Question

Case Presentation

Miguel is a 63 year male patient who presented to the emergency department complaining of a week history of progressive dyspnea, wheezing and productive cough with whitish phlegm. He denies any recent cold or flu-like symptoms. Miguel also denies any fever or chills. He has been using his Ventolin MDI but symptoms are worsening. On assessment you noted that the client developed severe dyspnea with exertion. He was assuming a tripod position and became pale and diaphoretic with movement. He presented with 2-3 word dyspnea.

Past Medical History

 _Diagnosed with COPD for 8 years

 _Hypertension

 _Smokes cigarette 1.5 pack/day for 25 years

 _Reduce to about 5 cigarettes per day

Medications

 _Salbutamol MDI 4 inhalations every 4-8 hours PRN

 _Ipatropium bromide MDI 2 inhalations QID

Physical examination findings Vital Signs
Blood pressure	178/90
Pulse	110
Respirations	36 laboured & shallow
Temperature	36.2 0C
SaO2	80% on room air

Skin & mucous membranes

 _diaphoretic

 _Cool & clammy to touch

Respiratory

 _2-3 words dyspnea

 _Use of accessory muscles at rest

 _“Barrel chest” appearance

 _Poor breath sounds bilaterally

 _Productive cough with whitish phelgm

 _Purse lip breathing with prolonged expiration

Cardiovascular

 _Heart sounds are normal

 _tachycardia

Extremities

 _peripheral pulses 2+ bilaterally in all extremities

 _clubbing

 _cyanotic nail beds

 _+2 bilateral pitting edemae

Gastrointestinal

_no nausea & vomiting

 _abdominal distention

 _anorexia & weight loss

Laboratory Results Tests	Results	Normal value
White blood cell count	11.0 × 109 /L	4.0-10.0 × 109 /L
Reb blood cell	6.4 X 1012/L	4.0 – 5.2 X 1012/L
Serum sodium	148 mmol/L	135-145 mmol/L
Serum chloride	110 mmol/L	98 – 106 mmol/L
Serum potassium	3.8 mmol/L	3.5-5.0 mmol/L
Blood urea nitrogen (BUN)	7.0 mmol/L	2.5-8.0 mmol/L

Chest X-ray

 _hyperinflated lungs with a flattened diaphragm

 _large anterior posterior diameter

Pulmonary Function Tests (PFTs)

 _increased residual volume and total lung capacity

 _decreased forced expiratory volume and vital capacity.

Diagnosis

Miguel was diagnosed with acute COPD exacerbation. He was ordered the following medications:

 _salbutamol (Ventolin®) 5 mg q1hr PRN by nebulizer

 _Ipatropium bromide (Atrovent®) 500 mcg by nebulizer PRN (max. 3 doses)

 _Prednisone 50 mg po X 3 days

Discussion Question:

Explain in detail why expiration is significantly impaired and an increased residual volume was noted in Miguel

Answer 1

Miguel is suffered with obstructive disease and the detail of this is given below :

The definition of obstructive disease is lung disease with impaired expiration. It presents with decreased FVC, decreased FEV1, and most notably, a dramatic decrease in FEV1/FVC. In obstructive disease, the air that should be expired is not, which leads to air trapping and an increased FRC.

1. Asthma: a multifactorial disease characterized by chronic bronchial inflammation leading to eventual air trapping. Several key characteristics are as follows.

(a) Airway disease is mostly reversible (i.e., with the administration of a beta-agonist).

(b)Can cause chronic cough, wheeze, tachypnea, and dyspnea.

2. Chronic obstructive pulmonary disorder (COPD): a constellation of clinical symptoms that share features of both emphysema and chronic bronchitis leading to expiratory airflow limitation.

(a) Chronic bronchitis demonstrates long-term airway inflammation causing excessive cough and sputum production.

(b) Emphysema characteristically shows enlarged airspaces (loss of alveolar elasticity) leading to chronic dyspnea. The overly-distended airspaces prevent the lungs from adequately emptying.

(c) Smoking is the primary cause of the disease and is directly related to the severity of the disease course.

(d) Cigarettes induce inflammation in the lungs.

(e) Airways show small airway disease and parenchymal destruction.

And increased residual volume was noted because :

1. The residual volume (RV) is the amount of air that is left after expiratory reserve volume is exhaled. The lungs are never completely empty; there is always some air left in the lungs after a maximal exhalation.

2. Residual volume is also important for preventing large fluctuations in respiratory gases (O2 and CO2).

but Lung volumes depend on body size, especially height. Total lung capacity (TLC) corrected for age remains unchanged throughout life. Functional residual capacity and residual volume increase with age, resulting in a lower vital capacity. Gas exchange in the lungs occurs across the alveolar capillary membrane.

so due to age (mainly) this increased residual volume was noted.