62 year old man with a cough! Dr. Aflah Sadikeen Consultant Respiratory Physician Colombo
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1 62 year old man with a cough! Dr. Aflah Sadikeen Consultant Respiratory Physician Colombo
2 History Mr.KS, a 62 year-old, has been feeling unwell - Worsening cough for the last 5 days - Feels out of breath and wheezing more - Denies any chest pain or fever - Acknowledges that he feels his chest is heavy He has a productive cough for 8m and has produced yellow sputum on three occasions. Each time treated with antibiotics His wife accompanies him and says he has become too breathless, at times to get to his room upstairs
3 History PMH: Type 2 Diabetes, HTN and admitted a month ago with chest infection. Nebulized twice by the GP Current Meds: Salbutamol 100 micrograms MDI, 2 puffs when required upto 4 times daily Metformin 1g bd, Gliclazide 40mg bd, Losartan 50mg od Social Hx: Retired 2 years ago after working as a factory storekeeper. Smoker, 10 cigarettes per day over the last 25 yrs and gave up alcohol around 5 years ago Has a dog and a cat at home for the last 2 yrs
4 Examination General and Cardiac Not cyanosed and not pale. Presence of Pitting ankle edema Unable to assess the JVP BP 130/70, Pulse rate 110 / min and irregularly irregular No murmurs Chest Respiratory rate 22 / min SpO₂ - 88% on air Use of accessory muscles Auscultation wide spread wheezing and crackles predominant on both lower zone
5 1. What are the possibilities for his Acute presentation? a. LVF with AF b. Lower Respiratory Tract infection with AF c. Exacerbation of Chronic lung disease with AF d. ACS and AF precipitated by LRTI e. All of above
6 Initial management Initial resuscitation done O₂ via venturi facemask O₂ driven Nebulisation Salbutamol 2.5mg and Ipravent 0.5mg IV hydrocortisone 200mg? IV Frusemide 40mg Re-assurance Close monitoring vital parameters - SpO₂ 94% ECG Intermittent AF resolved on the repeat ECG with no ischemic changes Patient stressed that he is better and now stable enough to go home with antibiotics Planned for CXR and bloods for further assessment as out patient after prescribing oral Co-Amoxyclav
7 The different types of Mr.KS s cough The 2 different types of cough Acute cough Chronic cough
8 Is it important to differentiate the type Acute Cough of cough? - Last for less than three weeks - Causes for acute are common cold, URTI, exacerbation of asthma or COPD, - LRTI, bronchiectasis, pneumonia can usually progresses to sub-acute cough Sub-acute Cough - Lasting for three to eight weeks duration. - Pneumonia (bacterial, viral, fungal), pertusis infection bronchiectasis - Non respiratory causes include GERD
9 Is it important to differentiate the type Chronic Cough of cough? - Cough lasting for more than 8 weeks - Must be evaluated thoroughly - Cigarette smoking is the most common - COPD, asthma, tuberculosis, ILD, lung CA Unexplained chronic - Idiopathic cough, Refractory cough, Psychogenic cough, Tic cough, Sensory neuropathic cough
10 Evaluation Assessment of symptoms Severity of breathlessness, cough, sputum production, wheezing, chest tightness, weight loss or anorexia Change in alertness or mental status, fatigue, confusion, anxiety, dizziness, pallor or cyanosis COPD should be considered in any patient with a chronic cough, dyspnea or sputum production
11 Evaluation Medical History Allergies Sinus problems Other respiratory disease eg Bronchiactasis Risk factors for chronic lung diseases including infections Exposures (occupational and environmental) Family history Co-morbidities that may affect activity Medications Prior hospitalizations or evaluation to date
12 PAL 12
13 2. Which of the following symptom/s helps in the differential diagnosis of COPD? a. Chronic cough b. Any sputum production c. Dyspnea d. Increased sputum production e. All of the above
14 CXR -PA Follow up FBC,ESR within normal limit Still complains of breathlessness on exertion with a cough mmrc Grade - 2
15 3. Which of the following is the most appropriate in confirming the diagnosis of COPD? a. Chest X-ray b. Arterial blood gas c. Spirometry d. High resolution CT scan of chest e. Clinical examination
16 Spirometry done 4 weeks after the acute event
17 Spirometry Gold standard for diagnosis Standard to establish severity and stage Perform both pre- and post-bronchodilator Irreversible airflow limitation is the hallmark of COPD decreased FEV1 decreased FEV1/FVC ratio (<0.8) coved appearance to the expiratory limb of a flow-volume loop
18 COPD - Diagnostic Criteria Key Indicators Dyspnea Progressive, usually worse with exercise, persistent, described as increased effort to breathe Chronic cough Maybe intermittent, maybe nonproductive Chronic sputum production Any pattern History of exposure to risk factors Tobacco smoke, occupational dust, chemicals, fumes or smoke from cooking or heating fuels Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2009
19 COPD - Diagnostic Criteria GOLD Criteria (continued) Symptoms and risk factors are not diagnostic in themselves but should prompt spirometry in patients >40 yrs of age Diagnosis should be confirmed by pre- and postbronchodilator spirometry Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2009
20 Spirometry Classification for COPD Stage 1: Mild FEV1:FVC FEV1 80% of predicted value 2: Moderate 50% to 79% of predicted value 3: Severe 30% to 49% of predicted value <0.80 <30% of predicted value 4: Very OR severe <50% of predicted value with chronic respiratory failure Adapted from GOLD, 2009
21 Pulmonary Asthma Bronchogenic carcinoma Bronchiectasis Tuberculosis Cystic fibrosis Interstitial lung disease Bronchiolitis obliterans Alpha-1 antitrypsin deficiency Recurrent aspiration Tracheobronchomalacia Recurrent pulmonary emboli Foreign body Differential Diagnoses Non-pulmonary Congestive heart failure Hyperventilation syndrome/panic attacks Vocal cord dysfunction Obstructive sleep apnea (undiagnosed) Aspergillosis Chronic fatigue syndrome
22 Clinical Features in Differentiating COPD from Asthma Clinical Feature COPD Asthma Age Older than 35 years Any age Cough Persistent, productive Intermittent, usually nonproductive Smoking Typical Variable Dyspnea Nocturnal symptoms Progressive, persistent Breathlessness, late in disease Variable Coughing, wheezing
23 Clinical Features in Differentiating COPD from Asthma (continued) Clinical Feature COPD Asthma Family history Less common More common Atopy Less common More common Diurnal symptoms Spirometry Less common Irreversible airway limitation More common Reversible airway limitation
24 4. What is the best management option to decrease the progression of the COPD in this patient? a. Good Glycemic control b. Adding ICS + LABA to SAMA c. Adding LAMA + LABA to SAMA d. Adding LAMA to SAMA e. Smoking cessation
25 Goals of Therapy in COPD Relieve symptoms Improve exercise tolerance Improve health status Reduce symptoms Prevent disease progression Prevent and treat exacerbations Reduce mortality Reduce risk
26 Combined Assessment of COPD - Management plan
27 Pharmacotherapy in COPD
28 What else need to be done to Mr.KS for the Management of COPD? Some considerations include Smoking Cessation Pulmonary Rehabilitation Diabetes (and whether referral needs to be made?) Adherence and Inhaler Technique (does Mr KS know how to use MDI and DPI) Social Care & Mental Health Pneumococcal vaccine (protect against streptococcus pneumonia) and influenza vaccines
29 Mr. KS was followed up in the clinic for 1yr Developed worsening cough with purulent sputum over 3 days and was struggling to get to the washroom On admission - BP 130/85, PR 110 regular, good volume No cyanosis, RR - 32/min SpO₂ 88% After initial Nebulisation SpO₂ 86% - Use of Accessory Muscles - Widespread wheeze on auscultation - Mild confusion - worried about his dog
30 5. What suggests as clinical feature/s of exacerbations of COPD? a. Acute increased dyspnoea b. Change in sputum purulence or increased sputum volume c. Development of fever, Increased cough or wheezing d. Malaise and fatigue as the systemic symptoms e. All of above
31 AECOPD
32 Potential causes of AECOPD
33 Does Mr. KS need urgent hospital admission? How to assess the severity of the patient by clinical examination? Signs of severity Use of accessory respiratory muscles Paradoxical chest wall movements Worsening or new onset central cyanosis or desaturation despite initial Nebulisation Development of peripheral edema Hemodynamic instability Deteriorated mental status
34 Management of AE COPD Supplemental oxygen therapy via venturi mask target saturation 88-92% Bronchodialtors - Short-acting inhaled beta2- agonists with or without short-acting anticholinergics Short course ( 14 days) of oral corticosteroids Antibiotic administration should be based upon local sensitivity patterns A&E / ICU management - use of non invasive ventilation (BiPAP)
35 Impact of COPD Exacerbation
36 Thank You
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