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PULMONARY DISEASE
OBJECTIVES:
ToThis
be case
a presentation
To aims to:
3
1
4
discuss To be able To be able
able to the to know to present
present a etiology, the the
case of a risk pathogene manageme
patient with factors, sis and nt of
COPD. clinical diagnose a COPD.
manifestati patient with
ons of COPD.
COPD.
DATE AND
INFORMAN RELIABILIT
TIME OF
T Y
HISTORY
AUGUS
PATIEN
T 15, 98 %
T
2018
WIDOW
DOB:
10/04/1941
76/M
SAN
C.B ROMAN
CATHOLIC
SEBASTIAN
SAMAR
FILIPINO ADMITTED FOR THE
1ST
TIME AT OUR
CENTER
DOA: AUGUST 12, 2018
TOA: 11:05 AM
CHIEF COMPLAINT
DIFFICULTY
OF
BREATHING
HISTORY OF PRESENT
ILLNESS
1 • Dyspnea
• Easy fatigability
MONT • Relieved by rest
H • Productive cough to a whitish
PTA sputum
NO FEVER, CHEST
PAIN, ABDOMINAL
PAIN, DYSURIA
• CBC
• NA, K,
SOUGHT BLOOD
CONSUL CHEMIST
RY
T AS • SPIROME
OPD TRY
• 12-L ECG
SOUGHT
CONSULT AS OPD
OPD (07/03/18)
HEMOGLOBI 142
N
SPIROME
CBC
TRY
HEMATOCRIT 0.40
WBC COUNT 6.1
NA, K 12-L ECG PLATELET CT 260
NEUTROPHIL 54
S
BLOOD LYMPHOCYT 32
CHEMIST E
RY
MONOCYTE 3
SOUGHT OPD
CONSULT AS (07/03/18)
OPD
GLUCOSE 4.9
LDL 3.51
SPIROME
CBC
TRY VLDL 0.64
CHOLESTEROL 5.0
TRIGLYCERIDE 1.40
NA, K 12-L ECG S
DIRECT HDLC 0.9
BLOOD ALBUMIN 37
CHEMIST ALT 35
RY
SOUGHT
CONSULT AS
OPD OPD
(07/03/18
)
SPIROME
CBC NA 140.9
TRY
K 4.51
NA, K 12-L ECG BUN 5.4
CREATININ 83
BLOOD E
CHEMIST
RY
SOUGHT
CONSULT AS
OPD SPIROMETRY
VERY SEVERE
CBC SPIROMETRY
OBSTRUCTIVE TYPE OF
DEFECT WITH GOOD
RESPONSE TO
BRONCHODILATOR.
NA, K 12-L ECG PLEASE CORRELATE
CLINICALLY.
BLOOD
CHEMISTRY
SOUGHT
CONSULT AS
OPD
12-L ECG
CBC
SPIROME SINUS
TRY
TACHYCARDIA,
LEFT AXIS
NA, K 12-L ECG
DEVIATION,
BLOOD
ANTEROSEPTAL
CHEMIST WALL ISCHEMIA
RY
LEVOCETIRIZINE +
N-ACETYLCYSTEINE
MONTELEUKAST DOXOFYLLINE
600 mg, 1 tab in ½
10/5 mg, 1 tab 200 mg, 1 tab BID
glass of water OD
OD
IPRATROPIUM + ROSUVASTATIN
TRIMETAZIDINE
SALBUTAMOL 20 mg, 1 tab
neb 35 mg, 1 tab BID
ODHS
CARVEDILOL
ASPIRIN
6.25 mg, ½ tablet
80 mg, 1 tab OD
BID
ON INTERIM…
NO
RELIEVED BY
FOLLOW UP
NEBULIZATION OF
SALBUTAMOL +
CONSULT
PERSISTENCE OF THE IPRATROPIUM EVERY DONE.
MENTIONED 8 HOURS
SYMPTOMS WERE • MAINTENANCE
NOTED. MEDICATIONS TAKEN
WITH GOOD
• OCCASIONAL DYSPNEA COMPLIANCE
• EASY FATIGABILITY
• PRODUCTIVE COUGH
HISTORY OF PRESENT ILLNESS
WORSENING OF
PROVIDING NO
THE DIFFICULTY HENCE,
RELIEF OF THE
OF BREATHING ADMITTED.
DYSPNEA
EVEN AT REST
OCCASIONAL
DYSPNEA, EASY
HOURS PTA
FATIGABILITY,
PRODUCTIVE
COUGH
PAST MEDICAL HISTORY
HYPERTENSION
Losartan 50 Carvedilol 6.25
mg/tablet, 1 tablet
• 10 YEARS OD – poor mg/tablet, 1
compliance tablet BID
• HIGHEST BP
RECORDED: 170/80 MAINTENANCE Trimetazidine Rosuvastatin
mmHg MEDICATIONS:
35mg/tablet, 1
tablet BID 20mg/tablet, 1
tablet OD
NO OTHER Aspirin
Doxofylline,
80mg/tablet, 1
COMORBIDITIES tablet OD 200mg/tablet,
NOTED. 1 tablet BID
• (-) DM
• (-) ASTHMA
PAST MEDICAL HISTORY
PREVIOUS
SURGERY ALLERGY
HOSPITALIZATION
MAY 2018 at
Tacloban Doctors
due to chest tightness NONE NONE
and productive
cough. Patient was
admitted for 7 days
and was discharged
improved.
MOTHER WIFE
Died at the Died at 74 due to an
unknown lung disease
age of 84 due but was known to be a
to a fire chronic smoker
smoking 1 pack per
incident day.
FATHER
Died at 71 NO OTHER
HEREDOFAMILIAL
(+) Hypertension
FAMILY DISEASES NOTED
HISTOR
Y
PERSONAL SOCIAL HISTORY
ALCOHOLIC
EDUCATIONAL ATTAINMENT:
COLLEGE GRADUATE SMOKER BEVERAGE DRINKER
Occupation:
Duration: 51 years Duration: 55 years
Elementary Teacher
Amount/Type: 2
glasses per session
REVIEW OF SYSTEMS
•(-) weight loss; afebrile; (+) body
GENERAL malaise; (-) weight gain, (+) easy
fatigability, (+) loss of appetite
INTEGUMENT
• Skin: Dry, warm, no scars
• Nails: Good capillary refill, no clubbing, pinkish nail
HEAD
EYES
MOUTH/THROAT
CHEST/LUNGS
ABDOMEN
EXTREMITIES
PHYSICAL EXAMINATION
76
HISTORY
• NO NVE
• EASY FATIGABILITY
• CHEST AND LUNGS: MID
MALE
• PRODUCTIVE COUGH TO BASAL RALES, (+)
• EXERTIONAL WHEEZING
DYSPNEA • GRADE 1 BIPEDAL PITTING
EDEMA
DIFFERENTIAL DIAGNOSIS
RULE IN RULE OUT
√ Fatigue No neck vein engorgement
CHF √ Exertional Dyspnea
√ 2- pillow orthopnea
√ Rales
√ Wheezing
√ Grade 1 bipedal edema CANNOT
√ Alcoholic beverage drinker TOTALLY RULE
FRAMMINGHAM DIAGNOSTIC CRITERIA OUT
MAJOR MINOR
ORTHOPNEA DYSPNEA ON
RALES EXERTION
CARDIOMEGALY
RULE IN RULE OUT
√ Age Fever
COMMUNITY √ Tachypnea Pleuritic chest pain
ACQUIRED √ Rales
√ Wheezing
PNUEMONIA – √ Productive cough
MODERATE RISK
CANNOT
C: No confusion of new onset
U: 14.0 mmol/L TOTALLY RULE
R: 23 cpm
B: 90/60 mmHg
OUT
65: Patient is 76 years old
INTERPRETATION: 2
RULE IN RULE OUT
Exposure to
EASY FATIGABILITY second hand
smoking
PRODUCTIVE
COUGH
BASIS
2-PILLOW
ORTHOPNEA
AT THE EMERGENCY ROOM . .
.
S-O A P
(+) Exertional dyspnea COPD IN ACUTE DIAGNOSTICS THERAPEUTICS
(+) Easy fatigability EXACERBATION 12 L – ECG SALBUTAMOL + IPRATROPIUM NEBULE
(+) Productive cough CHEST XRAY – PA VIEW + 2 CC PNSS NOW THEN Q 8 HOURS
(+) Loss of appetite CHF FC III CBC PLATELET N-ACETYLCYSTEINE 600MG, DISSOLVE
CAP-MR U/A IN ½ GLASS OF WATER ODHS
TB SUSPECT TROPONIN I
R/O ABG DOXOFYLLINE 200MG TABLET BID
MYOCARDIAL ROSUVASTATIN 20MG TABLET ODHS
INFARCTION TRIMETAZIDINE 35MG TABLET BID
OBJECTIVE SUPPORTIVE
CARVEDILOL 6.25MG TABLET BID
AWAKE, CONSCIOUS, IVF: PNSS 1L @ 10 GTTS/MIN ASA 80MG TABLET OD
COHERENT, IN MILD DIET: LOW SALT, LOW FAT DIET LEVOCETIRIZINE + MONTELUKAST
RESPIRATORY DISTRESS 5/10MG TABLET OD
BP: 90/60 MMHG O2 INHALATION AT 2 LPM
PR: 66 BPM MONITORING I AND O CLOSELY
RR: 23 CPM AND ACCURATELY
T: 36.6 C PROVIDE MEASURING CONTAINER
SPO2: 98%
C/L: (+) mid to basal rales
(+) wheezing
EXTREMITIES: (+) grade 1
bilateral pitting edema
NYHA DESCRIPTION GENERAL GUIDE EXAMPLES
I Symptoms occur with
greater than ordinary
No limitation of physical activity Can do outdoor work
Can climb >/= 2 flights of stairs
physical activity with ease
IV Symptoms may be
present even at rest
Unable to carry on activity
without symptoms
Cannot carry out
activities above
Dyspnea at rest
OPD HOSPITAL DAY 1
CBC HEMOGLOBIN 142 127
ALBUMIN 37 30 35 – 50
127
GOLD 3 •
•
Greater shortness of breath
Reduced exercise capacity
FEV1 30 TO < 50%
PREDICTED
SEVERE •
•
Fatigue
Repeated exacerbations
1 I get short of breath when hurrying on the level or walking up a slight hill
2 I walk slower than people of the same age on the level because of
breathlessness, or I stop for breath when walking on my own pace on the
level
3 I stop for breath after walking 100 meters or after a few minutes on the level
1 I get short of breath when hurrying on the level or walking up a slight hill
2 I walk slower than people of the same age on the level because of
breathlessness, or I stop for breath when walking on my own pace on the
level
3 I stop for breath after walking 100 meters or after a few minutes on the level
A
Low symptom severity </= 1 (not leading to hospital admission) mMRC 0-1 CAT <
Low exacerbation risk 10
B
High symptom severity </= 1 (not leading to hospital admission mMRC CAT
Low exacerbation risk >/2 >/= 10
C
Low symptom severity >/= 2 or >/= 1 leading to hospital admission mMRC 0-1 CAT <
High exacerbation risk 10
D
High symptom severity >/= 2 or >/= 1 leading to hospital admission mMRC CAT
High exacerbation risk >/= 2 >/= 10
OVERVIEW OF MANAGEMENT
ANTICHOLINERGIC
PDE – 4 INHIBITORS VACCINATIONS
(ANTIMUSCARINIC)
INHALED
METHYLXANTHINES
CORTICOSTEROIDS
OVERVIEW OF MANAGEMENT
ANTICHOLINERGIC
BETA 2 AGONISTS
(ANTIMUSCARINIC) METHYLXANTHINES INHALED
CORTICOSTEROIDS
SHORT ACTING: SHORT ACTING
• SALBUTAMOL THEOPHYLLINE
• IPRATROPIUM BECLOMETHASONE
• TERBUTALINE BROMIDE
• OXITROPIUM AMINOPHYLLINE
LONG-ACTING BROMIDE BUDESONIDE
• FORMETEROL,
SALMETEROL,
LONG ACTING DOXOFYLLINE
VILANTEROL, MOMETASONE
OLODATEROL, • TIOTROPIUM
INDACATEROL
FLUTICASONE
PDE – 4 INHIBITORS ANTIBIOTICS
MUCOLYTICS/ANTI
OXIDANTS VACCINATIONS
N-ACETYLCYSTEINE
THREE INTERVENTIONS
DEMONSTRATED TO INFLUENCE
THE NATURAL HISTORY OF COPD
INTERVENTION REMARKS
SMOKING CESSATION Biggest impact in the
natural history of COPD
OXYGEN THERAPY
LUNG VOLUME REDUCTION
SURGERY
EXACERBATIONS IN CHRONIC
OBSTRUCTIVE PULMONARY
DISEASE
ETHIOPATHOGENESIS
• Associated with increased airway
inflammation, increased mucus production,
and marked gas trapping
• Mainly triggered by respiratory viral infections
(others: bacterial infections, environmental
factors)
MANIFESTATIONS
Key symptom during exacerbations: increased
dyspnea
Other symptoms: increased sputum production,
purulence and volume, increased cough,
wheezing
Symptoms usually last between 7-10 days during
exacerbations: but 20% of patient do not
recover at 8 weeks
CLASSIFICATION OF EXACERBATED
COPD AMONG HOSPITALIZED PATIENTS
NO RESPIRATORY ACUTE RESPIRATORY ACUTE RESPIRATORY
FAILURE FAILURE FAILURE
NON-LIFE THREATENING THREATENING
RESPIRATORY RATE 20-30 BREATHS/MIN > 30 BREATHS/MIN
USE OF ACCESSORY NO YES
MUSCLES
CHANGE IN MENTAL NONE YES (ACUTE CHANGES)
STATUS
HYPOXEMIA IMPROVED WITH IMPROVED WITH NOT IMPROVED WITH
SUPPLEMENTAL O2 AT SUPPLEMENTAL O2 AT 35- SUPPLEMENTAL O2 AT > 40
28-35 % FIO2 40 % FIO2 % FIO2
PACO2 NOT INCREASED HYPERCARBIA HYPERCARBIA (INCREASED
(INCREASED FROM FROM BASELINE OR
BASELINE OR ELEVATED AT ELEVATED AT >60 MMHG
50-60 MMHG) OR WITH ACIDOSIS – PH:
</= 7.25)
MANAGEMENT OF ACUTE
EXACERBATIONS
CLASSIFICATION OF OVERVIEW OF MANAGEMENT
EXACERBATION
MILD SHORT ACTING BRONCHODILATORS