Chronic obstructive pulmonary disease (COPD) is a progressive lung disease that affects millions of people around the world. It is primarily caused by smoking and is characterized by a persistent obstruction of airflow that worsens over time.
COPD can lead to a range of symptoms, including coughing, wheezing, shortness of breath, and chest tightness, which can significantly impact a person’s quality of life.
This case study will review the diagnosis and treatment of an adult patient who presented with signs and symptoms of this condition.
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COPD Clinical Scenario
A 56-year-old male patient is in the ER with increased work of breathing. He felt mildly short of breath after waking this morning but became extremely dyspneic after climbing a few flights of stairs. He is even too short of breath to finish full sentences. His wife is present in the room and revealed that the patient has a history of liver failure, is allergic to penicillin, and has a 15-pack-year smoking history. She also stated that he builds cabinets for a living and is constantly required to work around a lot of fine dust and debris.
On physical examination, the patient showed the following signs and symptoms:
- His pupils are equal and reactive to light.
- He is alert and oriented.
- He is breathing through pursed lips.
- His trachea is positioned in the midline, and no jugular venous distention is present.
- Heart rate: 92 beats/min
- SpO2: 84%
- Respiratory rate: 22 breaths/min
- He has a larger-than-normal anterior-posterior chest diameter.
- He demonstrates bilateral chest expansion.
- He demonstrates a prolonged expiratory phase and diminished breath sounds during auscultation.
- He is showing signs of subcostal retractions.
- Chest palpation reveals no tactile fremitus.
- Chest percussion reveals increased resonance.
- His abdomen is soft and tender.
- No distention is present.
- His capillary refill time is two seconds.
- Digital clubbing is present in his fingertips.
- There are no signs of pedal edema.
- His skin appears to have a yellow tint.
Lab and Radiology Results
- ABG results: pH 7.35 mmHg, PaCO2 59 mmHg, HCO3 30 mEq/L, and PaO2 64 mmHg.
- Chest x-ray: Flat diaphragm, increased retrosternal space, dark lung fields, slight hypertrophy of the right ventricle, and a narrow heart.
- Blood work: RBC 6.5 mill/m3, Hb 19 g/100 mL, and Hct 57%.
Based on the information given, the patient likely has chronic obstructive pulmonary disease (COPD).
The key findings that point to this diagnosis include:
- Barrel chest
- A long expiratory time
- Diminished breath sounds
- Use of accessory muscles while breathing
- Digital clubbing
- Pursed lip breathing
- History of smoking
- Exposure to dust from work
What Findings are Relevant to the Patient’s COPD Diagnosis?
The patient’s chest x-ray showed classic signs of chronic COPD, which include hyperexpansion, dark lung fields, and a narrow heart.
This patient does not have a history of cor pulmonale; however, the findings revealed hypertrophy of the right ventricle. This is something that should be further investigated as right-sided heart failure is common in patients with COPD.
The lab values that suggest the patient has COPD include increased RBC, Hct, and Hb levels, which are signs of chronic hypoxemia.
Furthermore, the patient’s ABG results indicate COPD is present because the interpretation reveals compensated respiratory acidosis with mild hypoxemia. Compensated blood gases indicate an issue that has been present for an extended period of time.
What Tests Could Further Support This Diagnosis?
A series of pulmonary function tests (PFT) would be useful for assessing the patient’s lung volumes and capacities. This would help confirm the diagnosis of COPD and inform you of the severity.
Note: COPD patients typically have an FEV1/FVC ratio of < 70%, with an FEV1 that is < 80%.
The initial treatment for this patient should involve the administration of low-flow oxygen to treat or prevent hypoxemia.
It’s acceptable to start with a nasal cannula at 1-2 L/min. However, it’s often recommended to use an air-entrainment mask on COPD patients in order to provide an exact FiO2.
Either way, you should start with the lowest possible FiO2 that can maintain adequate oxygenation and titrate based on the patient’s response.
Example: Let’s say you start the patient with an FiO2 of 28% via air-entrainment mask but increase it to 32% due to no improvement. The SpO2 originally was 84% but now has decreased to 80%, and his retractions are worsening. This patient is sitting in the tripod position and continues to demonstrate pursed-lip breathing. Another blood gas was collected, and the results show a PaCO2 of 65 mmHg and a PaO2 of 59 mmHg.
What Do You Recommend?
The patient has an increased work of breathing, and their condition is clearly getting worse. The latest ABG results confirmed this with an increased PaCO2 and a PaO2 that is decreasing.
This indicates that the patient needs further assistance with both ventilation and oxygenation.
Note: In general, mechanical ventilation should be avoided in patients with COPD (if possible) because they are often difficult to wean from the machine.
Therefore, at this time, the most appropriate treatment method is noninvasive ventilation (e.g., BiPAP).
Initial BiPAP Settings
In general, the most commonly recommended initial BiPAP settings for an adult patient include this following:
- IPAP: 8–12 cmH2O
- EPAP: 5–8 cmH2O
- Rate: 10–12 breaths/min
- FiO2: Whatever they were previously on
For example, let’s say you initiate BiPAP with an IPAP of 10 cmH20, an EPAP of 5 cmH2O, a rate of 12, and an FiO2 of 32% (since that is what he was previously getting).
After 30 minutes on the machine, the physician requested another ABG to be drawn, which revealed acute respiratory acidosis with mild hypoxemia.
What Adjustments to BiPAP Settings Would You Recommend?
The latest ABG results indicate that two parameters must be corrected:
- Increased PaCO2
- Decreased PaO2
You can address the PaO2 by increasing either the FiO2 or EPAP setting. EPAP functions as PEEP, which is effective in increasing oxygenation.
The PaCO2 can be lowered by increasing the IPAP setting. By doing so, it helps to increase the patient’s tidal volume, which increased their expired CO2.
Note: In general, when making adjustments to a patient’s BiPAP settings, it’s acceptable to increase the pressure in increments of 2 cmH2O and the FiO2 setting in 5% increments.
To improve the patient’s oxygenation, you can increase the EPAP setting to 7 cmH2O. This would decrease the pressure support by 2 cmH2O because it’s essentially the difference between the IPAP and EPAP.
Therefore, if you increase the EPAP, you must also increase the IPAP by the same amount to maintain the same pressure support level.
However, this patient also has an increased PaCO2, which means that you must increase the IPAP setting to blow off more CO2. Therefore, you can adjust the pressure settings on the machine as follows:
- IPAP: 14 cmH2O
- EPAP: 7 cmH2O
After making these changes and performing an assessment, you can see that the patient’s condition is improving.
Two days later, the patient has been successfully weaned off the BiPAP machine and no longer needs oxygen support. He is now ready to be discharged.
The doctor wants you to recommend home therapy and treatment modalities that could benefit this patient.
What Home Therapy Would You Recommend?
You can recommend home oxygen therapy if the patient’s PaO2 drops below 55 mmHg or their SpO2 drops below 88% more than twice in a three-week period.
Remember: You must use a conservative approach when administering oxygen to a patient with COPD.
You may also consider the following pharmacological agents:
- Short-acting bronchodilators (e.g., Albuterol)
- Long-acting bronchodilators (e.g., Formoterol)
- Anticholinergic agents (e.g., Ipratropium bromide)
- Inhaled corticosteroids (e.g., Budesonide)
- Methylxanthine agents (e.g., Theophylline)
In addition, education on smoking cessation is also important for patients who smoke. Nicotine replacement therapy may also be indicated.
In some cases, bronchial hygiene therapy should be recommended to help with secretion clearance (e.g., positive expiratory pressure (PEP) therapy).
It’s also important to instruct the patient to stay active, maintain a healthy diet, avoid infections, and get an annual flu vaccine. Lastly, some COPD patients may benefit from cardiopulmonary rehabilitation.
By taking all of these factors into consideration, you can better manage this patient’s COPD and improve their quality of life.
There are two key points to remember when treating a patient with COPD. First, you must always be mindful of the amount of oxygen being delivered to keep the FiO2 as low as possible.
Second, you should use noninvasive ventilation, if possible, before performing intubation and conventional mechanical ventilation. Too much oxygen can knock out the patient’s drive to breathe, and once intubated, these patients can be difficult to wean from the ventilator.
Furthermore, once the patient is ready to be discharged, you must ensure that you are sending them home with the proper medications and home treatments to avoid readmission.
Hopefully, this case study has given you a better understanding of COPD and the interventions that are used to treat it. Thanks for reading, and, as always, breathe easy, my friend.
John Landry is a registered respiratory therapist from Memphis, TN, and has a bachelor's degree in kinesiology. He enjoys using evidence-based research to help others breathe easier and live a healthier life.
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