1. At this point, can you think of at least two diagnoses? What is your most likely diagnosis?
Chronic bronchitis and emphysema with possible complication involving pneumonia.
2. Explain the main reasons for your diagnosis.
I picked out chronic bronchitis for a couple of reasons. One of the first things pointing me in that direction was that the patient has a history of COPD, which is commonly caused by chronic bronchitis. Along with that, his productive cough with grey sputum, heavy smoking history (30 pack-year), and shortness of breath while walking are all classic presentations of chronic bronchitis.
http://www.nhlbi.nih.gov/health/health-topics/topics/copd
I also considered emphysema as another possibility as part of his differential diagnosis. His difficulty breathing and heavy smoking history point to emphysema. His arterial blood gas (ABG) levels also show signs of respiratory acidosis (pH 7.17), which can be caused by the inability to properly expel air through ventilation, which is a common cause of emphesema.
The patient also has a fever, which, tied in with his other symptoms of coughing, shortness of breath, and lack of innoculation for pneumonia lead me to think that the patient may have pneumonia. Pneumonia is likely exacerbating his COPD.
http://www.mayoclinic.org/diseases-conditions/emphysema/basics/definition/con-20014218
3. How would you interpret his clinical picture? Hint: Use the GOLD criteria for COPD (Look this up)
GOLD criteria for COPD:
Stage III Severe COPD, FEV1/FVC <0.70, FEV1 30-49% normal
Patient's FEV1 is 35%, which puts him in Stage III Severe COPD.
http://www.webmd.com/lung/copd/gold-criteria-for-copd
4. In a patient with COPD, assessment of symptoms should include the following?
Severity of breathlessness
Sputum production
Wheezing
Weight loss/anorexia
All of the above
Answer: All of the above. Severity of breathlessness and wheezing are symptoms created by the lack of elastic fibers in his lungs. Sputum production can be indicative of the chronic bronchitis that is associated with COPD. The anorexia is linked with the loss of apetite common in patients with COPD. The weight loss, along with anorexia, has been linked to an increased basal metabolism caused by the extra work required for breathing in patients with COPD.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2695204/
5. Which of the following is the least likely cause of patient’s symptoms?
COPD exacerbation
Recurrent aspiration
Heart failure
Pneumonia
Asthma exacerbation
Asthma exacerbation is unlikely causing the patient's symptoms. The symptoms seemed to be more linked to his COPD, which is causing his heart failure. Those together likely explain most of the symptoms. Asthma was not reported and would have likely been caught earlier in life.
6. Which other further investigations do you think would be appropriate? Why? What results would you expect? What might be expected on this patient’s chest Xray?
Pulse oximetry
Spirometry
Alpha-1-antitrypsin level
None of the above
I think pulse oximetry and alpha-1-antitrypsin level would be appropriate. Pulse oximetry can be quickly done to check O2 saturation, checking whether the patient's COPD is interfering with his alveolar-capilary function. Alpha-1-antitrypsin levels test the level of the enzyme that protects elastic fibers from elastase. Low levels are indicative of emphysema and COPD, severity can be marked by the percentage. Springometry could be used in a healthier patient with COPD, but I would elect that JS not undergo the test because of his complications with pneumonia and the discomfort and inaccuracy of the test in his condition.
His lung X-ray would likely show an increased size of his chest, an elongated and narrowed heart, and flattening of his diaphragm.
http://www.webmd.com/lung/copd/chest-x-rays-for-chronic-obstructive-pulmonary-disease-copd
7. Does JS present with clinical factors that increase risk of severe COPD exacerbations? If so, can you list at least two?
Smoking and age.
8. What would be the best option to improve his symptoms and slow progression? Would you treat JS as an outpatient or inpatient? Explain your choices.
Continuing to not smoke is essential to minimize damage to the lungs. Inhaled steroids might be helpful remeding his shortness of breath. Continuing oxygen therapy would also likely be necessary due to his significantly reduced alveolar function. I would probably treat JS as an inpatient. His chest tightness and inability to speak in full sentences are very concerning.
9. Would you be concerned that the patient takes a beta blocker? Why? Advise the patient to stop taking the beta blocker? (Look it up)
There is hesitation among physicians with using beta blockers on patients with COPD. Beta blockers, which are for beta 1 receptors on the heart, are thought to nonspecifically bind to beta 2 receptors of the airway, which would result in the restriction of airflow and exacerbate the symptoms of COPD. However, research has also found that BB are "well tolerated in patients with cardiac disease and concomitant COPD with no evidence of worsening of respiratory symptoms or FEV1." Since the patient has a demonstrated need for BB, I would keep him on them.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2699954/
10. What do you think about the possibility of using non-invasive positive pressure ventilation (bi-level positive airway pressure or BiPAP) in this patient?
A BiPAP could be used in this patient.
JSs ABGs show: pH 7.17, PCO2 55, PO2 62, HCO3- 25 Patients respond well to BiPAPs when the patient has PaCO2 >45 or a pH <7.30. JS's lab results show that he is in both of these categories.
11. What is the main difference between bi-level positive airway pressure (BiPAP) and continuous positive airway pressure (CPAP)? What are the indications for using these different modes of non-invasive mechanical ventilation?
CPAP uses a continuous pressure throughout the breathing cycle to keep the airway open of a patient who is unable to breath on his/her own. It's often used for patients with sleep apnea, obesity, and premature infants.
https://www.nhlbi.nih.gov/health/health-topics/topics/cpap
BiPAP uses different pressures during inspiration and expiration, which is said to complement a patient's own breathing cycle.
https://www.ncbi.nlm.nih.gov/pubmed/11728761