Chronic Obstructive Pulmonary

Disease
PGI Ponferrado/ PGI Salita/ PGI Mondelo
Objectives I. To present a case the exhibits signs
and symptoms, which are commonly
found in patients with COPD
II. To give an overview on the
pathophysiology of the disease in
conjunction to the presentation of
the patient
III. To discuss methods on how to
diagnose COPD
IV. To inform about the available
treatment options
 Chronic I. CASE
II. DIFFERENTIAL
Obstructive DIAGNOSES
Pulmonary III. PATHOPHYSIOLOGY
Disease IV.CLINICAL
MANIFESTATION
V. DIAGNOSIS
VI.TREATMENT
General Data ● M.O.
● 67/M/RPV
● Married
● Christian
● Sta. Rosa, Laguna
Chief Complaint Difficulty of breathing
 History of Present Illness

3 years prior 1 year prior 1 day prior

3 months prior
Recurrences Recurrences Recurrences
in the interim in the interim in the interim
(+) non productive cough (+) productive cough, (+) progression of dyspnea(+) shortness of breath
(+) easy fatigability whitish to watery-colored (+) non productive cough (+) productive cough,
(-) dyspnea sputum (+) easy fatigability whitish sputum
(-) fever (+) dyspnea on exertion (-) fever (+) difficulty sleeping
(-) weight loss (+) easy fatigability (-) fever
(-) fever
-> Hence, CONSULT
Self-medicated with
Carbocisteine
-> Partial relief
Past Medical History

(+) Hypertension (2014) - Losartan 50mg OD, Amlodipine 5mg OD (compliant)

UBP: 120/80 HBP 140/90

(+) Cholecystectomy (2008, VMMC)

(-) Diabetes Mellitus

(-) Cardiovascular disease
(-) Stroke
(-) Bronchial Asthma
(-) PTB
(-) Thyroid Disorder
(-) Allergies to food nor medication
Family History

(+) Hypertension - Both sides

(+) Diabetes Mellitus - Maternal

(-) Stroke
(-) Cardiovascular disease
(-) Asthma
(-) PTB
(-) Thyroid diseases
(-) Cancer
(-) Lung diseaseses
Personal and Social

(+) Smoker 1pack/ day X 37 years - 37 pack year smoker

(+) Occasional alcoholic beverage drinker

Denies illicit drug use

Resides in a 2-storey bungalow with his wife in Sta. Rosa, Laguna

Retired AFP Personnel

Reports exposure to smoke from burning of biomass in their area

Review of Systems
General: (+) weight loss, (+) loss of appetite, (-) cyanosis, (-) dizziness, (-) malaise, (-)
chills, (-) night sweats
HEENT: (-) blurring of vision, (-) lacrimation, (-) itching, (-) ear pain, (-) hearing loss, (-)
tinnitus, (-) colds, (-) sore throat
Cardiovascular: (-) chest pain, (-) orthopnea, (-) PND, (-) edema
Gastrointestinal: (-) abdominal pain, (-) vomiting, (-) diarrhea, (-) constipation, (-)
bowel incontinence,
(-) melena, (-) hematochezia
Genitourinary: (-) dysuria, (-) hematuria, (-) frequency, (-) urgency, (-) urinary
incontinence,
(-) weak stream, (-) intermittent stream, (-) straining
Review of Systems

Musculoskeletal: (-) pain, (-) warmth, (-) swelling, (-) limitation of movement
Endocrinologic: (-) polydipsia, (-) polyphagia, (-) polyuria, (-) heat/cold intolerance, (-)
irritability,
(-) tremors, (-) palpitations, (-) nervousness
Hematologic: (-) pallor, (-) easy bruisability, (-) bleeding
Neuropsychiatric: (-) tremors, (-) seizures, (-) weakness, (-) numbness, (-) memory loss,
(-) depression, (-) mood changes, (-) delusions, (-) hallucinations
Physical Examination

General Survey: conscious, coherent, ambulatory, not in cardiorespiratory distress

Vital Signs: BP: 140/90 mmHg PR: 71 bpm RR: 23 cpm T: 36.7°C O2 sat:
93%
Anthropometrics: Height: 1.73 m Weight: 67 kg BMI 22.4 (Normal)
HEENT: anicteric sclerae, pink palpebral conjunctivae, non-congested turbinates,
no nasoaural drainage no tragal tenderness, nonhyperemic posterior pharyngeal
wall
Neck: no cervical lymphadenopathy, non-distended neck veins
Lungs: (+) barrel chest, no retractions, equal vocal and tactile fremiti,
hyperresonant upon percussion, decreased breath sounds, (+) expiratory wheezes
Physical Examination

Heart: adynamic precordium, normal rate, regular rhythm, apex beat at 5th LICS
MCL, no murmurs
Abdomen: flabby abdomen, normoactive bowel sounds, tympanitic, soft, non-
tender
DRE: no skin tags, no external hemorrhoids, no fissures, tight anal sphincteric tone,
no masses, no blood/stool on tactating finger
Genitourinary: no CVA tenderness
Extremities: pulses full and equal, CRT <2 secs, no edema, no joint
swelling/tenderness, no limitation of movement
Neurologic Examination
 Salient Features
SUBJECTIVES
OBJECTIVES
● 67/M
● Not in cardiorespiratory distress
● CC: DOB
RR: 23 cpm O2 sat: 93%
● Progressive dyspnea, Productive cough, with whitish sputum ●
● Easy fatigability ● (+) barrel chest, hyperresonant upon
percussion, decreased breath sounds, (+)
● Difficulty sleeping wheeze
● Loss of appetite
● Weight loss
● No fever, chest pain, orthopnea, PND nor edema
● Smoker - 37 pack years; occasional alcoholic beverage drinker
● (+) Exposure to smoke from burning of biomass in their area
● HTN (2014) - Losartan 50mg OD, Amlodipine 5mg OD
(compliant)
● Cholecystectomy (2008, VMMC)
Clinical Impression

T/c Chronic Obstructive Pulmonary Disease

Hypertension Stage 2
S/p Cholecystectomy (2008)
 Differential Diagnosis
Pneumonia COPD Asthma Heart Failure

Predisposing factors: Predisposing factors: Predisposing factors: Predisposing factors:

Smoker - 37 pack years Allergy, rhinitis, eczema
History: (+) biomass fuel exposure Family history of History:
Cough Family history Asthma or atopy Nocturnal cough
Dyspnea Exposure to smoke or Dyspnea on exertion
Fever History: fumes Orthopnea/PND
Chronic cough
PE: Sputum production History: PE:
Crackles Dyspnea Cough Tachycardia (>120)
Anorexia Dyspnea Neck vein distention
Weight loss Chest tightness Cardiomegaly
Nocturnal worsening of Hepatomegaly
PE: symptoms S3 gallop
Barrel chest Rales
Hyperresonant PE: Ankle edema
Decreased breath sounds Wheeze
Wheeze
Pathophysiology
Risk Factors

● Cigarette smoking ( Pack years) ● Severe Alpha 1 anti-trypsin

● Air hyper responsiveness Deficiency
● Respiratory Infections ● Air pollution (Urban > Rural)
● Occupational Exposures (dust ● Passive or Second hand
and fumes) smoking exposure
Clinical Manifestation

Chronic Cough
Sputum production
Exertional Dyspnea
Diagnosis
SPIROMETRY
● standard confirmatory diagnostic tool
● used for classification of disease severity

Confirmation: post-bronchodilator FEV1/FVC < 0.70

– means airflow limitation is not fully reversible

Why do we need Spirometry?

o To screen individuals at risk for pulmonary disease

o To confirm diagnosis of COPD

o To assess severity of pulmonary dysfunction

o To guide to treatment selection

o To assess effects of therapeuticintervention

CXR

NORMAL AIRWAY TRAPPING

● Low set diaphragm

“Flattened”
● Hyperinflation from
airway trapping &
decreased elastic
recoil
ABG

NORMAL AIRWAY TRAPPING

● Provide additional
information about
alveolar ventilation
and acid base status
by measuring pH and
Pc02
Treatment
 Stable Phase

Two main goals of therapy

● Provide Symptomatic Relief
● Reduce Future Risk
Three interventions
● Smoking Cessation
● Oxygen Therapy (Chronically hypoxemic patients)
● Lung Volume Reduction Surgery
 Bronchodilators

Pharmacotherapy
● The inhaled route is preferred for medication delivery.
● In symptomatic patients, both regularly scheduled use
of long-acting agents and as-needed short-acting
medications are indicated

Anticholinergic Muscarinic Antagonists

● Short-acting ipratropium bromide improves symptoms
with acute improvement in FEV1.

Beta Agonists
● Short-acting beta agonists ease symptoms with acute
improvements in lung function.
● Long-acting agents (LABA) provide symptomatic
benefit and reduce exacerbations
 Pulmonary Rehabilitation
● This refers to a comprehensive treatment program that
Non-pharmacologic incorporates exercise, education, and psychosocial and
nutritional counseling

Lung Volume Reduction Surgery

● In carefully selected patients with emphysema, surgery to
remove the most emphysematous portions of lung
improves exercise, lung function, and survival.

Lung Transplantation
● COPD is currently the second leading indication for lung
transplantation