COPD Case Study: Patient Diagnosis and Treatment (2025)

Chronic obstructive pulmonary disease (COPD) is a progressive lung condition affecting millions worldwide, primarily linked to smoking. It is marked by a persistent reduction in airflow that gradually worsens, making it increasingly difficult to breathe.

Common symptoms of COPD include chronic coughing, wheezing, shortness of breath, and chest tightness, all of which can severely affect an individual’s daily life and overall well-being.

This case study explores the diagnosis and treatment of an adult patient presenting with classic signs and symptoms of COPD, providing insight into effective management strategies for this challenging condition.

COPD Clinical Scenario

A 56-year-old male presents to the ER with increased work of breathing. He reported feeling mildly short of breath upon waking, which worsened significantly after climbing several flights of stairs. Upon arrival, the patient was unable to speak in full sentences due to severe dyspnea. His wife, accompanying him, disclosed that he has a history of liver failure, is allergic to penicillin, and has a 15-pack-year smoking history. She also mentioned that he works as a cabinet maker, frequently exposed to fine dust and debris in his workplace.

Physical Findings

HEENT

• Pupils equal and reactive to light
• Alert and oriented
• Breathing through pursed lips
• Trachea midline, no jugular venous distention

Vital Signs

• Heart rate: 92 beats/min
• SpO2: 84%
• Respiratory rate: 22 breaths/min

Chest Assessment

• Increased anterior-posterior chest diameter (barrel chest)
• Bilateral chest expansion present
• Prolonged expiratory phase with diminished breath sounds upon auscultation
• Subcostal retractions observed
• No tactile fremitus on chest palpation
• Chest percussion reveals increased resonance

Abdomen

• Abdomen soft and non-tender
• No distention

Extremities

• Capillary refill time: 2 seconds
• Digital clubbing observed in fingertips
• No pedal edema
• Skin appears jaundiced

ABG Results

• pH: 7.35
• PaCO2: 59 mmHg
• HCO3: 30 mEq/L
• PaO2: 64 mmHg

Chest X-ray

• Flattened diaphragm
• Increased retrosternal air space
• Dark lung fields
• Slight right ventricular hypertrophy
• Narrow heart silhouette

Blood Work

• RBC: 6.5 million/mm³
• Hb: 19 g/dL
• Hct: 57%

Diagnosis

Based on the clinical presentation, lab results, and radiology findings, the patient is highly likely to have chronic obstructive pulmonary disease (COPD).

Key indicators supporting this diagnosis include:

• Barrel-shaped chest
• Tachypnea with prolonged expiratory time
• Diminished breath sounds
• Use of accessory muscles during breathing
• Digital clubbing
• Pursed-lip breathing
• History of significant smoking exposure
• Occupational exposure to dust

Note: These findings are consistent with advanced COPD, requiring immediate intervention to manage symptoms and prevent further progression.

Treatment

The primary goal of initial treatment for this patient is to correct hypoxemia while minimizing the risk of oxygen-induced hypercapnia, a concern in patients with COPD. The use of low-flow oxygen is recommended to carefully manage oxygen levels.

It’s acceptable to begin with a nasal cannula at 1–2 L/min, but it’s often more precise to use an air-entrainment mask for COPD patients, as it delivers an exact FiO2.

Regardless of the method, oxygen therapy should always start with the lowest possible FiO2 that maintains adequate oxygenation, adjusting as needed based on the patient’s response.

Example Scenario

Suppose you initiate oxygen therapy with an FiO2 of 28% using an air-entrainment mask, but after no improvement, you increase it to 32%. Initially, the patient’s SpO2 was 84%, but it has now dropped to 80%, with worsening retractions. The patient remains in a tripod position, showing signs of increased respiratory effort, including pursed-lip breathing. A repeat arterial blood gas (ABG) reveals a PaCO2 of 65 mmHg and a PaO2 of 59 mmHg.

Recommended Next Steps

The patient is exhibiting increasing signs of respiratory distress, with a rising PaCO2 and worsening hypoxemia despite supplemental oxygen. These ABG results confirm that the patient requires additional support for both ventilation and oxygenation.

Although mechanical ventilation is generally avoided in COPD patients due to the difficulty of weaning them off, noninvasive ventilation (NIV), such as BiPAP, is the most appropriate intervention at this point.

BiPAP provides ventilatory assistance while avoiding the need for intubation, helping to improve both oxygenation and carbon dioxide removal.

Note: By applying noninvasive ventilation, you can reduce the patient’s work of breathing, improve gas exchange, and hopefully prevent further deterioration without the complications associated with mechanical ventilation.

Initial BiPAP Settings

For adult patients, the most commonly recommended initial BiPAP settings are as follows:

• IPAP (Inspiratory Positive Airway Pressure): 8–12 cmH2O
• EPAP (Expiratory Positive Airway Pressure): 5–8 cmH2O
• Rate: 10–12 breaths per minute
• FiO2: Based on the patient’s previous oxygen requirements

For instance, in this case, you could initiate BiPAP with the following settings:

• IPAP: 10 cmH2O
• EPAP: 5 cmH2O
• Rate: 12 breaths/min
• FiO2: 32%, matching the previous oxygen level.

Adjusting BiPAP Based on ABG Results

After 30 minutes on BiPAP, an arterial blood gas (ABG) analysis shows acute respiratory acidosis with mild hypoxemia.

This indicates two issues:

• Elevated PaCO2 (carbon dioxide retention)
• Decreased PaO2 (low oxygen levels)

Recommended BiPAP Adjustments

Improving Oxygenation

To increase the patient’s PaO2, you can adjust either the FiO2 or EPAP. Since EPAP functions like PEEP (positive end-expiratory pressure), increasing it will improve oxygenation by preventing alveolar collapse.

Recommendation: Increase the EPAP from 5 cmH2O to 7 cmH2O, which will help boost oxygenation.

Since EPAP and IPAP together determine pressure support (the difference between them), increasing EPAP without changing IPAP will reduce the pressure support, which could affect ventilation.

To maintain the same pressure support, it’s important to increase IPAP by the same amount as EPAP.

Improving Ventilation

To address the high PaCO2, the focus should be on increasing IPAP. This will enhance the patient’s tidal volume and, in turn, help to blow off more CO2.

Recommendation: Increase the IPAP to 14 cmH2O. This adjustment will improve ventilation, allowing the patient to exhale more CO2 and bring the PaCO2 down.

Final BiPAP Settings After Adjustment:

• IPAP: 14 cmH2O
• EPAP: 7 cmH2O
• Rate: 12 breaths/min
• FiO2: 32%

After making these changes, reassess the patient’s condition. In this scenario, the patient’s ABG and clinical signs should improve, indicating more effective ventilation and oxygenation.

Patient Outcome and Discharge

Two days later, the patient’s condition has improved significantly, and they have successfully been weaned off BiPAP.

Their oxygenation has stabilized, and they no longer require supplemental oxygen. The patient is now ready for discharge.

Home Therapy and Treatment Recommendations

For patients with COPD, home oxygen therapy may be recommended if their PaO2 falls below 55 mmHg or if their SpO2 drops below 88% on more than two occasions within a three-week period.

However, it’s essential to take a conservative approach when administering oxygen therapy to COPD patients to avoid oxygen-induced hypercapnia.

Pharmacological Recommendations

The following pharmacological agents can be considered for long-term management of COPD:

• Short-acting bronchodilators (e.g., Albuterol): Useful for quick relief of acute symptoms.
• Long-acting bronchodilators (e.g., Formoterol): Help maintain airway patency over time, reducing the frequency of exacerbations.
• Anticholinergic agents (e.g., Ipratropium bromide): These provide sustained bronchodilation, especially useful in combination with bronchodilators.
• Inhaled corticosteroids (e.g., Budesonide):  Help reduce airway inflammation and decrease the frequency of flare-ups.
• Methylxanthine agents (e.g., Theophylline): Can be used in cases where other therapies are insufficient, though close monitoring is needed due to potential side effects.

Additional Recommendations

• Smoking cessation support: For patients who smoke, quitting is critical. Smoking cessation programs and nicotine replacement therapy can be very effective.
• Bronchial hygiene therapy: To help with secretion clearance, recommend therapies such as positive expiratory pressure (PEP) therapy or other airway clearance techniques.
• Physical activity and diet: Encourage the patient to stay active, as regular exercise improves lung function and overall health. A balanced, healthy diet can also support their recovery and energy levels.
• Infection prevention: Stress the importance of avoiding infections, particularly respiratory infections. The patient should get an annual flu vaccine and possibly a pneumonia vaccine.
• Cardiopulmonary rehabilitation: Some patients may benefit from a structured rehabilitation program that includes supervised exercise and education to improve breathing techniques and physical endurance.

Note: By incorporating these home therapies and lifestyle modifications, the patient’s COPD can be better managed, helping to prevent exacerbations and significantly improve their quality of life.

Final Thoughts

When treating a patient with COPD, there are two essential principles to keep in mind:

• Oxygen management: Always be cautious with the amount of oxygen administered, aiming to keep the FiO2 as low as possible to maintain adequate oxygenation without suppressing the patient’s drive to breathe.
• Noninvasive ventilation preference: Whenever feasible, opt for noninvasive ventilation (e.g., BiPAP) before resorting to intubation and conventional mechanical ventilation. Intubation can lead to prolonged ventilator dependence, making it more challenging to wean COPD patients.

Additionally, as the patient approaches discharge, it’s crucial to ensure they leave with the appropriate medications and home treatments to minimize the risk of readmission.

Proper management at home—including oxygen therapy, bronchodilators, and pulmonary rehabilitation—can greatly improve outcomes. By considering these key points, you can effectively manage COPD and help improve your patient’s quality of life.