1. Problem Case
호흡기 내과
R2 오원택

2. 2004년 7월 COPD – Chronic bronchitis type
M/67 이0재 내원일:
주소: 호흡 곤란 시작일: 내원 3일전
현병력 :
2004년 7월 COPD – Chronic bronchitis type
( FEV1 : 28%, FEV1/FVC : 31% - GOLD criteria stage IV )
로 계속해서 내과 외래를 다니던 환자로 3일전부터 cough, sputum,
mild dyspnea 있던중 내원일 새벽부터 dyspnea 심해져 ER 경유 입원
과거력: 당뇨(+): 2년 전, OHA 고혈압/결핵/간염(-/-/-) 수술력(-)
가족력 : 특이 사항 없음
개인력 : 술 (+) - 소주 1병/주1회
담배 (-) - ex-smoker 2 years ago, 40PY

3. Review of system Physical examination
General : fatigue(+) weight loss(-) fever(-) chills(-)
Skin : rash(-) pigmentation(-) Itching(-)
Respiatory : cough(+) sputum(+) : prulent, many
dyspnea(+) : 3 days ago, more aggravated
Cardiac : chest discomfort(-) orthopnea(-) palpiation(-)
Gastointestinal : abdominal pain(-), A/N/V/D/C (-/-/-/-/-)
Physical examination
V/S : 110/60 mmHg - 118/min - 22/min ℃
General : Drowsy mentality, acute ill looking apearance
Chest : Coarse breathing sound with wheezing at BLL
Rapid heart beat without murmur
Abdomen : Normoactive bowel sound, Soft & flat abdomen
Tenderness/Rebound tenderness(-/-)

4. Impression Plan 1. COPD with exacerbation 2. Type 2 DM
Diagnostic - 1) CBC/DC, CRP, ABGA
2) Chest X ray
3) Sputum D/S and culture for AFB, Bacteria
Therapeutic – 1) O2 supply, bronchodilators
2) antibiotics

5. Laboratory Finding (initial)
CBC/DC : 9640/mm g/dL – 51.7 % /㎣ (Seg %)
Chemistry : TB/DB / 0.1 mg/dL
AST/ALT / 23 U/L Pro/ALB 7.1 / 3.9 g/dL
Glucose mg/dL
BUN/Cr / 0.7 mg/dL Na/K/Cl /3.2 /93 mmol/L
ABGA : – 39.7 – 32.3 – 73.9 % ( Room air )
CRP : 3.5 mg/dL
Cold agglutinin : < 1: Mycoplasma antibody : < 1:4

6. Chest PA (initial)

7. ECG

8. Clinical course I 1. On admission day (05.1.19), intubation → ICU care
Culture : sputum – many of pseudomonas aeruginosa
blood - A pure of Burkholderia (Pseudo.) cepacia
→ Ventilator care + antibiotics
2. On , extubation
1) Last ABGA on ICU : % (O2 3L NP)
2) General ward transferred : ICU - total 16 days

9. Clinical course II 3. On 05.3.1, Dyspnea, sputum developed
V/S) 110/70 mmHg – 106 /min – 28 /min – 36.5 OC
CBC/DC : 10,200/mm g/dL – 37.6 % - 254,000/㎣ (Seg %)
CRP : 0.6 mg/dL
ABGA : ) % (O2 1 L via NP)
Sustained dyspnea in spite of deep breathing, bronchodilators
05.3.3) % (O2 0.5L via NP)

10. Chest PA ( )

11. Clinical course III 4. On 05.3.3, Re-Intubation
After many prulent sputum suctioned, T piece was applied.
5. On ,
NPPV ( Noninvasive Positive Pressure Ventilation ) was considered.

13. Clinical course IV DATE ABGA symptom complication
3.3 18:00, intubation, T FiO (1h) %
severe dyspnea
3.4 15:00, NPPV, I/E 12/6 O2 10L (1h) %
dyspnea(-)
Mask부위 자극
3.5 6:00, NPPV, I/E 12/6 O2 8L (8h) %
mild dyspnea
3.6 6:00, NPPV, I/E 12/6 O2 4L (1d) %
3.7 6:00, NPPV, I/E 12/6 O2 8L (1d) %
3.8 6:00, NPPV, I/E 12/4 O2 5L (1d) %
Dyspnea improved
Mask부위 통증
3.9 6:00, NPPV, I/E 10/3 O2 5L (1d) %
3.9 10:00, VM FiO O2 6L (1h) %
3.12 6:00, VM FiO O2 6L (1d) %
3.14 6:00, VM FiO O2 4L (1d) %
:00, NP O2 1L (2h) %