CASE 1

HPI:  JS is a 74 year old man who presents to your family medicine office with his wife complaining of shortness of breath and fever. They just moved to the area and had been planning to come to your office next week to establish care as new patients. Due to the onset of symptoms, JS called and was given a walk-in slot today. His wife did bring records from his last physician’s office.  She has noted no change in his alertness or mental status. Wife states that JS usually has a cough, worse in the morning, productive of gray sputum, gets short of breath if he walks more then 10 feet, and has episodes of wheezing if he gets sick (e.g. with an upper respiratory infection). He usually is able to help around the house with light work and fixing things. Currently, the patient has been unable to speak in full sentences for the past several hours per wife. He has a productive cough with sputum of unknown color with audible wheezing since last night. He is experiencing mild chest tightness and dyspnea.

Past Medical/Surgical History

Heart failure following myocardial infarction at age 68 years
COPD (on 2 L home oxygen)
Hypertension
Appendectomy

Family History

Father died of myocardial infarction at age 59 years (diabetes, hypertension, smoker)
Mother alive (atrial fibrillation, heart failure)
Healthy siblings

Social History

Married, 3 adult children
30 pack year smoking history (quit after MI)
Worked on a farm
No alcohol or illicit drug use

Medications / Allergies

Lisinopril 20 mg twice daily
Metoprolol 50 mg twice daily
Spironolactone 25 mg daily
Furosemide 40 mg daily (Diuretic)
Salmeterol/fluticasone 50/500 dry powdered inhaler (DPI) one puff inhaled twice daily
Tiotropium DPI one cap inhaled daily                
Albuterol/ipratropium metered dose inhaler (MDI) or solution for nebulization every 6 hours as needed
Levalbuterol – a beta2 agonist.  MDI two puffs every 4 to 6 hours as needed
Home oxygen
Beta blocker

He is confused about what to use when, so you are not sure which medications he actually takes. No known allergies.

JS Past Record Review  (brought by wife)

Echocardiogram with EF of 25%
Spirometry with FEV1 35% predicted that does not change significantly after inhaled bronchodilator

Unable to determine when last pneumoccal vaccine was give.

Patient and wife don’t recall “a pneumonia shot”.

Does know he got his “flu shot” last month at a grocery store.

An arterial blood gas (ABG): pH 7.17, PCO2 55, PO2 62, HCO3- 25

Physical examination

Vital Signs: BP 128/74; P 68, reg; RR 32; Ht 5ft 6 in; Wt 132 lbs; T 101.5 °F oral.
Unable to speak in full sentences, audible wheezing, alert and oriented

Pertinent positives:

General:  audible wheezing, no accessory muscle use
Nails: tar stains, clubbing
Chest: increased anteroposterior (AP) diameter; diffuse wheezing to auscultation
Heart: regular, no murmurs

1. At this point, can you think of at least two diagnoses?  What is your most likely diagnosis? 

This patient is very likely to suffer from respiratory disorder. Possibilities include COPD(chronic bronchitis), and asthma.

2. Explain the main reasons for your diagnosis.   

The patient has all key indicators for considering a diagnosis of COPD such as dyspnea, chronic cough, and chronic sputum production. His gray sputum, is indicative of COPD as well. It was reported that he gets shortness of breath when walking more than 10 feet, which is due to breaths start coming in before air from the last breath has been exhaled, leading to shortness of breath. Moreover, he has history of tobacco use, hypertension and COPD. Smoking is highly related to COPD and prior history of COPD is most indicative of COPD recurrence. Most importantly, spirometry is required to make a clinical diagnosis of COPD. The presence of a post-bronchodilator FEV1/FVC <.70 confirms the presence of persistent airflow limitation and thus of COPD (patient has .35)¹. Also, X-ray reveals flattening of the diaphragm, increased size of the chest, as measured from front to back and a long narrow heart which are common signs of COPD patient². 

Similarly, he could be suffering from asthma as it causes similar symptoms described above. In asthma patients, the muscles around the airways can tighten when something triggers symptoms³. This makes it difficult for air to move in and out of the lungs, causing symptoms such as coughing, wheezing, shortness of breath and/or chest tightness as it happend to JS. Excercise induced asthma is commonly seen, in which people develop asthma symptoms (bronchoconstriction) when they are engaged in activities. This was probably why JS felt shortness of breath when walking more than 10 feet. In addition, asthma symptoms tend to worsen during nighttime or early in the morning and this correlates with JS's worsened cough in the morning. Furthermore, clear/white/grey sputum can be seen in asthma patients as JS experienced⁴. However, most people with asthma have allergies (but JS is not aware of any), and JS's FEV1 did not change significantly after inhaled bronchodilator, which makes this option less likely than COPD. 

3.  How would you interpret his clinical picture?  Hint:  Use the GOLD criteria for COPD (Look this up)

Normal
Restrictive lung disease
Moderate COPD
Mild COPD
Severe COPD
Mild asthma

According to the GOLD criteria for COPD³, 

GOLD1(Mild) : FEV1>80% predicted

GOLD2(Moderate): 50%<FEV1<80% predicted

GOLD3(Severe): 30%<FEV1<50% predicted

GOLD4(Very severe): FEV1<30% predicted 

Based on the information given, JS has FEV1 of 35% from spirometry, which means that he has 'Severe COPD' (= GOLD 3).

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

The key indicators for considering a diagnosis of COPD include dyspnea (severity of breathlessness), chronic cough, and chronic sputum production. Wheezing would mean that the patient is having some difficulty breathing due to narrowed airways. However, wheezing alone would not help diagnosing for particular disease although it could be an indication of infection or inflammation or air way obstruction due to asthma or COPD⁵. Also, it is possible that people with COPD, especially those with emphysema, may begin to lose weight and muscle mass. It’s very common for those with breathing problems to exercise less often because they feel tired or fatigued, which may decrease appetites. They could also suffer from depression which contributes to weight loss⁶. More importantly, excess CO2 in the blood makes them feel exhaused all the time and they are actually using more of its energy to breath. Late-stage COPD patients with emphysema could be using as much as 20 percent more energy at rest than healthy individuals. Other than the criterias mentioned above, knowing family history of COPD as well as history of exposure to risk factors, such as tobacco smoke, occupational dusts and chemical would help diagnosing COPD. 

5. Which of the following is the least likely cause of patient’s symptoms?

COPD exacerbation
Recurrent aspiration
Heart failure
Pneumonia
Asthma exacerbation

First, his past history of hypertension, COPD and tobacco smoking puts him very risky for COPD exacerbation. Plus, his symptoms such as dyspnea, chest tightness, wheezing, sputum, and short of breath are all indications of COPD. It is well known that patients with COPD are more susceptible to pneumonia due to damaged lung⁷. Pneumonia is due to infections and its symptoms are very similar to COPD, plus pneumonia in COPD patients increase risk of life-threatening exacerbations and respiratory failure. Since pneumonia also causes fever, the patient's body temperature of 101.5F (normal 98.6F) indicates that he may be suffering from pneumonia as well. In addition, the patient does not recall a pneumonia shot. Similar to COPD, asthma exacerbation would cause airways to become swollen and inflalmed. So patients with asthma would experience very similar symptoms including cough, wheeze, and trouble breathing. In case of recurrent aspiration, which happens when breathing a foreign substance into airways, causes the same symptoms such as coughing, wheezing, fever, and chest discomfort⁶.

It is also possible that his shortness breath is caused from heart failure. He has a history of myocardial infarction and his father died of MI at age of 59 years old. He also has EF of 25% which is very low (normal >65%) which means that his heart is not pumping efficiently due to previous damage to heart. However, he has normal BP and regular beats of heart without murmurs at the moment. Plus, fluid is not present in his lungs on X-ray which would have been common in heart failure patients due to blood backing up in lungs from malfunctioning heart. Thus, heart failure is least likely cause of this patient's symptoms. 

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

Hypoxemia is what leads to exacerbations of COPD symptoms. Since hypoxemia is common in all stages of COPD, it would be a good idea to use this noninvasive test, such as pulse oximetry to routinely checkup and monitor blood oxygen levels (normal >95%). Also, the deficiency of alpha-1-antitrypsin level may mean that the patient contains the genetic risk factor that contribute to COPD⁸. Most importantly, spirometry is required to make a clinical diagnosis of COPD. The presence of a post-bronchodilator FEV1/FVC <.70 confirms the presence of persistent airflow limittion and thus of COPD.

Although COPD cannot be diagnosed with a chest X-ray alone, it can help doctor evaluate shortness of breath, help support a diagnosis of COPD, and detect advanced emphysema. In this patient's chest Xray, flattening of the diaphragm, increased size of the chest, as measured from front to back and a long narrow heart are seen, which are the common features of COPD patients on X-ray⁹.

7.   Does JS present with clinical factors that increase risk of severe COPD exacerbations? If so, can you list at least two?

Yes, Key factors associated with increased risk for COPD exacerbation identified are pulmonary hypertension, hypoxia, hypercapnia, and poor health status¹⁰. Foremost of all these factors is previous hospitalization for COPD. According to his past medical history, he has had suffered from COPD and hypertension (plus, tobacco history). In addtion, he is having dyspnea which is another key factor for increasing risk of COPD exacerbation.

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.

First of all, it would be critical to make sure that he has stopped smoking. Otherwise, the disease will get worse faster. Although medication would not treat his condition, as a physician it would be best to treat the patient with medications that help with opening airways, reducing airway inflammation, and bacterial infections. Bronchodilators would widen his airways and corticosteroids would reduce airway inflammation. Also, antibiotics to treat a bacterial infection in respiratory tract would be helpful¹¹.

Since, he has very high risk of COPD exacerbation(from Q7), which has very high mortality rate, I would treat JS as an inpatient. Hospitalized patients with exacerbations should receive regular doses of short-acting bronchodilators, continuous supplemental oxygen, antibiotics, and systemic corticosteroids. Noninvasive positive pressure ventilation or invasive mechanical ventilation is indicated in patients with worsening acidosis or hypoxemia.

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)

In years past, doctors have hesitated to give beta-blockers to patients with chronic obstructive pulmonary disease (COPD) because of concerns that the drugs might have adverse effects on the lungs (bronchoconstriction)¹². Beta-blockers may increase airway reactivity and bronchospasm, as well as decrease the response to inhaled or oral beta-receptor agonists.

However, recent studies have shown that beta-blockers could also exert a pulmonary beneficial effect as indicated by their reduction of exacerbations. Beta blockers improve survival rates in patients with chronic systolic heart failure and after myocardial infarction, including in those patients with coexisting COPD and reactive airway disease. Since not all beta-blockers are the same, using cardioselective beta-blockers (ie, those that block predominantly beta-1 receptors) would be the best option based on stronger evidence from clinical studies¹³.

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? 

The patient is probably suffering from COPD (eg. chronic bronchitis) indicated by gray sputum and other symptoms. In this case, using non-invasive positive pressure ventilation, such as BiPAP would be very helpful as he may suffer from sleep apnea. The machine delivers pressurized air through a mask to the patient's airways and the air pressure from BiPAP keeps the throat muscles from collapsing and reducing obstructions by acting as a splint¹⁴. Thus, BiPAP would allow patients to breathe easily and regularly throughout the night.

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?

Similar to a CPAP machine, a BiPAP machine is a non-invasive form of therapy for patients suffering from sleep apnea. Both CPAP and BiPAP machines allow patients to breathe easily and regularly throughout the night.

CPAP machines deliver a steady, continuous stream of pressurized air to patient's airways to prevent them from collapsing and causing apnea events. CPAP machines can only be set to a single pressure that remains consistent throughout the night¹⁴. However, many CPAP machines have a ramp feature that starts off with a lower pressure setting and gradually builds to the prescribed pressure. Regardless, some patients find the constant singular pressure difficult to exhale against. For patients with higher pressure strengths, exhaling against the incoming air can feel difficult, as if they're having to force their breathing out¹⁴.

The main difference between BiPAP and CPAP machines is that BiPAP machines have two pressure settings: the prescribed pressure for inhalation (ipap), and a lower pressure for exhalation (epap). The dual settings allow the patient to get more air in and out of their lungs¹⁴. BiPAPs can be set to include a breath timing feature that measures the amount of breaths per minute a person should be taking. If the time between breaths exceeds the set limit, the machine can force the person to breath by temporarily  increasing the air pressure.

The CPAP machine is usuaully used to treat mild sleep apnea. But depending on the levels of sleep apnea, doctors may recommend that you go with a BiPAP machine instead. For instance, people with lung disorders or certain neuromuscular disorders may better benefit from the BiPAP machine rather than the CPAP machine¹⁵. Also, BiPAPs can be helpful for patients with cardiopulmonary disorders such as congestive heart failure¹⁵.

References:

1) "American Academy of Allergy Asthma&Immunology." 2015. <http://www.aaaai.org/conditions-and-treatments/asthma.aspx> Nov 2015 Accessed.

2) "Different Sputum Colors and What They Mean." 2015. <http://www.md-health.com/Sputum-Color.html> Nov 2015 Accessed.

3) Decramer, Marc. "Global Initiative for Chronic Obstructive Lung Disease." 2015.<http://www.goldcopd.org/uploads/users/files/GOLD_Pocket_2015_Feb18.pdf> Nov 2015 Accessed.

4) Krucik, George. "COPD and Pneumonia: Understanding Your Risk." 2013. <http://www.healthline.com/health/copd/copd-and-pneumonia-understanding-your-risk#1> Nov 2015 Accessed.

5) "Asthma attack." 2015. <http://www.mayoclinic.org/diseases-conditions/asthma-attack/basics/definition/con-20034148> Nov 2015 Accessed.

6) "Pulmonary Aspiration." 2015. <http://www.summitmedicalgroup.com/library/adult_health

/sha_pulmonary_aspiration/> Nov 2015 Accessed.

7) "COPD Health Center." 2015. <http://www.webmd.com/lung/copd/copd-and-heart-failure> Nov 2015 Accessed.

8) "BiPAP (Bilevel positive airway pressure) or CPAP Therapy." 2015. <http://blog.aastweb.org/bipap-biphasic-positive-airway-pressure-vs.-cpap-therapy> Nov 2015 Accessed.

9) "COPD Testing: Why It's Important." 2015. <http://www.everydayhealth.com/hs/chronic-obstructive-pulmonary-function/importance-of-copd-testing/> Nov 2015 Accessed.

10) "COPD Health Center." 2014. <http://www.webmd.com/lung/copd/chest-x-rays-for-chronic-obstructive-pulmonary-disease-copd> Nov 2015 Accessed.

11) Ramsey, Scott. "Chronic Obstructive Pulmonary Disease, Risk Factors, and Outcome Trials." 2006. <http://www.atsjournals.org/doi/full/10.1513/pats.200603-094SS#.Vkz0hHhPJUQ> Nov 2015 Accessed.

12) "COPD Treatments: Improving Your Quality of Life." 2015. <http://www.webmd.com/lung/copd/copd-treatments-improving-your-quality-of-life?page=2> Nov 2015 Accessed.

13) Evensen, Ann. "Management of COPD Exacerbations." 2010. <http://www.aafp.org/afp/2010/0301/p607.html> Nov 2015 Accessed. 

14) Navas, Elsy. "Can patients with COPD or asthma take a beta-blocker." 2010. <http://www.ccjm.org/past-issues/past-issue-single-view/can-patients-with-copd-or-asthma-take-a-beta-blocker/175107569269fce957d9f12b06c90848.html> Nov 2015 Accessed.

15) Phillips, Kevin. "The Difference Between BiPAP and CPAP." 2014. <http://www.alaskasleep.com/blog/what-is-bipap-therapy-machine-bilevel-positive-airway-pressure> Nov 2015 Accessed.