Chronic obstructive pulmonary disease

Edited by Chien-Da HuangPhysician Educator/Associate Professor

Department of Thoracic Medicine and Medical EducationChang Gung Memorial Hospital

Taipei, Taiwan

Case-Based LearningCase-Based LearningThoracic MedicineThoracic Medicine

胸腔科案例 -- COPD

• 學習目標• To identify the symptoms and signs of COPD.• To understand the pathophysiology and common causes of COPD.• To identify the significant findings of physical examination in

patients with COPD. • To identify the significant findings of Lab examination in patients

with COPD.• To know about newest version of GOLD guideline • To understand the comorbidity of COPD.• To know the optimal treatment to reduce the rate of acute

exacerbation and to improve life of quality for this patients with very severe COPD?

Case presentation

• 66 year-old male • Chief complaints of this admission

– Aggravated shortness of breath on walking for 1 week– Increased amount of yellowish sputum

• Smoking history more than 30 pack per year, but quitting for 10 years

• Diagnosed as chronic obstructive pulmonary disease about 15 years

• He had experienced three episodes of respiratory failure in this year

Questions to be discussed?

• What are the factors aggravating dyspnea ?

• What are the causes of production of sputum?

• How do you define COPD?

• What is acute or chronic respiratory failure?

Physical examination

Physical examination – Body temperature: 36.5; pulse rate: 121

beats/min; respiratory rate: 27 /min; Blood pressure: 172/81 mmHg

– Ill-looking – Accessory muscle used – Decreased breathing sound in bilateral lung field ,

crackles over LUL– Poor lung expansion over BLL – Lower lower limbs: cold, mild pitting edema

Exercise Intolerance/Dyspnea on exertionExercise Intolerance/Dyspnea on exertion

Poor expansion of diaphragmPoor expansion of diaphragm Accessory muscle use Accessory muscle use

Decreased breathing sound in bilateral lung fieldDecreased breathing sound in bilateral lung field

Decreased lower limb muscle power

Peripheral vasoconstrictionPeripheral vasoconstriction

Lower limbs: vasoconstrictionLower limbs: vasoconstriction

Anti-gravity power of lower limb muscle: poorAnti-gravity power of lower limb muscle: poor

Questions to be discussed?

• What do you find in the video clips? Please explain and discuss

• Make comments or share clinical experience from tutors

Laboratory findings

Laboratory findings– Leukocytosis with shift to left (WBC: 16,000

Seg:85%, Band: 5%)– BUN: 20 mg/dl, Cr: 0.8 mg/dL, GOT: 26 U/L, GPT:

32 U/L, Na:142 meq/L, K:2.9 meq/L– ABG: pH: 7.438, PaCO2: 52.9 mmHg, PaO2: 60.0

mmHg, HCO3: 35 mm/L, Sat:90.7%, Room air

Questions to be discussed?

• What are SIRS/sepsis/septic shock?

• Why does the patient get hypokalemia?

• Please discuss the ABG data?

CXR and Sputum culture

• CXR: – LUL alveolar

infiltration– RLL peribronchial

cuffing change• Sputum culture

– Neutrophil 3+– Pseudomonas

aeruoginosa

Questions to be discussed?

• How and what do you read from the CXR?

• How and what do you read the sputum smear and culture from the data?

• What is Pseudomonas aeruoginosa?

FVC: 0.81L (25% pred.) FVC: 0.81L (25% pred.) FEV1: 0.39 L (16% pred.); FEV1: 0.39 L (16% pred.); FEV1/FVC: 48.1%FEV1/FVC: 48.1%FEV1 (BD response <12%)FEV1 (BD response <12%)

2007 GOLD Guideline:2007 GOLD Guideline:

Stage IV:Stage IV:Very severe COPDVery severe COPD

2012 GOLD guideline2012 GOLD guidelineCategory DCategory D

Pulmonary function testPulmonary function test

Questions to be discussed?

• What do you know about newest version of GOLD guideline?

• Try to read the pulmonary function test based on the GOLD guideline?

Medication

• Use of Antibiotics:– Ciprofloxacin 400 mg BID IVF

• Steroids– Oral steroids – Short-term of Hydrocortisone 100 mg iv q6H

• Theophylline 125 mg BID• Procaterol 25 mg/tab1# BID• Nebulization therapy :

– Ipratropium 0.5 mg/UD + Terbutaline 5 mg/UD

MCQ Question 1

The patient complained of aggravated dyspnea during the recovery phase of acute exacerbation in outpatient clinic.

Which factors should be taken into consideration for this patient with very severe COPD?

(A) Mucus retention with 2(A) Mucus retention with 2ndnd infection infection (B) Muscle dysfunction or atrophy(B) Muscle dysfunction or atrophy (C) All of above(C) All of above (D) None of all(D) None of all

Questions to be discussed?

• What are the comorbidities of COPD?

Factor 1: Mucus Retention When there will be mucus retention….

Airway collapse at early expirationAirway collapse at early expiration

Airway inflammation exacerbationAirway inflammation exacerbation

No effective cough functionNo effective cough function due to low inspiratory capacitydue to low inspiratory capacity

New infectionNew infection

Mucus retention is considered for this patient:Mucus retention is considered for this patient:Poor diaphragm movement --- low inspiratory capacityPoor diaphragm movement --- low inspiratory capacityDecreased breathing sound--- mucus plugDecreased breathing sound--- mucus plugPersistent airway inflammationPersistent airway inflammation

Structural changesStructural changes• Fiber size and compositionFiber size and composition• CapillarityCapillarity• Oxidative stress/enzymesOxidative stress/enzymes

Contributing FactorsContributing Factors• HypoxiaHypoxia• HypercapniaHypercapnia• Systemic inflammationSystemic inflammation• MalnutritionMalnutrition• Drugs (steroids, Drugs (steroids, 2 agonist)2 agonist)• Comorbid statesComorbid states (chronic inactivity)(chronic inactivity)

Functional changesFunctional changes• Muscle weaknessMuscle weakness• Reduced oxygen delivery Reduced oxygen delivery and utilizationand utilization

Factor 2:Muscle dysfunction in chronic obstructive pulmonary disease

Balasubramanian Curr Opin Pulm Med 2006; 12:106.Balasubramanian Curr Opin Pulm Med 2006; 12:106.

Muscle Muscle dysfunctiondysfunction

For this patient:For this patient:

Contributing FactorsContributing Factors• HypoxiaHypoxia• HypercapniaHypercapnia• Systemic inflammationSystemic inflammation• Drugs Drugs

•steroids, steroids, •oral or high dose inhaled oral or high dose inhaled 2 agonist)2 agonist)

MCQ Question 2

What is the optimal treatment to reduce the rate of acute exacerbation and to improve life of quality for this patients with very severe COPD? 1. Tiotropium, 2. Inhaled steroid + long-acting b-2

agonist, 3. inhaled long-acting b2 agonist, 4. pulmonary rehabilitation, 5. vaccination, 6. oxygen supplement

(A)(A) 1 + 2 + 5 1 + 2 + 5 (B)(B) 1 + 3 + 5 + 61 + 3 + 5 + 6(C)(C) 1 + 4 + 5 + 61 + 4 + 5 + 6(D)(D) 1 + 2 + 4 + 5 + 61 + 2 + 4 + 5 + 6

Individualized Treatment for this Patient

• Medicine– Tiotropium + Fluticasone/salmeterol (high dose)

• Hospital-Based Pulmonary Rehabilitation ProgramHospital-Based Pulmonary Rehabilitation Program – Mucus clearance technique– Exercise training program

• Walking• Upper limbs training• Inspiratory muscle training• Transcutaneous Electrical Stimulation (TENS)

• Oxygen supplement• Vaccination