Chronic Obstructive Pulmonary

Disease (COPD) – A case report

By Paul John V. Canero

(Post-graduate Intern, Veterans Memorial Medical Center)
Objectives
• To present a case of a 70 year old male who is
diagnosed to have COPD.
• To discuss the approach to patients with COPD
based on the 2017 COPD GOLD Guidelines.
• To discuss the management of patients with COPD
based on the 2017 GOLD COPD Guidelines.
Identifying data
• JS, 65 years old, Male, RPV
• Filipino,
• Roman Catholic,
• March 12, 1952 in Manila,
• Novaliches, Quezon City
• Consulted for the first time at Outpatient
department
Chief complaint:
non-productive cough
History of present illness

• 2 weeks prior to consult

(+) sudden onset of occasional, non-productive,

non-distressing cough

(-)fever, difficulty of breathing, shortness of breath,

colds, chest pain, hemoptysis, night sweats.

(+) self-medicated with Carbocysteine 500 mg/cap,

1 capsule 2 times : no relief of symptoms

No consult was done.

History of present illness
• 11 days prior to consult
• (+) occasional, non-productive, distressing cough,
• (+) intermittent fever (Tmax of 38.1 degrees Celsius)
• (+) occasional shortness of breath upon exertion
• (-) difficulty of breathing, chest pain, colds, orthopnea.
• (+)consult at a local health center where
• CBC and chest X-ray were requested
• (+) diagnosis : Pneumonia and Bronchial Asthma
• (+) Cefuroxime 500 mg/tab, 1 tablet every 12 hours for
7 days,
• (+) N-acetylcysteine 600 mg/tab, 1 tablet in ½ glass
water once a day for 5 days
• (+) Salbutamol nebulization every 8 hours for 5 days.

• Advised to follow-up after 7 days.

History of present illness
• Few hours prior to consult,

• (+) occasional, non-productive, distressing cough.

• (+) consult at FEU-NRMF OPD

• Working impression: COPD
• CBC, chest X-ray, Potassium, and Spirometry
studies were requested
• (+) Butamirate citrate tablet, 1 tab TID for 5
days.

• Advised to come back once with available laboratory

results.
 Past Medical History:
• (+)hypertension: >10 years
• (+) highest BP : 150/90
• (+) usual BP :120/80,
• (+) maintenance: Amlodipine 10 mg/tab, 1 tablet once a
day.

• (-)asthma, diabetes mellitus, thyroid problems and

tuberculosis, surgery, and blood transfusion.

• (-) allergy to foods and drugs.

• (+) usual childhood diseases such as chicken pox and measles.

• Unrecalled immunization.
Family History:

• Father – known hypertensive. Deceased at 80 years

old due to unknown cause.

• Mother – no known co-morbids. Deceased at 85

years old due to unknown cause.

• Siblings – all are apparently well

• (-) heredofamilial diseases such as, thyroid, lung,

asthma, kidney and hematologic diseases.
Personal and Social History:

• (+) college undergraduate.

• (+) 50 pack-year smoker and occasional alcoholic
beverage drinker.
• (+) bungalow house with 2 rooms
• (+) well lit and well ventilated with 5 household
members.
• (+) Water supply is from a Nawasa
• (+) Garbage is collected 3 times a week.
• Denies history of sexually transmitted disease and
illicit drug use.
 Review of Systems:
• Constitutional: no weight loss, no easy fatigability
• Skin: no itchiness, excessive dryness or sweating, jaundice, pallor or
cyanosis
• Head: no dizziness; vertigo
• Eyes: no blurring of vision, no pain, double vision, lacrimation or
photophobia
• Ears: no earache, deafness, tinnitus or ear discharge
• Nose and Sinuses: no change in smell, no nose bleeding, no nasal
obstruction, no nasal discharge
• Mouth and Throat: no gum bleeding, disturbances in taste, sore
throat or hoarseness
• Neck: no pain when being held, no limitation of movement, no
presence of mass
 Review of systems
• Breast: no pain, lumps or abnormal nipple discharge
• Respiratory System: no hemoptysis, shortness of breath or chest pain
• Cardiovascular System: no chest pain, palpitation, orthopnea, paroxysmal
nocturnal dyspnea, cyanosis, syncope, or easy fatigability
• Gastrointestinal System: no abdominal pain, dysphagia, diarrhea, constipation,
hematemesis, melena, hematochezia or regurgitation
• Genitourinary System: no urgency, bladder fullness, dysuria, urinary frequency,
polyuria, hematuria, incontinence, genital pruritus, or urethral discharge
• Extremities: no bipedal edema, no swelling of joints, stiffness, numbness or
limitation of movement
• Nervous System: no vertigo, syncope, loss of consciousness, paralysis,
numbness, loss of memory or confusion
• Hematopoietic System: no bleeding, pallor, easy bruising or history of transfusion
reaction
• Endocrine System: no intolerance to heat and cold, polyuria, polydypsia, or
polyphagia
 PHYSICAL EXAMINATION
• General Survey:
Conscious, coherent, not in cardiorespiratory distress with the
following vital signs:
• BP: 120/90 mmHg CR: 81 bpm RR: 20 cpm
Temp: 36.7°C
• Weight: 60 kgs
• Height: 1.65 m
• BMI: 22.0 kg/m2

• Skin: fair, normal skin turgor, nails are pink, smooth, with normal
nail folds.
• Head: hair is thin, white, evenly distributed, normocephalic, no
mass, no lesion, temporal arteries are not visible, palpable with
strong equal pulses.
PHYSICAL EXAMINATION
• Eyes: Eyebrows are black, evenly distributed, eyelids
non-erythematous rim, no ptosis, and no lesions noted;
palpebral fissures are normal and symmetrical; eyeballs
are normally set, no exopthalmos and enopthalmos;
eyelashes are thin, with outward direction of growth,
no matting, pink palpebral conjunctiva, anicteric sclera,
transparent cornea, black iris with regular contours,
pupils are 2-3mm equally reactive to light and
accommodation, lens are clear, no opacity.

• Ears: Auricles are symmetrical and no tenderness on

the tragal and mastoid area; auditory canals are patent,
no discharge, intact tympanic membrane, pearly white,
normal contour, visible cone of light.
 PHYSICAL EXAMINATION
• Nose: Nose is symmetrical, patent vestibules, mucosa is pink,
septum midline and intact, turbinates are not congested, no
nasal discharge, no tenderness over the frontal and maxillary
sinuses. Normal transillumination test.

• Mouth and Oral Cavity: Lips, buccal mucosa and gums are pink
and moist, smooth, no lesions, no swelling. Tongue is at
midline. Hard and soft palate are pinkish, no lesions; uvula is at
midline, tonsils are not enlarged; pharyngeal wall is pinkish
with no exudates, without dental caries.

• Neck: Neck is symmetrical, no limitation of movement, no

neck vein engorgement, no mass, normal muscle development
and tone, trachea in midline, no palpable lymph nodes, thyroid
gland not palpable. No carotid bruit noted.
 PHYSICAL EXAMINATION
• Chest / Lungs: Skin is brown, no lesions, no dilated
superficial blood vessels; bony thorax is elliptical,
symmetrical, no gross deformities, no retractions,
symmetrical chest expansion, no tenderness, equal vocal and
tactile fremitus, with occasional bilateral wheezes upon
auscultation, resonant percussion on all lung fields.

• Heart: Adynamic precordium, normal rate, regular rhythm,

apex beat at 5th intercostal space left midclavicular line,
normal S1 and S2, no S3 and S4 gallop, no murmur.

• Abdomen: flat, normoactive bowel sounds, no bruit over the

epigastrium and paralumbar area, soft, no tenderness, with a
liver span of 7 cm, no costovertebral angle tenderness.
PHYSICAL EXAMINATION

• Muscular: normal muscle size, consistency, no

atrophy and no involuntary movements

• Skeletal: no gross deformities, nodules, swelling and

malalignment on the thoracic and lumbar vertebrae

• Extremities: no gross deformities, full and equal

pulses, no bipedal edema.
 NEUROLOGIC EXAMINATION
• Cerebrum – conscious, coherent, oriented to time, place and person
• Cerebellum – no nystagmus, can do finger-nose-finger test, rapid alternating movement
• Cranial Nerves:
• CN I: can smell coffee
• CN II: 2-3mm equally reactive to light and accommodation. Fundoscopic examination:
(+) ROR, 2:3 A:V ratio, optic disc with distinct borders, (-) papilledema, (-) hemorrhages
• CN III, IV, & VI: intact EOMs
• CN V: (+) bicorneal reflex, good masseter tone
• CN VII: No facial asymmetry, can raise both eyebrows, can close eyes tightly.
• CN VIII: can hear spoken words
• CN IX & X: (+) gag reflex, uvula is in midline.
• CN XI: can turn head from side to side, can equally elevate both shoulders
• CN XII: tongue is in midline. No fasciculation.
NEUROLOGIC EXAMINATION

Motor function Sensory function DTR

5/5 5/5 100% 100% ++ ++

5/5 5/5 100% 100% ++ ++

No Brudzinski’s No Kernig’s Sign

Pathologic reflexes : (-) Babinski
reflex
July 2, 2017: Bilateral Interstitial Pneumonia, Hyperaerated lungs
June 13, 2017: Hyperinflated Lungs
CBC
July 2, 2017 June 13, 2017
Hemoglobin 137 140
Hematocrit 43 44
RBC 4.49 4.51
WBC 11.2 8.5
Neutrophils 80 60
Lymphocytes 10 26
Eosinophils 7 10
Monocytes 2 3
Basophils 1 1
Platelet count 346 360
Spirometry – July 13, 2017
Salient Features
• 65 years old, Male
• non-productive cough
• intermittent fever (Tmax of 38.1 degrees Celsius)
• occasional shortness of breath upon exertion
• 50 pack-year smoker
• Hypertensive for >10 years
• occasional bilateral wheezes upon auscultation
• Chest X-ray: Hyperinflated Lungs
• FEV1/FVC ratio: < 65%
• No history of previous hospitalization due to
exacerbations
Diagnosis
• GOLD A, Mild COPD
• HCVD CAD SR FC I
Definition
• Airflow limitation that is not fully
reversible
• Includes emphysema, chronic bronchitis,
small airway disease
• (+) Chronic Airflow obstruction***
Definition
• a common, preventable and treatable disease
• Characterized by:
• Persistent respiratory symptoms
• Airflow limitation
• due to airway and/or alveolar abnormalities
usually caused by significant exposure to noxious
particles or gases.
 Definition
• major cause of chronic morbidity and mortality
throughout the world.
• 4th leading cause of death in the world
• projected to be the 3rd leading cause of death
by 2020 d/t
• Continous exposure COPD risk factors
• Aging population
• Higher ≥ 40 year group
• Higher in men
 Definition
Emphysema Chronic Bronchitis
The alveoli are There is cough
destroyed, there is significant that is productive for at
hyperinflation of the lungs. least 3 months in a
There is permanent abnormal year for 2 consecutive
distension of the air spaces years.
distal to the terminal
bronchiole.

“PINK PUFFER” “BLUE BLOATER”

 Risk factors
• Environmental Host
• Tobacco Smoking – • Genetic abnormalities – a1
main risk factor antitrypsin deficiency
• Occupational • Aging
exposures • Poor lung growth during
• Indoor and outdoor child hood
Air Pollution • Socioeconomic Status
• Asthma and Airway Hyper-
reactivity
• Infections
 Medical History
• Exposure to risk factors • Comorbidities

• Past medical history • Impact of disease

on patient’s life
• Family history
• Social and family
• Pattern of symptoms support

• Possibilities for
reducing risk
factors, especially
smoking cessation
Pathogenesis (4 Interrelated events)
Chronic
Exposure to Structural Cell
cigarrete smoke death

Elastases Ineffective
damage the repair of
ECM of the Elastin
lungs

***Elastase:antielastase hypothesis
 Pathogenesis

CD8+ T
IL-8 cells
TNF-a

A-1 antitrypsin

Obstruction and loss of surface area

Pathogenesis
B2 receptors –
RELAXATION

M receptors -
CONTRACTION

Less surface
area, less O2
 Lung and Chest wall
Tug of war

COPD = chest wall becomes dominant (BARREL CHEST)

 Healthy, non-smoker

FEV1 Previous smoker

Chronic Smoker
Symptomatic

25 y/o 40 60
Clinical Manifestations

Three most common symptoms in COPD:

• Cough
• Sputum production
• Exertional dyspnea
Clinical Manifestations
Emphysema Chronic Bronchitis
Asthenic Usually overweight
Long history of exertional dyspnea Less dyspneic – d/t ↑ CO2
Scanty mucoid sputum Copious, purulent sputum
Chronic cough
Pink puffer Blue bloater
Prominent accessory muscles Accessory muscles not prominent
Barrel chest – by virtue of air
trapping
Tachypneic with purse lip
breathing
Decreased breath sound Crackles, wheezes
Hyperresonant Resonant
Cor pulmonale - late in the course Cor pulmonale - early in the
course
Diagnosis and Initial Assessment

Post-bronchodilator FEV1/FVC <0.70

Spirometry
Diagnosis and Initial Assessment
Classification of severity of airflow
limitation
 BODE Index

• APPROXIMATE 4 YEAR SURVIVAL INTERPRETATION

• 0-2 Points: 80%
• 3-4 Points: 67%
• 5-6 Points: 57%
• 7-10 Points: 18%
 OTHER INVESTIGATIONS
Chest X-ray: Seldom diagnostic but valuable to exclude
alternative diagnoses and establish presence of significant
comorbidities.
Lung Volumes and Diffusing Capacity: Help to
characterize severity, but no role in management.
Oximetry and Arterial Blood Gases: to evaluate need for
supplemental oxygen therapy.
Alpha-1 Antitrypsin Deficiency Screening: Perform when
COPD develops in patients under 45 years or with a strong
family history of COPD. A low concentration (< 20%
normal) is highly suggestive of homozygous deficiency.
Family members should also be screened.
Diagnosis
• Alpha-1 antitrypsin deficiency (AATD) screening
The WHO recommends that all patients with a
diagnosis of COPD should be screened once
especially in areas with high AATD prevalence. A
low concentration (< 20% normal) is highly
suggestive of homozygous deficiency. Family
members should also be screened.

***PiZ – severe deficieny of A1 At levels

 Management of Stable COPD
►Once COPD has been diagnosed, effective management
should be based on an individualized assessment to
reduce both current symptoms and future risks of
exacerbations.
 Management of Stable COPD
Identify and reduce exposure to known risk factors

 Important in the treatment and prevention of COPD.

 Cigarette smoking is the most commonly encountered and

easily identifiable risk factor for COPD, and smoking
cessation should be continually encouraged for all individuals
who smoke.

 Reduction of total personal exposure to occupational dusts,

fumes, and gases, and to indoor and outdoor air pollutants,
should also be addressed.
 Management of Stable COPD
Pharmacologic treatment

 Pharmacologic therapies can reduce symptoms, and

the risk and severity of exacerbations, as well as
improve health status and exercise tolerance.

 Most of the drugs are inhaled so proper inhaler

technique is of high relevance.
GOLD 2011

FEV1
GOLD 1 ≥ 80%
GOLD 2 50-79%
GOLD 3 30-49%
GOLD 4 <30%
 Revised GOLD 2017
• Spirometric grades are separated from the
ABCD groups.
• ABCD groups and pharmacotherapy will be
derived exclusively from patient
symptoms and exacerbation history.
• Spirometry in conjugation with patient
symptoms and exacerbation history
remains vital for:
1. Diagnosis
2. Prognostication
3. Therapeutic approaches
 Choice of thresholds
► COPD Assessment Test (CAT TM )
► Chronic Respiratory Questionnaire (CCQ® )
► St George’s Respiratory Questionnaire (SGRQ)
► Chronic Respiratory Questionnaire (CRQ)
► Modified Medical Research Council (mMRC) questionnaire
Revised 2017 ABCD Criteria
Short Acting B2 Formulation Onset Duration
Agonists (SABA) (Minutes)
Salbutamol Nebulization, Inhaled 5-15 2-6
Levalbuterol Nebulization, Inhaled Neb: 10-20 Neb: 5-8
Inhaled: 5-10 Inhaled: 3-6
Short Acting
Anticholinergics
Ipratropium Nebulization, Inhaled 1-30 4-6
 GOLD Group A
• All Group A patients should be offered
bronchodilators treatment based on
it’s effect on breathlessness (this can
be either short- or long-acting
bronchodilator).

• This should be continued if

symptomatic benefit is documented.

• If necessary, an alternative class of

bronchodilator (alternative mono
bronchodilator) can be used if benefit
is not achieved with the first.
 GOLD Group B
• For Group B patients, therapy
should begin with a long-acting
bronchodilator LABA or LAMA,
(no evidence to recommend one
over another), and should be
escalated to two bronchodilators
if breathlessness continues with
monotherapy
• If breathlessness is severe,
starting the patient on dual long-
acting bronchodilators can be
considered, however if the second
therapy does not improve
symptoms, the guidelines suggest
stepping down to one
bronchodilator.
 GOLD Group C
• It is recommended that treatment be
started with a single long-acting
bronchodilator, preferably a LAMA
(LAMA was superior to the LABA
regarding exacerbation prevention)

• A second long-acting bronchodilator

or the combination LABA and ICS may
be used for persistent exacerbations;

• As ICS increases the risk for

developing pneumonia in some
patients, our primary choice is
LABA/LAMA.
 GOLD Group D
• LABA and LAMA combination is preferred
as initial therapy over LABA and ICS as these
patients may be at higher risk of developing
pneumonia with ICS use.
• For patients with high blood eosinophil
counts or those with asthma-COPD overlap,
LABA and ICS could be considered first-line
therapy
• In patients who develop further
exacerbations on LABA and LAMA we
suggest two alternative pathways:
1) Escalation to LABA/LAMA/ICS (triple
therapy)
2) Switch to LABA/ICS – if it does not
positively impact
exacerbations/symptoms a LAMA can
be added.
 GOLD Group D
• For patients who still have
exacerbations with LABA/LAMA/ICS,
the following three options can be
considered:
1. Adding roflumilast (for patients
with FEV1 <50% predicted and
chronic bronchitis)

2. Adding a macrolide (azithromycin

preferred, however, antibiotic
resistance should be forced in
decision making)

3. Discontinuing ICS
 Non-pharmacologic Treatment
• Smoking Cessation
• Education and self-management
• Physical activity
• Pulmonary rehabilitation programs
• Exercise training
• End of life and palliative care
• Nutritional support
• Vaccination
• Oxygen therapy
 STOP SMOKING!!!
• Smoking cessation has the greatest capacity
to influence the natural history of COPD
(Improves Survival)

• If effective resources and time are dedicated

to smoking cessation, long-term quit success
rates of up to 25% can be achieved.
 Oxygen Therapy
Long-term oxygen therapy is indicated for stable
patients who have:

►PaO2 at or below 7.3 kPa (55 mmHg) or SaO2 at

or below 88%, with or without hypercapnia
confirmed twice over a three week period; or

►PaO2 between 7.3 kPa (55 mmHg) and 8.0 kPa

(60 mmHg), or SaO2 of 88%, if there is evidence
of pulmonary hypertension, peripheral edema
suggesting congestive cardiac failure, or
polycythemia (hematocrit > 55%).
Oxygen Therapy
Interventional bronchoscopy and surgery
• In selected patients with heterogeneous or homogenous
emphysema and significant hyperinflation refractory to
optimized medical care, surgical or bronchoscopic modes
of lung volume reduction (e.g., endobronchial one-way
valves or lung coils) may be considered.

• In selected patients with a large bulla, surgical bullectomy

may be considered.

• In selected patients with very severe COPD and without

relevant contraindications, lung transplantation may be
considered.
 Lung Transplantation
Very severe COPD
• progressive disease
• BODE score of 7 to 10
• Not candidate for lung volume reduction

• Considered for referral with at least one of the following:

1. History of hospitalization for exacerbation associated
with acute hypercapnia (PCo2> 50mmhg)
2. Pulmonary hypertension and/or cor pulmonale
despite oxygen therapy
3. FEV1 >20% and either DLCO <20% or homogenous
distribution of emphysema
Interventional bronchoscopy and surgery
 Vaccination
• Influenza vaccination can reduce serious illness
(such as lower respiratory tract infections
requiring hospitalization)24 and death in COPD
patients.

• Pneumococcal vaccinations, PCV13 and PPSV23,

are recommended for all patients ≥ 65 years of
age or in younger patients with significant
comorbid conditions including chronic heart or
lung disease.
Management of Exacerbations
• Exacerbation is defined as an acute worsening of
respiratory symptoms that results in additional
therapy.
• Precipitated by several factors especially respiratory
tract infections
• Goal:
• minimize the negative impact of the current
exacerbation
• to prevent subsequent events.
Management of Exacerbations
They are classified as:

Mild (treated with short acting bronchodilators only,

SABDs)
Moderate (treated with SABDs plus antibiotics and/or
oral corticosteroids) or
Severe (patient requires hospitalization or visits the
emergency room). Severe exacerbations may also be
associated with acute respiratory failure.
 Management of Exacerbations
No respiratory failure Acute respiratory Acute respiratory
failure — non-life- failure — life-
threatening threatening
• RR: 20-30 bpm • RR: > 30 bpm • RR: >30 bpm
• no use of accessory • using accessory • using accessory
respiratory muscles respiratory muscles
respiratory muscles • no change in mental • acute changes in
• no changes in mental status mental status
status
Classification • hypoxemia
of hospitalized patientsimproved • hypoxemia not
with supplemental improved with
• hypoxemia improved
oxygen via Venturi supplemental oxygen
with supplemental mask 25-30% FiO2 via Venturi mask or
oxygen given via • hypercarbia i.e., requiring FiO2 > 40%
Venturi mask 28-35% PaCO2 increased • hypercarbia i.e., PaCO2
compared with increased compared
inspired oxygen (FiO2)
baseline or elevated with baseline or
• no increase in PaCO2 50-60 mmHg elevated > 60 mmHg or
the presence of acidosis
(pH < 7.25).
Management of Exacerbations
 Management of Exacerbations
 The three classes of medications most commonly used for
COPD exacerbations are:
 Bronchodilators
 short-acting inhaled beta2-agonists, with or without
short-acting anticholinergics, are the initial
bronchodilators for acute treatment of a COPD
exacerbation.
 Corticosteroids
 systemic glucocorticoids in COPD exacerbations shorten
recovery time and improve lung function (FEV1). They
also improve oxygenation, the risk of early relapse,
treatment failure, and the length of hospitalization.
 Antibiotics
 shorten recovery time, reduce the risk of early relapse,
treatment failure and hospitilzation duration
 Management of Exacerbations
NON-INVASIVE VENTILATION (NIV)
Selection Criteria (at least one of the ff)
• Severe dyspnea with clinical signs suggestive of
respiratory muscle fatigue, increase work of breathing, or
both, such as use of respiratory accessory muscles and
paradoxical abdominal motion or retraction of the
intercostal spaces.
• Respiratory acidosis (<7.35) and/or Hypercapnia (PaCo2 >
45mmg)
Exclusion Criteria:
• Respiratory arrest, CV instability, change in mental status,
uncooperative patient, high aspiration risk, viscous or
copious secretions, recent facial or gastroesophageal
surgery, cranio facial trauma, fixed nasopharyngeal
abnormalities, burns and extreme obesity
Management of Exacerbations
INVASIVE MECHANICAL VENTILATION
Indications:
• Unable to tolerate NIV
• Status post-respiratory or cardiac arrest
• Diminished consciousness, psychomotor agitation
inadequately controlled by sedation
• Massive aspiration or persistent vomiting
• Persistent inability to remove respiratory
secretions
• Severe hemodynamic instability without response
to fluids and vasoactive drugs
• Severe ventricular or supraventricular
arrhythmias
• Life-threatening hypoxemia in patients unable to
tolerate NIV
 Prevention
• Smoking Cessation - greatest capacity to influence the natural
history of COPD
• Cessation early in the development of COPD can stop the
accelerated loss of lung function
• Cessation later in the course of disease may not be as effective
because airway inflammation may persist

• Avoidance of exposures to other noxious dusts and fumes

(environmental or occupational exposures)
• Slows disease progression
• May have benefit even late in the disease

• Vaccinations
• Influenza Vaccine
• Pneumococcal Vaccine
THANK YOU 