Case-Based Learning

Thoracic Medicine

Chronic obstructive
pulmonary disease
Edited by Chien-Da Huang
Physician Educator/Associate Professor
Department of Thoracic Medicine and Medical
Education
Chang Gung Memorial Hospital
Taipei, Taiwan
 -- COPD

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 with acute exacerbation.
To identify the significant findings of Lab examination in
patients with COPD with acute exacerbation.
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?
 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-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 for this
patient ?

What are the causes of production of sputum for this

patient?

How do you define COPD with acute exacerbation?

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 , pursed-lip breathing, lip cyanosis
Accessory muscle used , Hoovers sign
Poor lung expansion over BLL
Decreased breathing sound in bilateral lung field ,
crackles over LUL
Lower lower limbs: The antigravity power of lower
limb muscle is poor. Bilateral limbs also showed
vasoconstriction with cold. mild pitting edema
Exercise Intolerance/Dyspnea on
exertion
Poor expansion of diaphragm
Accessory muscle use

Decreased breathing sound in bilateral lung field

Decreased lower limb muscle power

Peripheral vasoconstriction

Lower limbs: vasoconstriction

Anti-gravity power of lower limb muscle: poor

Questions to be discussed?
What do you find in the pictures? Please explain
and discuss

Make comments or share clinical experience from

tutors
 10

COPD
:
What are your main diagnoses of this
patient? And, what is the process of
causal reasoning?
What are your further diagnostic
and/or treatment and health education
plans?
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 the definitions of 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?

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

2007 GOLD
Guideline:

Stage IV:
Very severe
COPD

2012 GOLD
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?

What are the comorbidities of COPD?

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
 18

COPD
:
The final diagnosis is COPD with acute exacerbation,
and the severity stage was IV, Category D

While starting the explanation of the further treatment

plan to the patient, he interrupted your presentation
and was not cooperative with your management, such
as chest care and ambulation of four limbs . He was
agitated and strongly asked for bronchodilator only. His
son was standing at bedside and watching you with
doubtful expression.
 19

COPD
:
How to handle the agitated situation?
How to let the patient to agree your
treatment plan?
Individualized Treatment for this
Patient

Medicine
Tiotropium + Fluticasone/salmeterol (high
dose)
Hospital-Based Pulmonary Rehabilitation
Program
Mucus clearance technique
Exercise training program
Walking
Upper limbs training
Inspiratory muscle training
Transcutaneous Electrical Stimulation (TENS)

Oxygen supplement
Vaccination
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 2nd infection

(B) Muscle dysfunction or atrophy
(C) All of above
(D) None of all
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) 1 + 2 + 5
(B) 1 + 3 + 5 + 6
(C) 1 + 4 + 5 + 6
(D) 1 + 2 + 4 + 5 + 6