R.S. has smoked for many years and has developed chronic bronchitis, a chronic o

Question

R.S. has smoked for many years and has developed chronic bronchitis, a chronic obstructive pulmonary disease (COPD). He also has a history of coronary artery disease and peripheral arterial vascular disease. His arterial blood gas (ABG) values are pH = 7.32, PaCO2 = 60 mm Hg, PaO2 = 50 mm Hg, HCO3- = 30 mEq/L. His hematocrit is 52% with normal red cell indices. He is using an inhaled ß2 agonist and theophylline to manage his respiratory disease. At this clinic visit, it is noted on a chest x-ray that R.S. has an area of consolidation in his right lower lobe that is thought to be consistent with pneumonia.

Please answer in depth

1. What clinical findings are likely in R.S. as a consequence of his COPD? How would these differ from those of emphysematous COPD?

Explanation / Answer

Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory lung disease that causes airflow obstruction from lungs. Symptoms include breathlessness, cough with mucus production and wheezing. It's caused by long-term exposure to irritating gases or particularly cigarette smoke.

The disease spectrum of COPD extends from chronic bronchitis to Emphysema. Chronic bronchitis is inflammation of the lining of the bronchial tubes, which carry air to and from the air sacs (alveoli) of the lungs. It's characterized by daily cough and mucus (sputum) production.

In case of R.S, He has Chronic bronchitis as a consequence of chronic smoking. Such smoking also affects other systems. Peripheral vascular disease is another dreadful condition associated with smoking and so as Coronary artery disease.

The ABG status of his shows Respiratory acidosis in partially decompensated state. Chronic hypoxia caused myeloproliferation results in Polycythemia vera ( increase in hematocret).

He would likely to have Respiratory distress as a result of chronic hypoxia & Coronary artery disease. Coronary artery disease and consolidation may cause chest pain. Chronic bronchitis it sel can cause thick productive cough. Peripheral arterial disease may results in pain in limbs, initially on exertion -- ultimately in resting state also, even aggravate the chest pain by affecting coronary vessels.

On Physical Examination, respiratory rate may increase in proportion to disease severity. Use of accessory respiratory muscles and paradoxical indrawing of lower intercostal spaces is evident (known as the Hoover sign). In advanced disease, cyanosis, elevated jugular venous pulse (JVP), and peripheral edema can be observed.

Thoracic examination reveals the following:

Hyperinflation (barrel chest)

Wheezing – Frequently heard on forced and unforced expiration

Diffusely decreased breath sounds

Hyperresonance on percussion

Prolonged expiration

Bronchial breath sounds often result from consolidation within lung parenchyma with a patent airway leading to the involved area, as in case of R.S. in Right lower zone.

There are certain characteristics which allows us to differentiate between COPD associated with chronic bronchitis and that with predomonat Emphysematous lung.

Chronic bronchitis characteristics include the following:

Patients may be obese

Frequent cough and expectoration are common.

Use of accessory muscles of respiration usually found.

Coarse rhonchi and wheezing may be heard on auscultation

Some times, patients may have signs of right heart failure (ie, cor pulmonale), such as edema and cyanosis

Emphysema characteristics include the following:

Patients may be very thin with a barrel chest

Patients typically have little or no cough or expectoration

Pursed lip breathing, a typical feature in this cas and use of accessory respiratory muscles; patients may adopt the tripod sitting position

The chest may be hyperresonant with wheezing.

Heart sounds are very distant

Overall appearance is more like classic COPD exacerbation

Thanks for asking.

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