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PT CASE: COPD EXACERBATION

DEDICATION:
With all my love and affection to my
mother that every day gives me her
affection and makes me have the
strength to continue fighting in this
World, despite the difficulties that
come my way day by day.
INTRODUCTION

People must breathe to live. When someone breathes out, residual cell products like
carbon dioxide are removed from the blood and exhaled back into the air.

Being the third largest cause of worldwide mortality and showing a steeply rising
trend in global prevalence, COPD is likely to emerge as the most important disease
for the physicians to manage. Understanding the risk factors disease of COPD will
be of great assistance in diagnosing and treating the disease in circunstances where
new mechanims, diagnostic tests and drug therapies are emerging at a rapid pace.

Chronic obstructive pulmonary disease (COPD) is a progressive inflammatory


disease of the lung characterized by chronic bronchitis, airway thickening and
emphysema.

COPD occurs when permanent blockages form in the pulmonary system. Being
diagnosed with COPD means that some portion of the bronchi or alveoli have been
permanently clogged, reducing the volume of air that can be handled by the lungs.
As this process progresses, the overall efficiency of the gas exchange process is
reduced.

Bronchitis is literally an inflammation of the bronchi. The walls of the bronchi within
the lungs become inflamed, and this inflammation decreases the diameter of the
bronchi so that less air is able to flow through the normal.

Emphysema also reduces the efficiency of the gas exchange process, only in a
different way. Emphysema affects the alveoli, specifically its sensitive membranes
through which the gas exchange process occurs. Emphysema causes the alveolar
membranes to lose elasticity, become brittle and then tear and tear.

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CONTENT

DEDICATION: ......................................................................................................... 0
INTRODUCTION ..................................................................................................... 1
I. FRAMEWORK .................................................................................................. 3
1.1 COPD ......................................................................................................... 3
1.1.1 RISK..3
1.1.2 SYMPTOMS................................ 3
1.1.3 DIAGNOSED. ................... 4
1.1.4 TREATMENT.. ..................... 4
1.2 PT CASE: COPD EXACERBATION IN A 65 YEAR OLD MEN .................. 5
1.2.1 CASE SUMMARY.. ................................ 5
1.2.2 DIAGNOSIS.. ..... 6
1.2.3 THE MOST APPROPRIATE NEXT DIAGNOSTIC STEP ........................ 6
1.2.4 INTERPRETATION OF THIS ABG. ................................ 6
1.2.5 THE MAINSTAYS OF TREATMENT OF ACUTE COPD
EXACERBATIONS. .......................... 6
II. CONCLUSION .................................................................................................... 8
III. BIBLIOGRAPHIC REFERENCE .........................Error! Bookmark not defined.
ANNEXES .............................................................Error! Bookmark not defined.
VOCABULARY..
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defined.

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I. FRAMEWORK

1.1 COPD

COPD (Chronic Obstructive Pulmonary Disease) is a respiratory disorder


largely caused by smoking, characterized by progressive, partially
reversible airway obstruction. Over time, the airways of those suffering
from COPD become permanently obstructed or blocked and gradually
lose their ability to function.

As the disease progresses, it has a profound impact on the quality of


patients lives. Lung function may decline to the point where regular daily
activities such as walking and dressing are extremely difficult. The costs
associated with COPD affect the family, the healthcare system, and the
community as a whole with loss of productivity and the need for additional
healthcare services.

1.1.1 RISK
About 90 per cent of COPD cases are caused by cigarette smoking.
Both current and former smokers are at risk of developing COPD.

Other causes of COPD include:

Second-hand smoke
Air pollution at work and in the environment (dust or chemicals)
A history of childhood lung infections
Heredity (for example, a rare genetic disorder called Alpha-1
antitrypsin deficiency)
1.1.2 SYMPTOMS

COPD symptoms may include:


Shortness of breath Chronic cough
Phlegm (or mucus) production
Frequent lung infections
Reduced ability to go about daily activities
A barrel-shaped chest
Fatigue Unexplained weight loss

Individuals with COPD generally need to alter their lifestyle in order


to better cope with the disease. This includes quitting smoking,

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taking steps to avoid shortness of breath, staying active and eating
well.

1.1.2.1 EXACERBATIONS/FLARE-UPS:

People with COPD can experience exacerbations or lung


attacks which involve a worsening of the disease and its
symptoms. The more lung attacks a patient experiences,
the greater the likelihood their overall health and lung
function will decline, and their risk of hospitalization
increases. The average patient experiences two to three
lung attacks per year. COPD lung attack outcomes can
range from the need for further medical intervention to
death.

1.1.3 DIAGNOSED

Demonstration of airflow obstruction through spirometry is the only


definitive test for COPD. This diagnostic test measures the amount
of air the lungs can hold as well as the time it takes the patient to
fully exhale. The more blocked the airways are, the longer it takes
to blow the air out.

Physicians may conduct additional tests, including: Physical


examination of the patient
Chest x-ray to see if there is damage to the lungs
Blood test to measure the amount of oxygen and carbon
dioxide in the blood6

Most patients with COPD are not diagnosed until the disease is well
advanced. Often people think their symptoms feeling short of
breath or coughing are a normal part of getting older.

1.1.4 TREATMENT

While COPD cannot be cured, it can be treated. The goals of


COPD management include preventing disease progression and
improving symptoms, activity levels of patients and enhancing
their quality of life.

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To date, smoking cessation remains the single most effective
intervention to reduce the risk of COPD and slow its progression.
COPD management includes both pharmacotherapy (including
medicines to open the airways and reduce inflammation), and non-
medicinal interventions (including pulmonary rehabilitation,
exercise training, and oxygen). (1)

1.2 PT CASE: COPD EXACERBATION IN A 65 YEAR OLD MEN


1.2.1 CASE SUMMARY

A 65 year old Cuban male comes to the ED because of


shortness of breath. He notes that over the last 2-3 years he
has had gradual worsening of his ability to exert himself without
feeling out of breath, and it has been acutely worse for the past
week, including a worsening productive cough. On questioning,
he reveals that he coughs almost every morning as well, and
this has been going on for even longer, perhaps 4-5 years. The
cough is now productive of yellowish-brownish sputum. He
denies chest pain, fevers, chills or night sweats. He has no
history of lower extremity edema. The rest of his review of
systems is negative.

Other than an appendectomy when he was in his 20s, the


patient denies any significant past medical history. He denies
taking any medications, but does state that a year ago he went
to a walk-in clinic for cough and got some kind of inhaler, which
he used over the course of a month or two until it was gone. He
lives in an apartment with his wife, and has smoked a pack of
cigarettes a day for 40 years.

On exam, his BP is 144/88 mmHg, HR is 98, respiratory rate is


28 breaths per minute. His temp is 97.6. Oxygen saturation is
documented as 93% on 4 L. You find him sitting up in the ED
bed, leaning forward. He appears uncomfortable with labored
breathing and his lips are bluish. There is no cervical
lymphadenopathy, JVD or carotid bruits. Chest exam shows
mild intercostal retractions seen around the anterolateral costal
margins. Wheezes and rhonchi are present bilaterally, without
crackles. Heart exam is unremarkable, though the heart sounds
are distant. Lower extremities show no cyanosis, clubbing or
edema.

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1.2.2 DIAGNOSIS
COPD with acute exacerbation

1.2.3 THE MOST APPROPRIATE NEXT DIAGNOSTIC STEP


Given the patients respiratory difficulty seen on exam and
possible hypoxia, an ABG would be helpful to measure
adequacy of oxygenation (PaO2) and ventilation (PCO2). In this
case, the ABG was taken and found to be 7.32/58/86/30. It was
done while the patient was on room air.

1.2.4 INTERPRETATION OF THIS ABG


(This ABG shows marked respiratory acidosis with a partial
compensatory metabolic alkalosis).

The patients room air saturation is subsequently found to be 84-


86%. You vaguely remember something about some kind of
respiratory drive and suppressing it with too much oxygen. You
also remember that some people disputed this.

1.2.5 THE MAINSTAYS OF TREATMENT OF ACUTE COPD


EXACERBATIONS

Routine treatment includes use of bronchodilators, systemic


corticosteroids and antibiotics. For patients sick enough to be
hospitalized, oxygen and possibly mechanical ventilation are
often used.

A. BRONCHODILATORS

A.1 Inhaled Beta Adrenergic Agonists

Bronchodilators: the mainstay of therapy for acute


exacerbations. Rapid onset of action and efficacy in
producing bronchodilation. Data indicate similar
efficacy with nebulizer or MDI, but MDI requires patients
to be more alert, and nebs still recommended by many
experts.
2.5 mg of albuterol is as efficacious in improvement of
spirometry and clinical outcomes, but 5mg still used
often. (Nair, 2005).

A.2 Anticholinergic Bronchodilators

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May be used in combination with beta adrenergic
agonists to produce bronchodilation in excess of that
achieved with either agent alone.

B. SYSTEMIC CORTICOSTEROIDS

Reduce 30 day treatment failure rate (23% vs 33%), 90


day treatment failure rate (37-48%) and length of
hospital stay (8 vs 10 days), while improving lung
function (Niewoehner, 1999).

Oral steroids have been shown to be effective for


outpatient therapy, while serious COPD exacerbations
requiring hospitalization usually call for starting with
intravenous steroids, though data is limited.

C. ANTIBITICS

Antibiotics are recommended for acute exacerbations of


COPD that are characterized by increased volume and
purulence of secretions. They decrease mortality and
treatment failure rates, while accelerating improvement
of peak expiratory flow rates (Ram, 2006).

D. MUCOKINETIC REGIMENS

The use of mucolytic agents, chest physiotherapy, and


intermittent positive pressure breathing and directed
coughing have not been shown to be effective.

E. METHYLXANTHINES

Methylxanthines do not appear to significantly help in


patients with mild to moderate exacerbations of COPD.
They may be of limited use in patients with severe
exacerbations, but they have a narrow therapeutic index
and high risk of toxicity.

F. OXYGEN THERAPY

Venturi masks can provide precise FiO2 values, which


can help monitor oxygen status over time in patients
where nasal cannula is insufficient.(2)

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II. CONCLUSION

With every passing day the understanding about of COPD is improving and
simultaneously becoming more complex. The increasing life expectancy all over
the world suggests that COPD would emerge as the most important disease for
the physicians to manage.

Age-standardized death rate amongst persons with COPD doubled from 1970
to 2015. COPD is now the 4th leading cause of death, and the only leading
cause of death for which the mortality rate is increasing.

Cigarette smoking is implicated in 90% of COPD cases.

The strongest predictors of mortality are older age and a decreased forced
expiratory volume per second. 60 year old smokers with chronic bronchitis
have a 10 year mortality rate of 60 percent, which is four times higher than the
mortality rate for age-matched asthmatics.

Alpha1-antitrypsin deficiency should be suspected when COPD develops in a


patient younger than 45 years who does not have a history of chronic.

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