Respiratory diseases – Chronic Obstructive Pulmonary Disease

Respiratory diseases – Chronic Obstructive Pulmonary Disease

Pathophysiology & Clinical Findings of the Disease

1. Are the spirometry results consistent with obstructive or restrictive pulmonary disease? What is the most likely pulmonary diagnosis for this patient?

The above spirometry results show that the patient has Obstructive Pulmonary Disease. The symptoms and investigations are suggestive of Chronic Obstructive Pulmonary Disease. Spirometry and clinical findings results helped to reach the diagnosis. The absolute value of spirometry FEV1/FVC was expected to be 81, but the results showed a value of 64, less than 70% which is one of the main requirements of diagnosing COPD, where the value is less than 70% of the expected value.

2. Explain the pathophysiology associated with the chosen pulmonary disease.

The airway in the lung tissue is inflamed, which interferes with oxygen circulation, reducing the airflow in and out of the lungs (Lange et al., 2021). Additionally, there is increased mucus secretion due to the high number of goblet cells and increased size of submucosal glands. This results in scar formation and destruction of the alveolar wall, which causes attachment making it difficult to eliminate carbon (IV) oxide.

3. Identify at least three objective findings from the case that support the chosen diagnosis.

Relevant results that lend to the diagnosis of COPD in the above case scenario include wheezes present at the time of expiration, shortness of breath, and worsening breathlessness.

4. Identify at least three objective findings from the case that support the chosen diagnosis.

Other observations made during examination beyond the patient’s control include wheezes that occur during forced exhalation on both lungs, hyperinflation of lungs bilaterally with a flat diaphragm visible on the chest x-ray, and a flat chest. These subjective and objective findings indicate that the patient suffers from COPD.

Management of the Disease

1. Classify the patient’s disease severity. Is this considered stable or unstable?

The patient’s condition is classified as unstable because of progressive episodes of breathlessness and other comorbidities such as hypertension, atherosclerotic coronary artery disease, and hyperlipidemia. These illnesses lead to disease complications, and their interaction is likely to worsen COPD in the patient after some time and can easily cause death. COPD is at stage 1 according to the Gold Criteria. At this stage, the patient does not realize they have COPD because the symptoms are mild and worsen as time progresses. The Gold Criteria of COPD stage 1 is explained to be an expected value of greater than 80% of forced expiratory volume in a measure of one second (MacLeod et al., 2021). According to the patient’s results, the value falls at 81%, above the predicted value by 1%; therefore, it falls in stage 1 of COPD.

2. Identify two (2) “Evidence A” recommended medication classes for the treatment of this condition and provide an example (drug name) for each.

Management of this condition includes various classes of drugs, such as bronchodilators and corticosteroids. Bronchodilators include Long-acting beta-2 antagonists (LABA), Long-acting muscarinic antagonists (LAMA), and short-acting bronchodilators such as levalbuterol and albuterol. Examples of LABA include indacaterol, arformoterol, formoterol, and salmeterol. Examples of LAMA are umeclidinium, aclidinium, tiotropium, and ipratropium. Most doctors prescribe corticosteroids such as budesonide, prednisolone, and fluticasone.

3. Describe the mechanism of action for each of the medication classes identified above.

Bronchodilators make breathing more efficient by opening up the airways. The medical personnel may prescribe short-acting bronchodilators in an emergency when the patient immediately requires relief. Using inhalers and nebulizations are ways to administer short-acting bronchodilators. Side effects that may occur with the use of short-acting bronchodilators include increased heart rate, nervousness, tremors, dry mouth, headache, and cough. Short-acting bronchodilators are contraindicated on patients with a heart condition. Long-acting bronchodilators are used in COPD that require treatment for a longer period, and they are taken twice or once daily and can be in the form of nebulizers or inhalers. These drugs work slowly, and they do not act as quickly as those required for immediate relief and are therefore not meant for emergencies. These drugs cause the following side effects: blurred vision, heart arrhythmias, an allergic reaction that includes swelling or a rash, dizziness, running nose, and stomach upsets.

Corticosteroids function by reducing inflammation, thus easing breathing by allowing free airflow into the lungs. They inhibit molecules that are associated with inflammation, such as chemokines, cytokines, adhesion molecules, and arachidonic acid metabolites. Many corticosteroids are available in the market; some are used as inhalers and are prescribed combined corticosteroids and long-acting bronchodilators. Some corticosteroids can be taken as tablets through the mouth, while others are injected and used as short-term drugs if COPD suddenly worsens (Guo et al.,2022). Side effects of these drugs include sore throat, nausea, and flu for fluticasone. Budesonide causes oral thrush and colds, and prednisolone causes weight gain, muscle weakness, stomach upsets, and headaches.

4. Identify two (2) “Evidence A” recommended non-pharmacological treatment options for this patient.

Non-pharmacological treatment of COPD includes interventions to improve the patient’s well-being without necessarily using drugs. They help the patient manage acute distress associated with breathing difficulties, become physically fit and make breathing less difficult. These include Regular physical activities such as cycling, walking, swimming, and jogging, which improve blood and oxygen circulation in the body and the patient’s quality of life. Additionally, exercise also improves the function of the heart muscles and cardiovascular system, thus lowering blood pressure. However, measures should be taken in patients with heart-related conditions and severe breathing difficulties.

Cessation of smoking. Smoking is a major cause of COPD; therefore, quitting is a good measure to prevent the condition from worsening. It can also reduce the chances of acquiring other infections that worsen COPD. Various strategies can be used to help the patient to stop smoking since it’s not easy. It includes drug therapy, such as nicotine use, and behavioral therapies. Behavioral therapy focuses on changing the patient’s mindset about their smoking urge. It focuses on learning the disadvantages of smoking and developing good alternative behavior. It also focuses on evaluating thought processes that are not helpful regarding smoking. The victim is taught about monitoring themselves, tolerating and changing negative thinking patterns.

Oxygen therapy is another non-pharmacological treatment option. In its late stages, COPD causes difficulties in breathing; therefore, supplemental oxygen is recommended. Oxygen concentrators and oxygen tanks can administer it. Oxygen concentrators are set up in a room, and oxygen is obtained and concentrated from the air. Oxygen tanks are portable, and the patient can easily move around. The use of oxygen relieves the muscles that are exhausted from strenuous breathing.

Another way is diet support. Patients suffering from COPD constantly lose a lot of weight, their muscles weaken with time, and eventually, they become physically unfit. Supplements that contain high calories are advisable, and the patients are also advised on routine weight check-ups. The patients should also watch out for excessive weight gain, which would render them unhealthy. Education programs for patients are another way to manage COPD. In these programs, patients are advised to take their medication well and use oxygen appropriately. The programs teach about some inhalation techniques and advise on preventing and managing acute respiratory illnesses. These programs also aim to educate the patient on how to tolerate this condition and live longer with it.

References

‘Lange, P., Ahmed, E., Lahmar, Z. M., Martinez, F. J., & Bourdin, A. (2021). Natural history and mechanisms of COPD. Respirology, 26(4), 298-321.

Guo, P., Li, R., Piao, T. H., Wang, C. L., Wu, X. L., & Cai, H. Y. (2022). Pathological mechanism and targeted drugs of COPD. International Journal of Chronic Obstructive Pulmonary Disease, 1565-1575.

MacLeod, M., Papi, A., Contoli, M., Beghé, B., Celli, B. R., Wedzicha, J. A., & Fabbri, L. M. (2021). Chronic obstructive pulmonary disease exacerbation fundamentals: Diagnosis, treatment, prevention and disease impact. Respirology, 26(6), 532-551.

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The purpose of this assignment is to apply pulmonary pathophysiological concepts to explain the assessment findings of a patient with respiratory disease. Students will examine all aspects of the patient’s assessment including Chief Complaint (CC), History of Present Illness (HPI), Past Medical History (PMH), Family History (FH), Social History (SH), Review of Systems (ROS), and Medications and then answer the questions that follow on the provided Comprehensive Case Study template.

Activity Learning Outcomes
Through this assignment, the student will demonstrate the ability to:

Examine the case scenario and analyze the spirometry results to determine the most likely respiratory diagnosis. (CO1)
Explain the pathophysiology of the respiratory disease. (CO1)
Differentiate between subjective and objective findings which support the chosen diagnosis. (CO4)
Apply evidence-based practice guidelines to classify the severity of the respiratory disorder and employ an appropriate treatment plan. (CO1, CO5)

A.C. is a 61-year-old male with complaints of shortness of breath.

History of Present Illness

A.C. was seen in the emergency room 1 week ago for an acute onset of mid-sternal chest pain. The event was preceded by complaints of fatigue and increasing dyspnea for 3 months, for which he did not seek care. He was evaluated by cardiology and underwent a successful and uneventful angioplasty prior to discharge. Despite the intervention, the shortness of breath has not improved. Since starting cardiac rehabilitation, he has felt that his breathlessness is worse. The cardiologist has requested that you, his primary care provider, evaluate him for further work-up. Prior to today, his last visit with your practice was 3 years ago when he was seen for acute bronchitis and smoking cessation counseling.

Past Medical History

Hypertension
Hyperlipidemia
Atherosclerotic coronary artery disease
Smoker
Family History

Father died of acute coronary syndrome at age 65
Mother died of breast cancer at age 58.
One sister, alive, is a 5-year breast cancer survivor.
One son and one daughter have no significant medical history.
Social History

35-pack-year smoking history; he has cut down to one cigarette at bedtime following his cardiac intervention.
Denies alcohol or recreational drug use
Real estate agent

Allergies

No Known Drug Allergies
Medications

Rosuvastatin 20 mg once daily by mouth
Carvedilol 25 mg twice daily by mouth
Hydrochlorothiazide 12.5 mg once daily by mouth
Aspirin 81mg daily by mouth
Review of Systems

Constitutional: Denies fever, chills or weight loss. + Fatigue.
HEENT: Denies nasal congestion, rhinorrhea or sore throat.
Chest: + dyspnea with exertion. Denies productive cough or wheezing. + Dry, nonproductive cough in the AM.
Heart: Denies chest pain, chest pressure or palpitations.
Lymph: Denies lymph node swelling.
General Physical Exam

Constitutional: Alert and oriented male in no apparent distress.
Vital Signs: BP-120/84, T-97.9 F, P-62, RR-22, SaO2: 93%
Wt. 180 lbs., Ht. 5’9″
HEENT

Eyes: Pupils are equal, round, and reactive to light and accommodation, with normal conjunctiva.
Ears: Tympanic membranes intact.
Nose: Bilateral nasal turbinates without redness or swelling. Nares patent.
Mouth: Oropharynx clear. No mouth lesions. Dentures well-fitting. Oral mucous membranes dry.
Neck/Lymph Nodes

Neck supple without JVD.
No lymphadenopathy, masses or carotid bruits.
Lungs

Bilateral breath sounds clear throughout lung fields. + Bilaterally wheezes were noted with forced exhalation along with a prolonged expiratory phase. No intercostal retractions.
Heart

S1 and S2 have regular rates and rhythms, with no rubs or murmurs.
Integumentary System

Skin cool, pale and dry. Nail beds pink without clubbing.
Chest X-Ray

Lungs are hyper-inflated bilaterally with a flattened diaphragm. No effusions or infiltrates.
Spirometry