+ CASE-6

SALWA AL-SAADOUN

2062040030
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 A fiftyyear old male patient attends the medical unit
complaining of bouts of cough with sputum, particularly
more in the morning and in the cold weather, wheeze,
exertional breathlessness and occasionally chest
tightness . His symptoms are steadily increasing in
severity and duration over the past 5 years. He reports to
suffer from the recurrent respiratory infections; then he
gets fever, the sputum become more purulent and
sometimes streaked with blood. He also reports to
smoke 15-20 cigarettes daily for about 25 years. His
symptoms increase when he smokes, gets infection and in
adverse atmospheric conditions.
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 The chest examination shows central cyanosis, pursed

lip breathing, tracheal descent, deepening of supra-
sternal and supra-clavicular fossae during inspiration,
together with indrawing of costal margin and
intercostals spaces. The antero-posterior diameter of
the chest is increased relative to the lateral diameter. The
auscultation reveals ronchi, which are more during
forced expiration, loud pulmonary second sound and
tricuspid regurgitation.
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 There are also flapping tremor, peripheral edema, and
raised JVP. The pulse is 90/minute, bounding in
character, BP is 110/75 and body temperature is 39oC.
 FEV1 is < 40% predicted (reduced), FEV1/FVC ratio is
<60% (reduced) and the total lung capacity (TLC) and
the residual volume is increased. Measurement of blood
gases shows low PaO2 and increased PaCO2.
 chest radiograph shows hypertranslusent lung field,
disorganized vasculature ,pulmonary artery shadow
and low flat diaphragm.
 FEV1 improves with an injection of ipratropium as well
as with oral prednisolone (30mg for 2 weeks)
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 COPD is characterized by poorly reversible progressive airflow limitation
associated with persistent inflammatory response of the lungs.

 COPD was previously diagnosed as chronic bronchitis or emphysema.

 COPD is predominantly caused by smoking

 Airflow limitation is caused by airway narrowing BY:

 hypertrophy of mucus-secreting glands and mucus hypersecretion

 Bronchial wall inflammation and mucosal edema Chronic

bronchitis
 Epithelia cell layer may ulcerate which heel with scaring

 Loss of elastic recoil due to dilatation and destruction of lung tissue

Emphysema
distal to terminal bronchioles
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 Cough
 Sputum
 Exertional breathlessness.
 Fever
 Peripheral edema and raised JVP
 Central cyanosis, flapping tremor and rebounding pulse
character
 Recurrent respiratory infection
 Reduced FEV1 and FEV1/FVC
 Low PaO2 and increased PaCO2
+
 Treat hypoxia
 Treat the symptoms:

 Cough
 Sputum
 Exertional breathlessness.
 Fever
 Peripheral edema

 Treat infection
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 Removal of risk factors:
 cessation of smoking
 Oxygen therapy
 Drug therapy:
 Bronchodilator

 Corticosteroid

 Antibiotics

 Mucolytics

 diuretics
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 Hypoxemia is the respiratory derive in COPD patient

 Low oxygen concentration(24%) is given via a
Venturi mask. So, not reduce respiratory derive and
precipitate worsening hypercapnia and respiratory
acidosis
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Non-opioid efficacy safety suitability cost TOTAL

NSAID +++ ++ ++ ++ 9
paracetamol ++ +++ +++ +++ 11

 P-drug is paracetamol
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Drug Group Efficacy Safety Suitability Cost Total

Anti-muscarinics ++ +++ +++ ++ 10

B2 agonists +++ +++ ++ +++ 11

Methylxanthine
++ + + ++++ 8

 P-Drugs is
B2-adrenergic agonist and Anti-muscarinic
+

Drug
Anti-
Efficacy Safety Suitability Cost Total
muscarinics

Tiotropium +++ +++ ++++ ++ 12

Ipratropium
+++ +++ +++ ++++ 13
bromide
 P-Drug is Ipratropium bromide
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Tota
Β2 agonists Efficacy Safety Suitability Cost
l
Salbutamol +++ +++ +++ ++++ 13

Terbutaline +++ +++ +++ +++ 12

Salmeterol +++ ++ +++ ++ 10

Formoterol +++ ++ +++ ++ 10

 P-Drug: Salbutamol
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Drug Efficacy Safety Suitability Cost Total

Prednisolone +++ +++ +++ ++++ 13

Budesonide ++ +++ ++ ++ 9

Beclomthasone ++ +++ ++ +++ 10

Ciclesonide ++ +++ ++ ++ 9

Fluticasone ++ +++ ++ ++ 9

 P-drug is Prednisolone
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Drug Efficacy Safety Suitability Cost Total

amoxicillin +++ +++ +++ +++ 12

Augmentin ++++ ++ +++ ++ 11

Cefaclor
+++ ++ +++ ++ 10

cefixime +++ ++ +++ +++ 11

P-drug is amoxicillin
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Drug Efficacy Safety Suitability Cost Total

N-acetyl +++ ++ +++ +++ 11

Cysteine

Dornase +++ ++ ++ + 8
Alpha

 P-drug is N-acetyl Cysteine

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 salt or fluid restriction

Group Efficacy Safety Suitability Cost total

Loop diuretics ++++ ++ +++ ++ 11

)Frusemid(
Thiazide +++ ++ ++ +++ 10

Potassium- ++ + ++ +++ 8
sparing

 P-drug is frusemid
+Name of institution: KFHU
Patient’s name : age: 50 sex: male
MR#: Date:
Rx
 Paracetamol 500 mg PO every 4 hours
 Ipratropium bromide nebuliser solution 250-500 mcg 4 times daily
 Sulbutamol 200 μg every 6 hours
 Prednisolone 30 mg PO for 2 weeks
 Amoxicilin 250 mg PO tablet TID
 N-acetyl Cysteine 750 mg PO TID
 Furosemide PO initially 40 mg, maintenance 20–40 mg daily

Dr name Dr signature
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 Educate the patient about the COPD and the importance of

immediate management of the exacerbation
 Instruct the patient to stop smoking and avoid other risk factors
as air pollution
 Take pneumococcal vaccine and influenza vaccine to prevent
infection
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