CHRONIC OBSTRUCTIVE PULMONARY DISEASE 5A
A 72-year-old man with chronic obstructive pulmonary disease (COPD) presents to the emergency department with progressively worsening shortness of breath. Using 2 L/min of oxygen at home, he is usually able to walk around the house without limitation. Over the past 4 days, however, he has had increasing dyspnea on exertion and increased cough productive of thick green sputum. He has not had chest pain or worsening of his chronic mild ankle edema. He had smoked 2 packs of cigarettes daily for the past 50 years. Previous pulmonary function tests (PFTs) demonstrated a decreased forced expiratory volume in 1 second (FEV1) and FEV1/FVC (forced vital capacity) ratio. Physical examination shows tachycardia, tachypnea, and decreased breath sounds with diffuse wheezing bilaterally. Arterial blood gas (ABG) analysis shows acidemia from a partially compensated respiratory acidosis. He is placed on noninvasive positive-pressure ventilation with marked improvement of his acidemia.
What are the salient features of this patient’s problem? How do you think through his problem?
Salient features: Worsening dyspnea; change in cough and sputum; home oxygen use; 100 pack-year smoking history; obstructive pattern on spirometry; wheezing and respiratory distress; lower extremity edema; acidemia with partially compensated respiratory acidosis; improvement on noninvasive positive pressure ventilation
How to think through: This patient with COPD presents in respiratory distress. Already on oxygen at home, he has little pulmonary reserve. What test best assesses the severity of his pulmonary status? (ABGs.) His ABGs show acute respiratory acidosis, and noninvasive positive-pressure ventilation is initiated. In addition to ventilatory support, what are the treatment priorities? (Corticosteroid, inhaled β-agonist, inhaled anticholinergic agents.) What clinical developments would necessitate transition to endotracheal intubation? (Altered mental status, failure to decrease PaCO2.) When the patient has recovered to baseline, what therapies decrease COPD exacerbations? (Smoking cessation, inhaled corticosteroids, influenza and pneumococcal vaccinations.) What other therapy decreases the mortality rate? (Home oxygen.)
CHRONIC OBSTRUCTIVE PULMONARY DISEASE 5B
What are the essentials of diagnosis and general considerations regarding chronic obstructive pulmonary disease?
Essentials of Diagnosis
History of cigarette smoking
Chronic cough, dyspnea, and sputum production
Rhonchi, decreased intensity of breath sounds, and prolonged expiration on physical examination
Airflow limitation on PFT
General Considerations
Airflow obstruction is caused by chronic bronchitis, emphysema, or both.
Obstruction is progressive and may be accompanied by airway hyperreactivity, which is partially reversible.
Chronic bronchitis is characterized by excessive mucous secretions with productive cough for 3 months or more in at least 2 consecutive years.
Emphysema is abnormal enlargement of air spaces distal to terminal bronchiole with destruction of bronchial walls without fibrosis.
Cigarette smoking is the most important cause; 80% of patients have tobacco smoke exposure.
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