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VI. PATHOPHYSIOLOGY (CATACUTAN, CARMEL MAE T.

OCCUPATIONAL Old Age RESPIRATORY


RISK FACTORS SMOKING 65 years old
87 pack years EXPOSURE INFECTIONS Cough; low
Worked for 30 yrs H. influenza
grade fever
at a local sugar mill infection

-Mucous gland
-diminished lung
enlargement and -macrophage and
function
goblet cell -inc. inflammatory neutrophil
hyperplasia response to dust recruitment
-impairs ciliary action and smoke -inflammatory
-allergies cytokines activation

BMI: 17
PE CHEST: prominent Inflammation
Cachexia SPUTUM G/S:
rib cage with Oxidative stress
Gram – bacilli
decreased AP
SPUTUM C/S:
diameter
H. influenza
Fibrosis and thickening CXR: Hyperinflated
of alveolar walls lungs, pneumonic
infiltrates at right mid
Wheezing lung area
Spirometry: Obstruction of airways in both
FEV 1 lung fields
FEV1/FVC

Air trapping
Tachypnea

Pressure in airways >


pressure in pleural Hyperinflation of the
space lungs Anxious

Air enters pleural Flattened diaphragm Difficulty breathing


cavity

Ventilation:Perfusion
Alveolar hypoxia
PNEUMOTHORAX mismatch

Hypercarbia Hypoxemia
PE CHEST:
CXR: Positive
Hyperresonant on
Pneumothorax, right
percussion
chest, 30%
Decreased vocal Respiratory Increase RBC
ECG: Tachycardic, small
and tactile acidosis production to
QRS complex, prominent
fremitus compensate for
P waves, Right axis
deviation dec. Oxygen

ABG: pH 7.20
PCO2 88 mmHg
PO2 50 mmHg CBC: Hgb 17 g/dL
HCO3 28 mEq/L HCT 51%

VII. THERAPEUTIC MANAGEMENT


A. LIST OF PROBLEMS B. THERAPEUTIC OBJECTIVES
I. COPD 1. To assess further and tailor an individualized plan of care
 Difficulty breathing for the patient.
 Hypoxemia 2. To provide immediate relief of symptoms by
 Hypercarbia pharmacologic and non-pharmacologic means.
 Respiratory acidosis 3. To ensure adequate nutrition to admitted patient.
 Pulmonary hypertension 4. To continuously monitor for new arising problems and
II. COMMUNITY-ACQUIRED PNEUMONIA improvements by the care plan rendered.
 Bacterial infection 5. To collaborate with the patient, family, and other
 Fever members of the healthcare team in finalizing treatment
 Purulent cough schemes and maximizing patient’s compliance.
III. PNEUMOTHORAX AND ACUTE RESPIRATORY FAILURE 6. To educate the patient about the disease and ensure
 Atelectasis understanding for maximum compliance and lesser risks
 Worsening dyspnea for complications.
 Sudden dec. in BP
 Respiratory distress, tachypnea, tachycardia
C. ADVICE AND INFORMATION D. NON-PHARMACOLOGIC MANAGEMENT
1. Educate the patient about his present health conditions— 1. Admission Protocols.
probable etiology, risk factors, course of disease, worsening 2. Administer Oxygen Inhalation at 2 lpm, via nasal cannula.
signs and symptoms, medical options for treatment Ventilatory support as indicated.
including its benefits, adverse effects, risks and prognosis. 3. Administer nebulization—Salbutamol 2.5mg q30mins.
2. Educate the patient and family about the laboratory 4. Start venoclysis—D5NM 1L at 33 drops/min.
findings and the cause of the condition along with its 5. Monitor vital signs q4H, prn during periods of
course. hemodynamic instability. Close monitoring of heart rate,
3. Inform the patient and family about the therapeutic course blood pressure and cardiac arrhythmias.
and discuss risk factors that can promote remission or 6. Acquire serum sample for laboratory tests—CBC,
progression of his condition, and how he will be able to Creatinine, Na+, K+, RBS, BUA
cooperate fully. 7. Monitor ABG q4H.
4. Impart knowledge about patient’s medications, its 8. If patient is stable, consider spirometry testing—pre and
indications, and its possible side effects which he might post bronchodilator testing.
need to inform the physician about. 9. Monitor Intake and Output q shift.
5. Inform patient’s significant others about the patient’s 10. Diet: As Tolerated. Enteral or TPN if on mechanical
condition and how they can be able to maximize familial ventilation.
support for the patient. 11. Advice early ambulation as tolerated; turning and
6. Emphasize the need for medication compliance especially positioning q2H. Refer to pulmonary therapist for
since the patient will be on anti-hypertensive and anti- rehabilitation.
lipemic therapy, for immediate resolution of signs and 12. Monitor for signs of complications, and refer accordingly.
symptoms and for prevention of driving progression of 13. Watch out for signs of depression and refer accordingly.
disease. 14. Advice for a Comprehensive Pulmonary Rehabilitation
7. Emphasize on the need to prevent exposure to triggering Program.
factors especially those acquired exogenously or in the
environment—allergens, house dust, mites, pets, passive EXACERBATIONS OF COPD
smoking, respiratory infections. 1. Assess severity of symptoms, blood gases and chest
8. Strongly accentuate the importance of smoking cessation radiograph.
and lifestyle change in the prevention of worsening his 2. Administer controlled oxygen therapy and repeat ABG
condition. after 30-60 minutes.
3. Increase doses and/or frequency of bronchodilator use.
4. Add oral or IV glucocorticoids.
5. Consider antibiotics (oral or occasionally IV) when there
are signs of bacterial infection.
6. Consider non-invasive mechanical ventilation.
VIII. PHARMACOLOGIC MANAGEMENT (CATACUTAN, CARMEL MAE T.)
DRUG NAME MECHANISM OF ACTION SAFETY SUITABILITY
SHORT-ACTING B2 AGONIST (SABA)
Salbutamol Salbutamol activates adenyl cyclase, Side effects: Tremor, nervousness, Treatment & prevention of
the enzyme that stimulates the nausea and vomiting, tachycardia, bronchospasm in bronchial
production of cyclic adenosine-3', 5'- palpitations, chest pain, shakiness, asthma, bronchitis, emphysema.
monophosphate (cAMP). Increased dizziness, headache, insomnia,
cAMP leads to activation of protein inhalation site sensation,
kinase A, which inhibits hyperactivity, HTN, hypotension,
phosphorylation of myosin and increased sweating, allergic
lowers intracellular ionic Ca reactions, DM, muscle cramps, flu-
concentrations, resulting in smooth like syndrome, conjunctivitis, UTI,
muscle relaxation. hypokalaemia.

Contraindications: IV (in the


treatment of premature labour): Pre-
existing or risk factors for ischaemic
heart disease, gestational age <22 wk

LONG-ACTING ANTIMUSCARINIC AGENT (LAMA)


Tiotroprium Tiotropium bromide antagonizes the Side effects: Dry mouth, upper resp For management of Asthma and
bromide cholinergic effects of acetylcholine tract infection, pharyngitis, sinusitis, COPD.
by reversibly and competitively rhinitis, epistaxis, non-specific chest
binding to type 3 muscarinic (M3) pain.
receptors, resulting in bronchial
smooth muscle relaxation. Contraindications: Hypersensitivity
to tiotropium bromide, atropine or
its derivatives.

GLUCOCORTICOID
Hydrocortisone Hydrocortisone is a corticosteroid Side effects: Sodium and fluid Among patients admitted to the
used for its anti-inflammatory and retention. Potassium and calcium hospital d/t COPD, the use of
immunosuppressive effects. Its depletion. Muscle wasting, flucocorticoids has been
anti-inflammatory action is due to weakness, osteoporosis. demonstrated to reduce the length
the suppression of migration of of stay, hasten recovery, and
polymorphonuclear leukocytes and Contraindications: Viral/fungal reduce the chance of subsequent
reversal of increased capillary infections, tubercular or syphilitic relapse for a period of up to 6
permeability. It may also be used lesions, bacterial infections unless months.
as replacement therapy in used in conjunction with appropriate
adrenocortical insufficiency. chemotherapy.

ANTIBACTERIAL
Cefuroxime Cefuroxime inhibits bacterial cell Side effects: rash, fever, pruritus, To treat respiratory infections/
wall synthesis by binding to one 1 erythema, urticaria, Stevens-Johnson pneumonia.
or more of the penicillin-binding syndrome, erythema multiforme
proteins (PBPs) which in turn
inhibit the final transpeptidation Contraindications: Hypersensitivity
step of peptidoglycan synthesis in to cefuroxime or to other
bacterial cell walls, thus inhibiting cephalosporins.
cell wall biosynthesis and arresting
cell wall assembly resulting in
bacterial cell death.
LONG-ACTING B2 AGONIST/INHALED CORTICOSTEROID (LABA/ICS)
Salmeterol + Salmeterol, a long acting β2- Side effects: Mouth and throat For management of Asthma and
Fluticasone agonist which acts locally in the candidiasis, throat irritation, COPD.
lung to mediate bronchodilation. hoarseness/dysphonia,
Fluticasone, a corticosteroid with nasopharyngitis, lower respiratory
mainly glucocorticoid activity, tract infections (e.g. pneumonia and
reduce symptoms and bronchitis), hypokalaemia, headache,
exacerbations of asthma. tremors, palpitation, muscle cramps.
Prolonged high dose use may cause
Cushing's syndrome, Cushingoid
features, adrenal suppression,
retardation of growth in children and
adolescents, bone mineral density
decrease, cataract and glaucoma.

Contraindications: Not for primary


treatment of status asthmaticus or
other acute attacks of asthma.

THEOPHYLLINE
Aminophylline Theophylline competitively blocks Side effects: Nausea, vomiting, To relieve acute bronchospasm.
phosphodiesterase which increases epigastric pain, abdominal cramps,
cyclic adenine monophosphate anorexia, diarrhoea, haematemesis;
(cAMP) tissue concentrations headache, irritability, restlessness,
causing bronchodilatation, diuresis, nervousness, insomnia, dizziness,
CNS and cardiac stimulation, and reflex hyperexcitability, seizures;
gastric acid secretion. palpitations, sinus tachycardia,
extrasystoles, increased pulse rate,
flushing, circulatory failure,
hypotension, ventricular
arrhythmias; transient increase in
urinary frequency, dehydration,
twitching of fingers and hands,
tachypnoea, elevated serum AST
concentrations.

Contraindications: Hypersensitivity
to theophylline and other xanthine
derivatives. Porphyria

ANTIPYRETIC
Tramadol Tramadol exhibits analgesic action Side effects: Thrombocytopenia, To manage fever (38C).
by peripheral blockage of pain leucopenia, pancytopenia,
impulse generation. It produces neutropenia, agranulocytosis, pain
antipyresis by inhibiting the and burning sensation at inj site.
hypothalamic heat-regulating Rarely, hypotension and tachycardia.
center. Its weak anti-inflammatory
activity is related to inhibition of
prostaglandin synthesis in the CNS.

MUCOLYTIC
Ambroxol Ambroxol is a metabolite of Side effects: Mild GI effects and To lyse mucous in productive
bromhexine and is used similarly as allergic reactions. cough.
a mucolytic.

P DRUGS PRESCRIPTION PRICES


1. Salbutamol (Ventolin) 2.5 mg via inhalation, q 30 mins P 490.08/box
2. Tiotroprium bromide (Spiriva) 1 cap (18 mcg) via inhaler device, OD P 197.25
3. Hydrocortisone (Hydrovex) 100 mg IV, q 6 hrs P 150.00/vial
4. Cefuroxime (Axetine) 750 mg IVTT ANST, q 8 hrs P 250.00/powd. for inj.
5. Salmeterol + Fluticasone 50/125 mcg MDI puff, BID P 366.42
(Combiwave SF125)
6. Aminophylline (Aminosol) 400 mg/day, PO P 23.15
7. Paracetamol (Biogesic) 500 mg q 4 hrs P 3.25/tab
8. Ambroxol (Mucosolvan) 30 mg/ml 1tsp TID, PO P 124.25

IX. PRESCRIPTION WRITING

Carmel Mae Catacutan, M.D. Carmel Mae Catacutan, M.D. Carmel Mae Catacutan, M.D.
Silliman University Medical Center Silliman University Medical Center Silliman University Medical Center
Dumaguete City Dumaguete City Dumaguete City
(035) 225-0330 (035) 225-0330 (035) 225-0330

Patient: MT Date: 01/16/18 Patient: MT Date: 01/16/18 Patient: MT Date: 01/16/18


Address: Tanjay Age/Sex: 65/M Address: Tanjay Age/Sex: 65/M Address: Tanjay Age/Sex: 65/M

Rx Rx Rx
Salbutamol (Ventolin) #15 nebules Tiotroprium bromide (Spiriva) #1 Hydrocortisone (Hydrovex) #2 vials

Sig: 2.5 mg via inhalation, q 30 mins Sig: 1 cap (18 mcg) via inhaler device, Sig: 100 mg IV, q 6 hrs
OD

Carmel Mae Catacutan, M.D. Carmel Mae Catacutan, M.D.


Carmel Mae Catacutan, M.D.
Lic.No 083093 Lic.No 083093
Lic.No 083093

PTR No. 33098 PTR No. 33098


PTR No. 33098

Carmel Mae Catacutan, M.D. Carmel Mae Catacutan, M.D. Carmel Mae Catacutan, M.D.
Silliman University Medical Center Silliman University Medical Center Silliman University Medical Center
Dumaguete City Dumaguete City Dumaguete City
(035) 225-0330 (035) 225-0330 (035) 225-0330

Patient: MT Date: 01/16/18 Patient: MT Date: 01/16/18 Patient: MT Date: 01/16/18


Address: Tanjay Age/Sex: 65/M Address: Tanjay Age/Sex: 65/M Address: Tanjay Age/Sex: 65/M

Rx Rx Rx
Cefuroxime (Axetine) #1 pack Salmeterol + Fluticasone Aminophylline (Aminosol) #7
(Combiwave SF125) # 1 inhaler
Sig: 750 mg IVTT ANST, q 8 hrs Sig: 400 mg/day, PO
Sig: 50/125 mcg MDI puff, BID

Carmel Mae Catacutan, M.D. Carmel Mae Catacutan, M.D. Carmel Mae Catacutan, M.D.
Lic.No 083093 Lic.No 083093 Lic.No 083093

PTR No. 33098 PTR No. 33098 PTR No. 33098


Carmel Mae Catacutan, M.D. Carmel Mae Catacutan, M.D.
Silliman University Medical Center Silliman University Medical Center
Dumaguete City Dumaguete City
(035) 225-0330 (035) 225-0330

Patient: MT Date: 01/16/18 Patient: MT Date: 01/16/18


Address: Tanjay Age/Sex: 65/M Address: Tanjay Age/Sex: 65/M

Rx Rx
Paracetamol (Biogesic) #5 tabs Ambroxol (Mucosolvan) # 1 syrup

Sig: 500 mg q 4 hrs Sig: 30 mg/ml 1tsp TID, PO

Carmel Mae Catacutan, M.D. Carmel Mae Catacutan, M.D.


Lic.No 083093 Lic.No 083093

PTR No. 33098 PTR No. 33098

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