Here is a case study for students and medical practitioners aimed at providing a clinical simulation exam scenario in patients with COPD.
A COPD case study
The 56-year-old patient presents with a difficulty in breathing. The patient complained of feeling short of breath in the morning upon waking up. The breathlessness became worse after climbing just a few steps. He is too short of breath even while talking and has difficulty in finishing sentences.
His wife has revealed that the patient has a history of hepatic failure and allergy to penicillin. He also has a smoking history of 15 pack-year. His occupation involves building cabinets for which he is constantly required to work around fine dust and debris.
Physical examination
The patient's pupils are equal and reactive and he appears alert and oriented. He also has a pursed-lip pattern of breathing. His trachea is in the midline and there is no jugular venous distension.
The vital parameters of the patient are as follows:
- Heart rate: 92 beats per min
- Respiratory rate: 22 breaths per min
- SpO2: 84%
Chest assessment:
- The patient presents with a larger than the normal anterior-posterior (AP) diameter of the chest.
- An equal and bilateral chest expansion is noted.
- The chest auscultation reveals diminished breath sounds and a prolonged expiratory phase
- Palpation does not reveal any tactile fremitus
- Percussion of the chest reveals increased resonance
- Subcostal retractions are need
Per abdomen examination
- The abdomen is soft and tender
- Distension: Not present
Extremities:
- The skin appears to be slightly yellowish
- There is no pitting edema in the legs
- Digital clubbing is noted in the fingertips
Laboratory and radiology findings
- ABG Results: PaCO2 59 mm of Hg, pH 7.35 mm of Hg, PaO2 64 mm of Hg, and HCO3 30 mEq/L
- Chest X-ray: Revealed a flat diaphragm, dark lung fields, increase in the retrosternal space, a narrow heart, and mild hypertrophy of the right ventricle
- Blood tests: Hemoglobin 19 gm per 100 mL, RBC 6.5 mill per m3, and hematocrit value 57%
Diagnosis
Based on the medical history of the patient, his symptoms, and physical examination, he is suspected to have Chronic Obstructive Pulmonary Disease (COPD).
What are the key findings from the patient’s medical history and assessment in view of the diagnosis?
Here are some important signs and symptoms the patient has complained of that are common in those suffering from COPD:
- A prolonged expiratory time
- Barrel-shaped chest
- Tachypnea
- Use of accessory muscles of breathing
- Diminished breath sounds
- Pursed lip breathing
- Digital clubbing
- Exposure to dust at the workplace
- History of smoking
How do the abnormal laboratory findings and radiology results justify the diagnosis of COPD in this patient?
The chest x-ray of the patient has revealed the classic signs of COPD such as hyperextension, a narrow heart, and dark lung fields.
It is important to note that though the patient does not have a history of cor pulmonale, congestive heart failure is very common in patients with COPD. Also, the right ventricle of the patient is hypertrophied. It needs to be brought to the attention of the cardiologist for further investigation and assessment of the heart functions.
The laboratory values such as the increased RBC, hematocrit, and hemoglobin levels also point to the diagnosis of COPD. These levels often increase in response to chronic hypoxemia experienced commonly by COPD patients.
The ABG results of the patient also indicate the possibility of COPD as the interpretation suggests compensated respiratory acidosis with hypoxemia. Compensated blood gas levels indicate an issue that could have existed for an extended duration of time.
Which other tests could be helpful in confirming the diagnosis of COPD?
A series of PFT (pulmonary function tests) can be recommended to assess the lung volumes, functions, and capacities of the patient. This would help to confirm or rule out the diagnosis of COPD and provide insights into the severity of the condition.
Generally, the PFT of COPD patients shows the FEV1:FVC ratio to be lower than 70% and an FEV1 value to be less than 80%.
Treatment of COPD
What is the initial treatment for the patient?
As this patient has COPD, the initial line of treatment could be low-flow oxygen to manage hypoxemia. A nasal cannula at 1 to 2 L/min is often recommended along with the air-entrainment mask to ensure the exact FiO2 supply to the lungs.
The patient may be treated with the lowest possible FiO2. The FiO2 can be titrated later based on how he responds to the oxygen being delivered.
What is the next treatment recommendation?
The recent ABG results have revealed a rise in the PaCO2 levels and a decline in the PaO2 levels. This suggests that the patient needs further treatment with ventilation and oxygenation.
Mechanical ventilation needs to be avoided in COPD patients as much as possible as they often have a difficulty in weaning from the device. So, the most appropriate treatment for this patient could be BiPAP (Bilevel Positive Airway Pressure).
Which drug therapies are recommended?
Home oxygen therapy can be recommended if the PaO2 reduces below 55 mm of Hg or the SpO2 reduces below 88% more than twice in a 3-week period.
Other than these, the patient may be prescribed a short-acting or long-acting bronchodilator, an anticholinergic agent, inhaled corticosteroids, and methylxanthines.
Smoking cessation is critical for all patients who smoke. Nicotine replacement therapy could also be indicated in this case.
Conclusion
During the treatment of a patient with COLD, the amount of oxygen being delivered needs to be kept at the lowest possible for maintaining the correct levels of FiO2. Non-invasive ventilation before conventional mechanical ventilation or intubation may also be helpful in emergency situations.
Medical students and doctors can attend our AARC Approved Live Respiratory CEUs to learn more about similar cases. Our Respiratory Therapy Continuing Education CEUs are aimed at providing a clinical simulation of a range of pulmonary conditions to help you improve your knowledge and skills needed for the management of acute and chronic lung diseases.