaphoresis
INFARCTION √ Known hypertensive
with poor compliance
to maintenance
medication CANNOT
√ History of Dyslipidemia
√ Body malaise
TOTALLY RULE
OUT
ASSESSMENT
COPD IN ACUTE
EXACERBATION; HYPERTENSION
STAGE 2
PERSONAL
PAST MEDICAL PHYSICAL
HISTORY SOCIAL
76 MALE
HISTORY EXAMINATION
HISTORY

Admitted last May


CHEST AND
2018 due to
EXERTIONAL A known smoker; LUNGS: MID TO
productive
DYSPNEA 26 pack years BASAL RALES, (+)
cough, and
WHEEZING
dyspnea

Exposure to
EASY FATIGABILITY second hand
smoking

PRODUCTIVE
COUGH

BASIS
2-PILLOW
ORTHOPNEA
AT THE EMERGENCY ROOM . .
.
S-O A P
(+) Exertional dyspnea COPD IN ACUTE DIAGNOSTICS THERAPEUTICS
(+) Easy fatigability EXACERBATION 12 L – ECG SALBUTAMOL + IPRATROPIUM NEBULE
(+) Productive cough CHEST XRAY – PA VIEW + 2 CC PNSS NOW THEN Q 8 HOURS
(+) Loss of appetite CHF FC III CBC PLATELET N-ACETYLCYSTEINE 600MG, DISSOLVE
CAP-MR U/A IN ½ GLASS OF WATER ODHS
TB SUSPECT TROPONIN I
R/O ABG DOXOFYLLINE 200MG TABLET BID
MYOCARDIAL ROSUVASTATIN 20MG TABLET ODHS
INFARCTION TRIMETAZIDINE 35MG TABLET BID
OBJECTIVE SUPPORTIVE
CARVEDILOL 6.25MG TABLET BID
AWAKE, CONSCIOUS, IVF: PNSS 1L @ 10 GTTS/MIN ASA 80MG TABLET OD
COHERENT, IN MILD DIET: LOW SALT, LOW FAT DIET LEVOCETIRIZINE + MONTELUKAST
RESPIRATORY DISTRESS 5/10MG TABLET OD
BP: 90/60 MMHG O2 INHALATION AT 2 LPM
PR: 66 BPM MONITORING I AND O CLOSELY
RR: 23 CPM AND ACCURATELY
T: 36.6 C PROVIDE MEASURING CONTAINER
SPO2: 98%
C/L: (+) mid to basal rales
(+) wheezing
EXTREMITIES: (+) grade 1
bilateral pitting edema
NYHA DESCRIPTION GENERAL GUIDE EXAMPLES
I Symptoms occur with
greater than ordinary
No limitation of physical activity Can do outdoor work
Can climb >/= 2 flights of stairs
physical activity with ease

II Symptoms occur with


ordinary physical
Slight limitation of physical
activity
Can do gardening,
walking on level ground,
activity Can climb 2 flights of stairs but have sex without
with difficulty stopping

III Symptoms occur with


less than ordinary
Marked limitation of physical
activity
Can shower without
stopping, do indoor
physical activity Can climb </= 1 flight of stairs cleaning, dress without
stopping, play
bowling/golf

IV Symptoms may be
present even at rest
Unable to carry on activity
without symptoms
Cannot carry out
activities above
Dyspnea at rest
OPD HOSPITAL DAY 1
CBC HEMOGLOBIN 142 127

HEMATOCRIT 0.40 0.39


WBC COUNT 6.1 4.6
PLATELET CT 260 428
NEUTROPHILS 54 61
LYMPHOCYTE 32 36
MONOCYTE 3 3
EOSINOPHILS 11
URINALYSIS
COLOR YELLOW BACTERIA FEW

TRANSPARENCY SLT. TURBID A.URATES MODERATE


SP. GRAVITY 1.025 M. THREAD MODERATE
PH 5.0 PROTEIN TRACE
PUS CELLS 2-4/HPF SUGAR NEGATIVE
RBC CELLS 2-4/HPF CASTS COARSE
GRANULAR:
0-2/HPF
E. CELLS FEW CALCIUM FEW/HPF
OXALATE
ABG ACTUAL MEASURED VALUES REFERENCE VALUES
pH 7.453 mmHg 7.35-7.45 mmHg
pCO2 15.4 mmHg 35-45 mmHg
pO2 137.3 mmHg 80-105 mmHg
TCO2 11.3 mmol/L 23-27 mmol/L
cHCO 10.9 mmol/L 22-26 mmol/L
3
cBE -9.3 mmol/L
SO2 99.3 % 95% -98%
12 – L ECG
SINUS RHYTHM WITH OCCASIONAL PACS,
ANTERO LATERAL WALL ISCHEMIA
12 – L ECG
SINUS SINUS RHYTHM WITH OCCASIONAL
PACS, ANTERO LATERAL WALL ISCHEMIA
TROPONIN I
NORMAL
VALUE
< 0.01 < 0.01 UG/L
CHEST XRAY (AP VIEW)
IMPRESSION:
- BIBASAL PNEUMONIA
- CARDIOMEGALY WITH PULMONARY
CONGESTION
- ATHEROMATOUS AORTA
PROBLEM LIST
1. DYSPNEA
2. BIPEDAL EDEMA
HOSPITAL DAY 1 : #1 DYSPNEA
S-O A P
(+) Dyspnea (decreased) COPD IN DIAGNOSTICS THERAPEUTICS
(+) Easy fatigability ACUTE
• CXR SALBUTAMOL + IPRATROPIUM
(+) Productive cough EXACERBATI
• SPIROMETRY NEBULE + 2 CC PNSS NOW THEN Q
(+) Loss of appetite ON
• ABG DETERMINATION 8 HOURS
• NA, K, IONIZED CALCIUM N-ACETYLCYSTEINE 600MG,
T/C CAP-MR
DISSOLVE IN ½ GLASS OF WATER
OBJECTIVE TB SUSPECT
ODHS
AWAKE, CONSCIOUS, LEVOCETIRIZINE + MONTELUKAST
COHERENT 5/10MG TABLET OD
SUPPORTIVE
BP: 110/80 MMHG
PR: 67 BPM • MODERATE HIGH BACK REST PIPERACILLIN + TAZOBACTAM 4.5
RR: 22 CPM • O2 SUPPORT TO PRN AT 2 LPM G EVERY 8 HOURS
T: 36.6 C FOR DYSPNEA AND O2 SAT <92% PANTOPRAZOLE 40 MG IV NOW
SPO2: 98% • MONITOR HYDRATION STATUS THEN OD AC BREAKFAST
C/L: EVERY 4 HOURS
(+) mid to basal rales
(+) wheezing all over
lung fields
OPD HOSPITAL DAY 1 NORMAL VALUE

SODIUM 140.9 140 135-145

POTASSIUM 4.51 4.90 3.5-5.5

IONIZED CA 1.19 1.12-1.32


HOSPITAL DAY 1 : #2 BIPEDAL EDEMA
S-O A P
(+) Exertional dyspnea CHF FC III DIAGNOSTICS THERAPEUTICS
(+) Easy fatigability
• 2D ECHO • FUROSEMIDE 40
(+) 2 pillow orthopnea
• 12-L ECG MG IVTT OD WITH
• CXR BP PRECAUTION
• CBC
• SERUM ELECTROLYTES
OBJECTIVE • BUN, CREATININE, ALT, ALBUMIN, BUN
AWAKE, CONSCIOUS, • FBS, LIPID PROFILE
COHERENT • UTZ OF THE WAB
BP: 90/60 MMHG
PR: 66 BPM SUPPORTIVE
RR: 23 CPM
• LOW FAT, LOW CHOLESTEROL, LOW PROTEIN,
T: 36.6 C
SOFT DIET WITH STRICT ASPIRATION
SPO2: 98%
• MONITORING I AND O CLOSELY AND
No NVE
ACCURATELY
C/L: (+) mid to basal
• PROVIDE MEASURING CONTAINER
rales
• ELEVATE LEGS
EXTREMITIES: (+) grade 1
• LIMIT ORAL FLUID INTAKE
bilateral pitting edema
• MONITOR HYDRATION STATUS EVERY 4 HOURS
OPD HOSPITAL DAY NORMAL VALUE
1
GLUCOSE 4.9 5.1 4.1-5.9

LDL 3.51 1.83 0.00 – 2.59


VLDL 0.64 0.41 0.00 – 2.59

CHOLESTEROL 5.0 2.9 0.0 – 5.2

TRIGLYCERIDES 1.40 0.90 0.00 – 1.69

DIRECT HDLC 0.9 0.7 0.0 – 1.0

ALBUMIN 37 30 35 – 50

ALT 35 109 21-72


OPD HOSPITAL DAY 1 NORMAL VALUE

CREATININE 83 206 58-110

BUN 5.4 14.0 3.2-7.1

SODIUM 140.9 140 135-145

IONIZED CA 1.19 1.12-1.32


POTASSIUM 4.51 4.90 3.5-5.5
UTZ OF WAB
IMPRESSION:
-NORMAL ABDOMINAL ULTRASOUND
HOSPITAL DAY 2 : #1 DYSPNEA
S-O A P
(+) Dyspnea (decreased) COPD IN SUPPORTIVE THERAPEUTICS
(+) Easy fatigability ACUTE
(+) Productive cough EXACERBATI • MODERATE HIGH BACK REST SHIFT PANTOPRAZOLE IV TO
(+) Loss of appetite ON – • O2 SUPPORT TO PRN AT 2 LPM PANTOPRAZOLE 40 MG 1 TAB OD
FOR DYSPNEA AND O2 SAT PRE BREAKFAST
RESOLVING
<92%
OBJECTIVE • MONITOR HYDRATION STATUS
EVERY 4 HOURS
AWAKE, CONSCIOUS,
COHERENT
BP: 110/80 MMHG
HR: 67 BPM
RR: 20 CPM
T: 36.6 C
SPO2: 100%
C/L:
(+) bibasal rales
(+) wheezing at bibasal
lung field
HOSPITAL DAY 2 : #2 AZOTEMIA
S-O A P
(-) Dysuria ACUTE DIAGNOSTICS SUPPORTIVE
(-) Oliguria KIDNEY
INJURY BUN: 14.0 • LOW SALT, LOW FAT, LOW
CREATININE: 206 CHOLESTEROL, LOW CHON
• MONITORING I AND O CLOSELY
AND ACCURATELY
• PROVIDE MEASURING
OBJECTIVE CONTAINER
• LIMIT ORAL FLUID INTAKE
AWAKE, CONSCIOUS, • MONITOR HYDRATION STATUS
COHERENT EVERY 4 HOURS
BP: 90/60 MMHG
PR: 66 BPM
RR: 23 CPM
T: 36.6 C
SPO2: 100%

UO: 37.5 CC/HR


OPD HOSPITAL HOSPITAL DAY 3

CBC HEMOGLOBIN 142 127


DAY 1

127

HEMATOCRIT 0.40 0.39 0.39


WBC COUNT 6.1 4.6 4.9
PLATELET CT 260 428
NEUTROPHILS 54 61 39
LYMPHOCYTE 32 36 38
MONOCYTE 3 3 7
EOSINOPHILS 11 16
OPD HOSPITAL HOSPITAL NORMAL
DAY 1 DAY 3 VALUE
BUN 5.4 14.0 8.5 3.2-7.1
CREATININE 83 206 145 58-110

SODIUM 140.9 140 144.7 135-145

POTASSIUM 4.51 4.90 3.74 3.5-5.5


HOSPITAL DAY 3:
DISCHARGED
FINAL DIAGNOSIS
COPD IN ACUTE EXACERBATION
ISCHEMIC HEART DISEASE FROM CHF
FUNCTIONAL CLASS III
AKI – PRERENAL AZOTEMIA
CHRONIC OBSTRUCTIVE
PULMONARY DISEASE
ETIOPATHOGENESIS
• Characterized by expiratory airflow
limitation not fully reversible.
• HALLMARK: airflow obstruction
Unusual in the absence of
smoking or prior history of
smoking, except for patients
with alpha 1 antitrypsin
deficiency
ELASTASE – ANTIELASTASE
HYPOTHESIS:
balance of elastin-degrading enzymes
and their inhibitors determines the
susceptibility of the lung to destruction
resulting in air space enlargement.
Smoking tobacco
is the main risk
exposure of COPD.
A. PATHOLOGIC CHANGES
• Chronic inflammation and structural
changes resulting from repeated injury
and repair.
• Increased numbers of specific
inflammatory cell types in different
parts of the lung.
•Emphysema: anatomically defined
condition characterized by
enlargement and destruction of alveoli
•Chronic Bronchitis: clinical condition
characterized by chronic cough and
sputum production
•Small airways disease: condition where
the bronchioles and smaller airways are
narrowed.
3 MOST COMMON
SYMPTOMS:
1. COUGH
2. SPUTUM PRODUCTION
3. EXERTIONAL DYSPNEA
MANIFESTATIONS
CARDINAL SYMPTOMS SIGNS
MOST COMMON • May be normal in early stages
• Pink puffers (predominantly emphysema):
SYMPTOMS: thin, non-cyanotic, prominent use of
• Cough, sputum accessory muscles
production, exertional • Blue bloaters (predominantly chronic
dyspnea bronchitis): heavy and cyanotic
• Tripod position: to facilitate use of accessory
• COPD may be muscles
punctuated by • Signs of hyperinflation: barrel chest,
exacerbations (acute hyperresonance on percussion
worsening of • Others: pursed lip breathing, expiratory
wheezing, systemic wasting, weight loss
symptoms) • Signs of cor pulmonale: (bipedal edema,
ascites) in severe cases
MANIFESTATIONS
CARDINAL SYMPTOMS SIGNS
MOST COMMON • May be normal in early stages
• Pink puffers (predominantly emphysema): thin,
SYMPTOMS: non-cyanotic, prominent use of accessory
• Cough, sputum muscles
• Blue bloaters (predominantly chronic bronchitis):
production, exertional heavy and cyanotic
dyspnea • Tripod position: to facilitate use of accessory
• COPD may be muscles
• Signs of hyperinflation: barrel chest,
punctuated by hyperresonance on percussion
exacerbations (acute • Others: pursed lip breathing, expiratory wheezing,
systemic wasting, weight loss
worsening of • Signs of cor pulmonale: (bipedal edema, ascites)
symptoms) in severe cases
DIAGNOSIS
SPIROMETRY • Required to make the diagnosis of COPD
• Post-bronchodilator FEV1/FVC <0.70: confirms presence of
persistent airflow limitation
• FEV1, FEV1/FVC and all other measures of expiratory
airflow are reduced
• TLC, FRC and RV may be increased indicating air trapping
• DLCO may be reduced
CHEST • Useful for excluding other differential diagnosis
RADIOGRAPH • Low flattened diaphragms
• Increase in the volume of retrosternal airspace
(hyperinflation)
• Hyperlucent lung zones with possible bullae formation and
diminished vascular markings
CT SCAN • Not routinely requested
DIAGNOSIS
• Maybe helpful when the diagnosis is in doubt to rule out
concomitant diseases
• Useful if surgical procedure such as lung volume reduction is
contemplated
PULSE • To evaluate a patient’s O2 saturation and need for supplemental
OXIMETRY oxygen therapy
• Should be used to assess all stable patients with FEV1 < 35%
predicted or with clinical sign suggestive of respiratory failure or
right heart failure
• If peripheral saturation is < 92%, arterial blood gases should be
assessed
ARTERIAL • Resting or exertional hypoxemia
BLOOD GAS • Increased alveolar-arterial oxygen tension gradient
• In long-standing disease, may have chronically increased arterial
paCO2 but metabolic compensation (increased HCO3) maintains
pH to near normal
APROACH TO CLASSIFICATION
OF COPD
•The new “ABCD” assessment tool
incorporates patient-reported
outcomes and highlights importance
of exacerbation prevention.
Step 1: Confirm the diagnosis
Step 2: Assess airflow limitation
Step 3: Assess for symptoms and
risk of exacerbations
STEP 1: CONFIRM THE DIAGNOSIS
•COPD is considered in patients
with dyspnea, chronic cough, and
sputum production with a history of
exposure to risk factors.
•SPIROMETRY is required to confirm
diagnosis: post-bronchodilator
FEV1/FVC < 0.70
•FEV1/FVC ratio: reflects the proportion of
a person’s forced expiratory capacity
that they are able to expire in the first
second of forced exhalation to the full
vital capacity
STEP 2: ASSESS AIRFLOW
LIMITATION (ALSO BY SPIROMETRY)
•The classification is based on severity
of airflow limitation in COPD using
spirometry (post-bronchodilator FEV1)
•Spirometry should be performed after
the administration of an adequate
dose of a short-acting inhaled
bronchodilator
SPIROMETRIC CLINICAL FiNDINGS SPIROMETRY FINDINGS
CLASSIFICATION
FEV1/FVC FEV 1
GOLD 1 • Chronic cough and sputum
production
FEV1 >/= 80%
PREDICTED
MILD • Patient unaware that lung
function is abnormal

GOLD 2 • Chronic cough and sputum


production
FEV1 50 TO < 80%
POST PREDICTED
MODERATE • Shortness of breath on
exertion BRONCHODILATOR
• Stage where patients FEV1 / FVC < 0.70
typically seek medical
attention

GOLD 3 •

Greater shortness of breath
Reduced exercise capacity
FEV1 30 TO < 50%
PREDICTED
SEVERE •

Fatigue
Repeated exacerbations

GOLD 4 • Signs and symptoms of


respiratory failure (paO2 <
FEV1 < 30% PREDICTED

VERY SEVERE 60 mmHg) +/- PaCO2 > 50


mmHg)
• Cor pulmonale
SPIROMETRIC CLINICAL FiNDINGS SPIROMETRY FINDINGS
CLASSIFICATION FEV1/FVC FEV 1
GOLD 1 • Chronic cough and sputum
production
FEV1 >/= 80%
PREDICTED
MILD • Patient unaware that lung function is
abnormal

GOLD 2 • Chronic cough and sputum


production POST
FEV1 50 TO < 80%
PREDICTED
MODERATE • Shortness of breath on exertion BRONCHODI
• Stage where patients typically seek LATOR FEV1 /
medical attention
FVC < 0.70
GOLD 3 •

Greater shortness of breath
Reduced exercise capacity FEV1 30 TO < 50%
SEVERE • Fatigue PREDICTED
• Repeated exacerbations

GOLD 4 • Signs and symptoms of respiratory


failure (paO2 < 60 mmHg) +/- PaCO2
FEV1 < 30%
PREDICTED
VERY SEVERE > 50 mmHg)
• Cor pulmonale
CLASSIFICATION BASED ON
EXACERBATIONS
EXACERBATION IN COPD: defined as an
acute event characterized by worsening
of the patient’s respiratory symptoms that
is beyond normal day-to-day variations
and leads to a change in medication.
Best predictor of having frequent
exacerbation (>/= 2 per year) is a history of
previously treated events
MODIFIED MEDICAL RESEARCH COUNCIL
(MMRC) QUESTIONNAIRE FOR ASSESSING
SEVERITY OF BREATHLESSNESS
MMRC DESCRIPTION
GRADE
0 I only get breathless with strenuous exercise

1 I get short of breath when hurrying on the level or walking up a slight hill

2 I walk slower than people of the same age on the level because of
breathlessness, or I stop for breath when walking on my own pace on the
level

3 I stop for breath after walking 100 meters or after a few minutes on the level

4 I am too breathless or I am breathless when I’m dressing or undressing


MODIFIED MEDICAL RESEARCH COUNCIL
(MMRC) QUESTIONNAIRE FOR ASSESSING
SEVERITY OF BREATHLESSNESS
MMRC DESCRIPTION
GRADE
0 I only get breathless with strenuous exercise

1 I get short of breath when hurrying on the level or walking up a slight hill

2 I walk slower than people of the same age on the level because of
breathlessness, or I stop for breath when walking on my own pace on the
level

3 I stop for breath after walking 100 meters or after a few minutes on the level

4 I am too breathless or I am breathless when I’m dressing or undressing


COPD ASSESSMENT TEST (CAT)
• Comprehensive assessment of
symptoms
•Consists of 8 items which pertain to
symptoms of COPD – patient will give
a score (0-5 point rating scale) and
the points will be added
STEP 3: ASSESS FOR SYMPTOMS
AND RISK OF EXACERBATIONS
GROUP EXACERBATIONS PER YEAR SYMPTOM
ASSESSMENT

A
Low symptom severity </= 1 (not leading to hospital admission) mMRC 0-1 CAT <
Low exacerbation risk 10

B
High symptom severity </= 1 (not leading to hospital admission mMRC CAT
Low exacerbation risk >/2 >/= 10

C
Low symptom severity >/= 2 or >/= 1 leading to hospital admission mMRC 0-1 CAT <
High exacerbation risk 10

D
High symptom severity >/= 2 or >/= 1 leading to hospital admission mMRC CAT
High exacerbation risk >/= 2 >/= 10
OVERVIEW OF MANAGEMENT

BETA 2 AGONISTS MUCOLYTICS/ANTIOXID


ANTIBIOTICS
ANTS

ANTICHOLINERGIC
PDE – 4 INHIBITORS VACCINATIONS
(ANTIMUSCARINIC)

INHALED
METHYLXANTHINES
CORTICOSTEROIDS
OVERVIEW OF MANAGEMENT
ANTICHOLINERGIC
BETA 2 AGONISTS
(ANTIMUSCARINIC) METHYLXANTHINES INHALED
CORTICOSTEROIDS
SHORT ACTING: SHORT ACTING
• SALBUTAMOL THEOPHYLLINE
• IPRATROPIUM BECLOMETHASONE
• TERBUTALINE BROMIDE
• OXITROPIUM AMINOPHYLLINE
LONG-ACTING BROMIDE BUDESONIDE
• FORMETEROL,
SALMETEROL,
LONG ACTING DOXOFYLLINE
VILANTEROL, MOMETASONE
OLODATEROL, • TIOTROPIUM
INDACATEROL
FLUTICASONE
PDE – 4 INHIBITORS ANTIBIOTICS

MUCOLYTICS/ANTI
OXIDANTS VACCINATIONS
N-ACETYLCYSTEINE
THREE INTERVENTIONS
DEMONSTRATED TO INFLUENCE
THE NATURAL HISTORY OF COPD
INTERVENTION REMARKS
SMOKING CESSATION Biggest impact in the
natural history of COPD
OXYGEN THERAPY
LUNG VOLUME REDUCTION
SURGERY
EXACERBATIONS IN CHRONIC
OBSTRUCTIVE PULMONARY
DISEASE
ETHIOPATHOGENESIS
• Associated with increased airway
inflammation, increased mucus production,
and marked gas trapping
• Mainly triggered by respiratory viral infections
(others: bacterial infections, environmental
factors)
MANIFESTATIONS
Key symptom during exacerbations: increased
dyspnea
Other symptoms: increased sputum production,
purulence and volume, increased cough,
wheezing
Symptoms usually last between 7-10 days during
exacerbations: but 20% of patient do not
recover at 8 weeks
CLASSIFICATION OF EXACERBATED
COPD AMONG HOSPITALIZED PATIENTS
NO RESPIRATORY ACUTE RESPIRATORY ACUTE RESPIRATORY
FAILURE FAILURE FAILURE
NON-LIFE THREATENING THREATENING
RESPIRATORY RATE 20-30 BREATHS/MIN > 30 BREATHS/MIN
USE OF ACCESSORY NO YES
MUSCLES
CHANGE IN MENTAL NONE YES (ACUTE CHANGES)
STATUS
HYPOXEMIA IMPROVED WITH IMPROVED WITH NOT IMPROVED WITH
SUPPLEMENTAL O2 AT SUPPLEMENTAL O2 AT 35- SUPPLEMENTAL O2 AT > 40
28-35 % FIO2 40 % FIO2 % FIO2
PACO2 NOT INCREASED HYPERCARBIA HYPERCARBIA (INCREASED
(INCREASED FROM FROM BASELINE OR
BASELINE OR ELEVATED AT ELEVATED AT >60 MMHG
50-60 MMHG) OR WITH ACIDOSIS – PH:
</= 7.25)
MANAGEMENT OF ACUTE
EXACERBATIONS
CLASSIFICATION OF OVERVIEW OF MANAGEMENT
EXACERBATION
MILD SHORT ACTING BRONCHODILATORS

MODERATE SHORT-ACTING BRONCHODILATORS +


ANTIBIOTICS +/- ORAL CORTICOSTEROIDS

SEVERE REQUIRES HOSPITALIZATION OR ER VISITS


SOME MANAGED AS ACUTE RESPIRATORY
FAILURE (E.G. MECHANICAL VENTILATION)
MANAGEMENT OF SEVERE BUT NOT
LIFE THREATENING EXACERBATIONS
OF COPD AT THE ER
Assess severity of symptoms, blood gases and chest
radiograph
Administer controlled oxygen therapy and repeat ABG after
30-60 minutes
Increase doses and/or frequency of use of bronchodilators
Add oral or IV glucocorticoids
Consider antibiotics (oral or occasionally IV) when there are
signs of bacterial infection
Consider non-invasive mechanical ventilation
THERAPY FOR
ACUTE EXACERBATIONS
MANAGEMENT REMARKS
BRONCHODILATORS Initial bronchodilators: Inhaled B- agonists (SABA) with or without
short-acting anticholinergics

ANTIBIOTICS Bacteria frequently implicated in exacerbations:


Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis
GLUCOCORTICOIDS Reduces hospital stay, hastens recovery, and reduces chances of
subsequent exacerbations/relapses: also improves oxygenation

OXYGEN Maintain O2 saturation >/ 88 – 92%


Administration of oxygen does not reduce minute ventilation
DISCHARGE CRITERIA
•Inhaled beta-agonist use no more frequent than every 4 hours
•Patient is able to walk across room
•Patient is able to eat and sleep without frequent awakening by
dyspnea
•Patient has been clinically stable for 12-24 hours
•ABG has been stable for 12-24 hours
•Patient (or home cargiver) fully understands the use of medications
•Follow-up plans and home care arrangements have been
completed, follow-up < 30 days following discharge
THANK
YOU! 