Chronic obstructive pulmonary disease: A case report

Kanwaljeet Kaur*, J. Santhi

Nurse Educator, Kauvery Hospital, Chennai

Nursing Director, Kauvery Hospital, Chennai

*Correspondence: +91 62395 99787;[email protected]

Abstract

Chronic obstructive pulmonary disease (COPD), a common preventable and treatable disease, presents itself as persistent airflow limitation that is usually progressive and is caused by an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. COPD is a major cause of morbidity and mortality worldwide and results in an economic and social burden that is both substantial and increasing. Chronic obstructive pulmonary disease (COPD) is the third leading cause of death worldwide, causing 3.23 million deaths in 2019. Nearly 90% of COPD deaths in those under 70 years of age occur in low- and middle-income countries (LMIC). Early diagnosis and treatment, including smoking cessation support, is are needed to slow the progression of symptoms and reduce flare-ups. Environmental exposure to tobacco smoke, indoor air pollution and occupational dustsdust, fumes and chemicals are important risk factors for COPD. COPD prevalence, morbidity and mortality vary across countries. The natural history of COPD is punctuated by exacerbations which have major implications for the patient and healthcare system. In this review, we provide a concise overview of COPD exacerbations and their impact, outlining the population at risk, etiology and current management and preventive strategies.

Case Presentation

Mr. K was an 80-year-old male patient who was a chronic smoker who consumed 2 packs of cigarettes per day for 40 years and stopped smoking since in last 2-3 years. He came to emergency department with complaints of shortness of breath that got worsened from grade 3 to grade 4, cough with expectoration and palpitations. He was referred by an outside hospital. Patient had history of diabetes and hypertension for 4-5 years and had undergone B/L cataract surgery.

In the emergency department, the patient had B/L wheeze on auscultation and type 2 respiratory failure. Patient The patient was given nebulization, Iinjection. Lasix 40 mg and injection hydrocortisone and shifted to the intensive care unit for further management.

On arrival at ICU, the patient was conscious, oriented, afebrile, tachypneic and dyspneic.

B/L pitting edema was present, HR:- 96 bpm, BP:- 180/80 mmHg, SpO2: 90% on 4 liters L oxygen via nasal prongs.

Respiratory system

Bilateral normal vesicular breath sounds, decreased in intensity, with bilateral wheeze.

Other system examinations: Normal

Based on examination findings and the history of smoking by the patient, a provisional diagnosis of COPD exacerbation was made. The patient was put on NIV, nebulization with bronchodilators, systemic steroids, antibiotics, DVT prophylaxis and stress ulcer prophylaxis.

X-ray chest revealed bilateral hyperinflated lung fields and CT-chest was done which showed B/L emphysematous changes. Serial ABGs showed gradual improvement in Type II respiratory failure. The patient was then shifted to ward on nocturnal BIPAP.

ABG report

Value Units 11/9/22 12/9/22
pH 7.40 7.40
pCO2 mmHg 64 65
pO2 mmHg 98 177
HCO3 mmol/L 33.9 34.4
Parameters Units  3/9/22
Urea mg/dl 22.9
Creatine mg/dl 0.51
K+ mmol/L 3.89
Chloride mmol/L 76.4
Hco3 mmol/L 32.2
Uric acid mg/dl 2.47
Bilirubin-total mg/dl 0.71
Bilirubin-D mg/dl 0.36
Bilirubin-1 mg/dl 0.35
SGOT U/L 43.5
SGPT U/L 36.2
T- Protein g/dl 7.43
Albumin g/dl 4.19
Globulin g/dl 3.24
Calcium mg/dl 8.20
Alkaline phosphate U/L 105.6
Phosphorus mg/dl 2.83
Date 3/9 4/9 6/9 10/9
Na(mmol/L) 118 121 135 145
Parameters Units 3/9/22 10/9/22
Hb g/dl 14.1 13.4
Hematocrit % 44.2 41.7
WBC Cells/cumm 16800 14100
Platelet count Cells/cumm 315000 208000
Neutrophil % 78.0 71.2
Lymphocyte % 11.7 20.4
Monocyte % 8.6 7.7
Basophil % 1.6 0.5

Patient’s medications

Drug name Drug class
Inj. Meropenem 1gm IV TDS Antibiotic (carbapenems)
Inj. Fragmin 5000IU S/C OD Anticoagulant
Neb. Duolin1.25/500mcg

(Levo-salbutamol + Ipratropium)

 Bronchodilator + anticholinergic
Inj. Hydrocortisone 50mg IV TDS Corticosteroid
T. Pantoprazole 40mg PO BD Proton-pump-inhibitor
T. Amlodipine 10mg PO OD antihypertensive
Inj. Polymyxin 7.5mg BD Antibiotic (polymyxins)
Ensure protein powder Protein supplement

Discussion

COPD/chronic obstructive pulmonary disease is a chronic inflammatory lung disease in which airflow from the lungs becomes obstructed. Emphysema and chronic bronchitis are the conditions that contribute to COPD. Both these conditions occur together and the severity of the disease varies from individual to individual. Chronic bronchitis is inflammation of the bronchi and is characterised by cough and increased mucus production. Emphysema is a chronic disease in which the alveoli of the lungs are destroyed due to long exposure to cigarette smoking and other types of smoke. It is a progressive disease but it is preventable.

Causes

The cause of COPD in developed countries is tobacco and in developing countries, it is smoke from burning fuel.

Chronic untreated asthma also can lead to COPD

Lack of alpha 1 antitrypsin protein is responsible for COPD as well

Symptoms

Shortness of breath, especially during activity, wheezing, chest tightness, chronic cough, mostly with sputum, fatigue, ankle oedema.

Diagnosis

Spirometry is a non-invasive test to assess lung function and it will show obstruction. Arterial blood gases test will show CO2 retention. Chest X-ray and CT chest scan reveal emphysematous changes. Laboratory tests can reveal other conditions like alpha-1-antitrypsin (AAT) deficiency.

Treatment

With treatment we can slow down the progression of the disease and we can prevent complications as well

COPD is mainly managed by medical management but as the last treatment option, in severe COPD cases, surgery can also be considered.

Medical management

Medications can reduce symptoms and cut down on flare-ups.

  1. Bronchodilators: The mechanism of action of bronchodilators includes targeting the beta-2 receptor, which is a G-protein coupled receptor, in the lung airways. When the beta-2 receptor is activated, the smooth muscle of the airway relaxes. Subsequently, the patient experiences better airflow for a period.
  2. Corticosteroids: it helps in the reduction of airway inflammation, and suppress the immune response.
  3. Some combination nebulization respules are available in the market. So, those nebulisations can be prescribed for patients instead of giving separate nebulizers for bronchodilation and for addressing inflammation.
  4. Antibiotics: these drugs are given to treat the associated respiratory bacterial infections.
  5. Oxygen therapy: this is needed to reduce shortness of breath and hypoxia. It can be supplemented by nasal prongs, venturi mask or NIV depending on the severity of the illness. For COPD patient target SpO2 is 88-92%.

Surgical management

In severe COPD case, surgery is required. So, we have 3 different types of surgeries.

  1. Bullectomy: Here, large bullae are removed thereby allowing better functioning of the remaining normal lung parenchyma.
  2. Lung volume reduction surgery: In this, diseased lung tissue is removed.
  3. Lung transplant: The replacement of a diseased lung with a healthy one is called a lung transplant.

Complications

COPD can be associated with complications like dysrhythmias, respiratory infections, lung cancer, pulmonary artery hypertension, osteoporosis, sarcopenia and depression.

Health education to COPD patients after discharge

It is impossible to cure COPD, but we can slow the progression of the disease by following measures:

  1. Smoking cessation is quite helpful in achieving that. This is the single most cost-effective intervention to reduce the risk of developing COPD and stop its progression.
  2. One must avoid exposure to smoke and dust.
  3. We must educate the patients to take the medications properly as compliance with inhalers and nebulization is important.
  4. To come for follow-up as per doctor’s orders.
  5. To do breathing exercises and to eat a healthy diet.
  6. To get influenza and pneumococcal vaccines.

Nursing management

For COPD patients, nursing management is focused on improving the respiratory status of patients.

Nurses have to assess the patient for

  1. Signs and symptoms of COPD
  2. Exposure to risk factors
  3. Knowledge of the disease
  4. Alterations in vital signs
  5. Breath sounds and breathing pattern
  1. Nursing diagnosis
  2. Impaired gas exchange due to disease process.
  3. Ineffective airway clearance related to bronchoconstriction and increased mucus production.
  4. Self-care deficit related to fatigue.
  5. Activity intolerance related to hypoxemia.

Nursing care

    To achieve airway clearance

  1. The nurse must appropriately administer bronchodilators and corticosteroids and has to be aware of potential side effects.
  2. Direct or controlled coughing- The nurse instructs the patient in direct or controlled coughing, which is more effective and reduces fatigue associated with undirected forceful coughing.
    To improve breathing pattern:

  1. Inspiratory muscle training: This may help improve the breathing pattern.
  2. Diaphragmatic breathing: Diaphragmatic breathing reduces respiratory rate, increases alveolar ventilation, and sometimes helps expel as much air as possible during expiration.
  3. Pursed lip breathing- Pursed lip breathing helps slow expiration, prevents the collapse of small airways, and controls the rate and depth of respiration.

To improve activity intolerance:

    1. Manage daily activities: Daily activities must be paced throughout the day and support devices can be also used to decrease energy expenditure.

Exercise training: Exercise training can help strengthen muscles of the upper and lower extremities and improve exercise tolerance and endurance. Walking aids: Use of walking aids may be recommended to improve activity levels and ambulation.

To monitor and manage potential complications:

  1. Monitor cognitive changes: The nurse should monitor for cognitive changes such as personality and behaviour changes and memory impairment.
  2. Monitor pulse oximetry values: Pulse oximetry values are used to assess the patient’s need for oxygen and administer supplemental oxygen as prescribed.
  3. Prevent infection: The nurse should encourage the patient to be immunized against influenza and streptococcal pneumonia because the patient is prone to respiratory infection.

Conclusion

Chronic obstructive pulmonary disease is a chronic inflammatory lung disease in which airflow from the lungs becomes obstructed. Emphysema and chronic bronchitis are 2 contributing conditions for COPD. Chronic obstructive pulmonary disease (COPD) is the third leading cause of death worldwide, causing 3.23 million deaths in 2019. With treatment, we can slow down the progression of the disease and we can prevent complications as well. COPD is mainly managed by medical management but as the last treatment option, in severe COPD cases, surgery can also be opted.

References

  1. Cleveland clinic, Chronic Obstructive Pulmonary Disease (COPD), (online) Available from https://my.clevelandclinic.org/health/diseases/8709-chronic-obstructive-pulmonary-disease-copd.
  2. World health organisation, factsheet on Chronic obstructive pulmonary disease (COPD),(online)https://www.who.int/news-room/fact-sheets/detail/chronic-obstructive-pulmonary-disease-(copd)
  3. Brusselle GG, Humbert M. Classification of COPD: fostering prevention and precision medicine in the Lancet Commission on COPD. Lancet 2022;400(10356):P869-871. EDITORIAL. COPD: from an end-stage disease to lifelong lung health. Lancet 2022; 400(10356):P863.
  4. Woodward RB. Dying of a disease I never knew existed. 2022.https://www.bostonglobe.com/2022/08/12/opinion/dying-disease-i-never-knew-existed/
  5. Daiana Stolz, et al. Towards the elimination of chronic obstructive pulmonary disease: a Lancet Commission. Lancet Comm 2022;400(10356):P921-972.
Ms. Kanwaljeet Kaur

Ms. Kanwaljeet Kaur

Nurse Educator

J. Santhi

J. Santhi

Nursing Director

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