عملى:: Chest case ~ History of COPD

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- Question:
- What is your diagnosis ??
- Answer:
- A case of chronic bronchitis, COPD complicated by cor pulmonale & RVF.

- Question:
- Why ??
- Answer:

1- Because the patient is a male, chronic heavy smoker, 55 years of age,
with the following history:

1. Long history of chronic bronchitis: ( 3 months, 2 years …… at least )
 Chronic cough with expectoration of mucoid sputum.
 Chronic cough with expectoration of mucopurulent sputum.
 Chronic cough with gradual progressive dyspnea & wheezing.

2. Chest pain, due to:
 Pain in intercostals muscles.. from chronic cough.
 Pneumothorax……………… from rupture of emphysematous bullae.
 Pleurisy ……………………… from complicating pneumonia.

3. Oedema of lower limbs, due to:
 Cor pulmonale & RVF.
 Salt & water retention.

2- Because, On examination, I found:

1. Respiratory rate:
o Tachypnea with working accessory respiratory muscles.


2. Head examination:
o Puffiness of the eye lids due to chronic cough.

3. Neck examination:
- Congested neck veins due to:
o Increased intrathoracic pressure.
o Cor pulmonale & RVF.

4. Lower limbs:
o Oedema of lower limbs.


5. Chest signs:

Inspection
Shape: barrel-shaped chest ( increased AP diameter bilaterally ).
Movements: diminished bilaterally.

Palpation
Trachea: central.
TVF: diminished all over the chest.

Percussion
Hyper-resonance all over the chest.
Encroachement on the normal hepatic & cardiac dullness.

Auscultation
Breath sounds: vesicular breathing with prolonged expiration.
Additional sounds: generalized rhonchi, may be early inspiratory crepitations


- Question:
- What are the possible complications of COPD ??

- Answer:
1. Respiratory failure.
2. Right sided heart failure following cor pulmonale. Failure
3. Left sided heart failure.

4. Pulmonary infections.
5. Pneumothorax. Chest complications
6. Bronchiectasis.

7. Polycythemia.
8. Salt & water retention. General complications
9. Complications of chronic cough.


- Question:
- Is this patient complicated by cor pulmonale ??
- Answer:
- Yes, because there are epigastric pulsations of RVO ( only reliable sign of
corpulmonale in the presence of COPD ).


- Question:
- Is this patient complicated by RVF ??
- Answer:
- Yes, because there are: “ By history ”
o Pain in the right hypochondrium.
o Jaundice.
o Oedema of LLs.

And because there are: “ By examination ”
o Congested pulsating neck veins.
o Enlarged tender pulsating liver.
o Oedema of both lower limbs (not reliable alone)
o S3 gallop over the tricuspid area.

- Question:
- What is the importance of the lower border of the liver in a case of COPD ??
- Answer:
- The lower border of the liver may be palpable due to:

- Ptosed liver: pushed down by flat diaphragm due to hyperinflation (non tender).
- Enlarged liver: due to RVF ( tender).
NB: we confirm the size of the liver by the liver span.

- Question:
- Is the presence of oedema a sure evidence of RVF ??
- Answer:
- No, it can occur in absence of RVF, due to salt & water retention.

- Question:
- What causes salt & water retention in COPD ??
- Answer:
o Increased levels of: renin & aldosterone.
o Compensation for respiratory acidosis.

- Question:
- Is the patient complicated by LVF ??
- Answer:
- No, there were no signs of LVF.

- Question:
- What causes LVF in a patient with COPD ??
- Answer:
1. Hypoxia leading to myocardial ischemia.
2. Acidosis leading to myocardial depression.
3. Reversed Bernheim effect.
4. Volume overload due to hyperdynamic circulation due to VD.
5. Increased blood viscosity due to polycythemia.
6. Associated disease of the left side of the heart, especially CAD.

- Question:
- Is the patient complicated by respiratory failure??
- Answer:
- Respiratory failure is a laboratory diagnosis, looking for hypoxia with or without
hypercapnea. However: it seems that he is free from respiratory failure because
the patient did not have:
o Central cyanosis.
o Flapping tremors.
o CO2 narcosis ( hypersomnia & disturbed consciousness level ).
- Question:
- Why does your patient look plethoric ??
- Answer:
- Due to secondary polycythemia from the present hypoxia.

- Question:
- What are the important investigations you would ask for ??
- Answer:

INVESTIGATIONS

1. Chest X ray:

a) Signs of hyperinflation:
 Hypertranslucency of the lung fields.
 Transverse ribs & wide intercostal spaces.
 Low flat diaphragm.
 Heart shadow is elongated “ ribbon-shaped heart .”
 May be emphysematous bullae.

b) Increased bronchovascular markings.


2. Respiratory function tests:

Specific respiratory function tests:

a) Ventilation tests: features of obstructive hypoventilation:
- Disturbed all tests of ventilation.
b) Diffusion tests:
- Disturbed tests of diffusion: decreased CO transfer factor.
c) Perfusion tests:
- Disturbed tests of perfusion.

General respiratory function tests: ( arterial blood gases )
 Hypoxia.
 Hypercapnea.
 Increased bicarbonate.

3. Blood picture:
- May show polycythemia.

4. Serum alpha 1-antitrypsin:
- Decreased in primary emphysema.

- Question:
- What are the indications of corticosteroids in this patient ??
- Answer:
- Prednisone 1 mg / Kg / day orally is given in:
“ Patients not responding to the usual bronchodilators ”.


- Question:
- So what is your final diagnosis ??
- Answer:
- A case of chronic bronchitis, COPD complicated by cor pulmonale & RVF.



- Question:
- So, is your patient pink puffer or blue bloater ??
- Answer:
- My case is a mixture of the 2 types because they frequently co-exist.
- It is usually difficult to differentiate them into 2 separate clinical types.



NB COPD is a case in the exam ( long ) & ( short ): 100 % .

You must prepare the theoretical lessons of:
• Chronic bronchitis.
• Emphysema.
• COPD.
• Asthma.
• Respiratory failure.
• Bronchiectasis.
• Respiratory functions.