1. Chronic obstructive pulmonary disease Edited by Chien-Da Huang Physician Educator/Associate Professor Department of Thoracic Medicine and Medical Education Chang Gung Memorial Hospital Taipei, Taiwan Case-Based Learning Case-Based Learning Thoracic Medicine

2. 胸腔科案例 -- COPD 學習目標 To identify the symptoms and signs of COPD. To understand the pathophysiology and common causes of COPD. To identify the significant findings of physical examination in patients with COPD. To identify the significant findings of Lab examination in patients with COPD. To know about newest version of GOLD guideline To understand the comorbidity of COPD. To know the optimal treatment to reduce the rate of acute exacerbation and to improve life of quality for this patients with very severe COPD?

3. Case presentation 66 year-old male Chief complaints of this admission –Aggravated shortness of breath on walking for 1 week –Increased amount of yellowish sputum Smoking history more than 30 pack per year, but quitting for 10 years Diagnosed as chronic obstructive pulmonary disease about 15 years He had experienced three episodes of respiratory failure in this year

4. Questions to be discussed? What are the factors aggravating dyspnea ? What are the causes of production of sputum? How do you define COPD? What is acute or chronic respiratory failure?

5. Physical examination –Body temperature: 36.5; pulse rate: 121 beats/min; respiratory rate: 27 /min; Blood pressure: 172/81 mmHg –Ill-looking –Accessory muscle used –Decreased breathing sound in bilateral lung field, crackles over LUL –Poor lung expansion over BLL –Lower lower limbs: cold, mild pitting edema

6. Exercise Intolerance/Dyspnea on exertion

7. Poor expansion of diaphragm Accessory muscle use Decreased breathing sound in bilateral lung field

8. Decreased lower limb muscle power Peripheral vasoconstriction Lower limbs: vasoconstriction Anti-gravity power of lower limb muscle: poor

9. Questions to be discussed? What do you find in the video clips? Please explain and discuss Make comments or share clinical experience from tutors

10. Laboratory findings –Leukocytosis with shift to left (WBC: 16,000 Seg:85%, Band: 5%) –BUN: 20 mg/dl, Cr: 0.8 mg/dL, GOT: 26 U/L, GPT: 32 U/L, Na:142 meq/L, K:2.9 meq/L –ABG: pH: 7.438, PaCO2: 52.9 mmHg, PaO2: 60.0 mmHg, HCO3: 35 mm/L, Sat:90.7%, Room air

11. Questions to be discussed? What are SIRS/sepsis/septic shock? Why does the patient get hypokalemia? Please discuss the ABG data?

12. CXR and Sputum culture CXR: –LUL alveolar infiltration –RLL peribronchial cuffing change Sputum culture –Neutrophil 3+ –Pseudomonas aeruoginosa

13. Questions to be discussed? How and what do you read from the CXR? How and what do you read the sputum smear and culture from the data? What is Pseudomonas aeruoginosa?

14. FVC: 0.81L (25% pred.) FEV1: 0.39 L (16% pred.); FEV1/FVC: 48.1% FEV1 (BD response <12%) 2007 GOLD Guideline: Stage IV: Very severe COPD 2012 GOLD guideline Category D Pulmonary function test

15. Questions to be discussed? What do you know about newest version of GOLD guideline? Try to read the pulmonary function test based on the GOLD guideline?

16. Medication Use of Antibiotics: –Ciprofloxacin 400 mg BID IVF Steroids –Oral steroids –Short-term of Hydrocortisone 100 mg iv q6H Theophylline 125 mg BID Procaterol 25 mg/tab1# BID Nebulization therapy : –Ipratropium 0.5 mg/UD + Terbutaline 5 mg/UD

17. MCQ Question 1 The patient complained of aggravated dyspnea during the recovery phase of acute exacerbation in outpatient clinic. Which factors should be taken into consideration for this patient with very severe COPD? (A) Mucus retention with 2 nd infection (B) Muscle dysfunction or atrophy (B) Muscle dysfunction or atrophy (C) All of above (C) All of above (D) None of all (D) None of all

18. Questions to be discussed? What are the comorbidities of COPD?

19. Factor 1: Mucus Retention When there will be mucus retention…. Airway collapse at early expiration Airway inflammation exacerbation No effective cough function due to low inspiratory capacity due to low inspiratory capacity New infection Mucus retention is considered for this patient: Poor diaphragm movement --- low inspiratory capacity Decreased breathing sound--- mucus plug Persistent airway inflammation

20. Structural changes Fiber size and composition Fiber size and composition Capillarity Capillarity Oxidative stress/enzymes Oxidative stress/enzymes Contributing Factors Hypoxia Hypoxia Hypercapnia Hypercapnia Systemic inflammation Systemic inflammation Malnutrition Malnutrition Drugs (steroids,  2 agonist) Drugs (steroids,  2 agonist) Comorbid states Comorbid states (chronic inactivity) (chronic inactivity) Functional changes Muscle weakness Muscle weakness Reduced oxygen delivery Reduced oxygen delivery and utilization and utilization Factor 2: Muscle dysfunction in chronic obstructive pulmonary disease Balasubramanian Curr Opin Pulm Med 2006; 12:106. Muscledysfunction For this patient: Contributing Factors Hypoxia Hypoxia Hypercapnia Hypercapnia Systemic inflammation Systemic inflammation Drugs Drugs steroids,steroids, oral or high dose inhaled  2 agonist)oral or high dose inhaled  2 agonist)

21. MCQ Question 2 What is the optimal treatment to reduce the rate of acute exacerbation and to improve life of quality for this patients with very severe COPD? 1. Tiotropium, 2. Inhaled steroid + long-acting b-2 agonist, 3. inhaled long-acting b2 agonist, 4. pulmonary rehabilitation, 5. vaccination, 6. oxygen supplement (A)1 + 2 + 5 (B)1 + 3 + 5 + 6 (C)1 + 4 + 5 + 6 (D)1 + 2 + 4 + 5 + 6

22. Individualized Treatment for this Patient Medicine –Tiotropium + Fluticasone/salmeterol (high dose) Hospital-Based Pulmonary Rehabilitation ProgramHospital-Based Pulmonary Rehabilitation Program –Mucus clearance technique –Exercise training program Walking Upper limbs training Inspiratory muscle training Transcutaneous Electrical Stimulation (TENS) Oxygen supplement Vaccination