CHRONIC OBSTRUCTIVE PULMONARY

DISEASE
CASE BASED DISCUSSION BY :

ANBU RAJ A/L KUMARAGURUBARAN ( SUKD1600622)

ABDUL SALAM DOST ( SUKD1901925)
 TABLE OF CONTENT
1. Case Scenario
2. Chief Complaint And History Of Presenting Illness
3. Past Medical History, Drug History And Allergy History
4. Family History And Social History
5. Systemic Review
6. Summary
7. General Examination
8. Examination Of Respiratory System
9. Provisional And Differential Diagnosis
10. Introduction And Definition
11. Risk Factors
12. Pathophysiology
13. Clinical Features
14. Investigations
15. Management
16. Complications
17. References
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 CASE SCENARIO
Mr Cashran, a 54 year old taxi driver, presented with shortness of breath which progressively
increased in severity for the past 4 days. He is a chronic smoker for the past 40 years. He has also
been having chronic cough for the past 3 years associated with mucoid sputum. The dyspnoea
occurred after an episode of upper respiratory tract infection. He has not sought treatment prior
to this admission.

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CHIEF COMPLAINT :
● Shortness of breath

HPI :
SOB

● Onset: progressively increased in severity for the past 4 days

● A/F: wheeze, cough with mucoid sputum
● Duration: persistent breathlessness for 1 yr
● E/F: exertion and experiences reduced effort tolerance. He is now able
to climb one and a half flights of stairs before becoming breathless
● Dyspnoea is grade 4 on MRC breathlessness scale

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HPI (cont.)
● Cough
○ Timing: intermittent chronic cough
○ Duration: past 3 yrs
○ Associated w/: mucoid sputum
● Wheeze
○ Occurs w/ exertion and is worse on
waking in the morning
● Sputum
○ Color: mucoid, non-purulent
○ Volume: 1 tablespoonful
○ No blood in sputum
○ Not foul-smelling
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PMH and PSH
● No prior hospitalizations
● Hypertension for the past 1 yr
● No surgical history

DRUG HISTORY
● Amlodipine 5 mg od

ALLERGY HISTORY
● No history of any known allergies

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FAMILY HISTORY
● Eldest of 5 siblings
● Mother and 2 other siblings are also hypertensive
● No family history of asthma, DM, or IHD

SOCIAL HISTORY
● Used to work as a taxi driver but has stopped working full time 2 yrs
ago
● 40 pack-year history of smoking
● Drinks 1 to 2 bottles of beer with his friends on weekends

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SYSTEMIC REVIEW
● No loss of appetite or loss of weight
● Mild ankle oedema
● No other signs of heart failure such as orthopnoea or paroxysmal nocturnal dyspnoea

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 SUMMARY
Mr Cashran is a 54 year old taxi driver who presented with shortness of breath for the past four days.

He is a chronic smoker for the past 40 years who has been smoking about twenty sticks of cigarettes a
day.

He has been having intermittent chronic cough for the past 3 years. The cough is productive at times.
The sputum produced is mucoid in nature and about one tablespoonful in amount. There is no blood in
the sputum. It is also not foul-smelling. Mr Cashran then proceeded to have shortness of breath for the
past one year. The dyspnoea is persistently present and described as requiring increased effort to
breathe. It is worse on exertion and he experiences reduced effort tolerance. He is now able to climb
one and a half flights of stairs before becoming breathless. He has not consulted any doctors for these
symptoms prior to admission.

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 General Examination
Mr Cashran was well nourished and alert but was tachypnoiec. He was able to speak in sentences
but there was use of his accessory muscles. There was no clubbing or cyanosis seen. There was mild
ankle oedema, but no pallor or jaundice.

Vital signs

● Pulse rate: 72 beats per minute, regular with good volume. No bounding pulse.
● Respiratory rate: 28 bpm
● Blood pressure: 129/73 mmHg
● Temperature: 37 C
● SpO2: 95%

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 EXAMINATION OF THE RESPIRATORY SYSTEM
Hands:

● No peripheral cyanosis/ flapping

tremors
● No clubbing/ muscle wasting or
palmar erythema
● Presence of nicotine stains

Neck:

● No raised JVP
● Trachea was central
● Cricosternal distance reduced to 2
fingers

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INSPECTION PALPATION
● Barrel shaped chest ● Chest expansion reduced on b/s
● Chest moved equally w/ respiration ● Tactile fermitus was equal on b/s
● Use of accessory muscles w/ intercostal,
subcostal, and suprasternal retraction
● No chest wall deformities

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PERCUSSION AUSCULTATION
● Hyperresonance both lungs ● Expiratory rhonchi
● Fine crepitations heard at the lower
zones of both lungs

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PROVISIONAL DIAGNOSIS
● Acute exacerbation of newly diagnosed COPD due to upper respiratory tract
infection

Evidence for:
● Presence of persistent dyspnoea with reduced effort tolerance
● Chronic smoker
● Presence of chronic cough a/w mucoid sputum
● Hyperinflated chest
● Expiratory rhonchi
● During this admission, increasing severity of SOB even at rest and a/w a wheeze
suggest an episode of acute exacerbation
● History of upper RTI symptoms suggest it was the trigger for this episode of
exacerbation
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DIFFERENTIAL DIAGNOSIS
1. Asthma

SOB, wheezing, cough, use of accessory muscles, expiratory rhonchi, hyperresonant

lungs may suggest asthma

Evidence against:

● No family history of asthma

● No history of allergy
● Long smoking history strongly suggestive of COPD
● Onset early in life for asthma
● No history of waking due to SOB
● Dyspnoea during exercise suggests COPD
● Symptoms vary from day to day in asthmatics

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2. Congestive cardiac failure
● History of reduced effort tolerance
● Wheeze and sudden increase in dyspnoea
● Fine crepitations at bases of both lungs
● Mild pitting ankle oedema
Evidence against:
● No history of any cause of heart failure such as IHD or cardiac valve defect
● Additional investigations TRO CCF

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3. Bronchiectasis
● Chronic cough w/ sputum production
● Persistent SOB
● Reduced effort tolerance
● Wheeze

Evidence against:
● Sputum was mucoid in nature and not purulent
● Coarse crepitations heard in bronchiectasis
● No evidence of clubbing

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 INTRODUCTION
● Affects more than 5% of the population

● Third leading cause of death worldwide

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 DEFINITION
● Common preventable and treatable disease

● Persistent airflow limitation

● Includes :
○ Chronic bronchitis
○ Emphysema

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 RISK FACTORS
● Lung growth
● Occupational exposures
● Genetic factors
● Infections
● Socioeconomic status
● Tobacco smoke
● Indoor air pollution
● Cannabis smoking
● Airway hyper-reactivity
● Low birth weight

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PATHOPHYSIOLOGY

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PATHOPHYSIOLOGY

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 CLINICAL FEATURES
SYMPTOMS :
● Chronic and progressive dyspnea
● Chronic cough
● Chronic sputum production
● Wheezing
● Chest tightness
● Weight loss
● Respiratory infections

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 CLINICAL FEATURES
SIGNS :

● Prolonged expiration during quiet breathing

● Accessory respiratory muscle participate
● Hoover’s sign
● Tripod position
● Barrel chest
● Expiration through pursed lips
● Pitting oedema
● Decreased Tactile fremitus
● Hyperresonant
● Depressed diaphragm
● Diminished area of absolute cardiac dullness
● Prolonged expiration
● Reduced breath sounds
● Wheezing during quiet breathing
● Crackles
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CLINICAL FEATURES

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 INVESTIGATIONS
DIAGNOSIS :
● Basis of history ( breathlessness and sputum production in a chronic smoker )

● Physical examination

● Lung function testing ( confirmation of airflow limitation )

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 INVESTIGATIONS
● Full blood count ( anemia, polycythaemia, 𝛂1- antitrypsin)
● Arterial Blood Gases
● ECG and Echocardiography
● Chest X-ray
● High resolution CT scan
● Lung volumes and diffusing capacity
● Lung function test
○ Spirometry
○ Require to establish the diagnosis
○ Post-bronchodilator FEV1/ FVC < 0.70

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INVESTIGATIONS

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INVESTIGATIONS

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 MANAGEMENT
● Bronchodilators ( β2 Agonist, Anticholinergic agents, Theophylline )
● Glucocorticoids
● Combination therapy
● Phosphodiesterase-4 inhibitors
● Influenza vaccines
● Oxygen therapy
● Pulmonary rehabilitation
● Surgical intervention ( Bullectomy, Lung volume reduction surgery, lung transplantation)
● Smoking cessation

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 COMPLICATIONS
● Pneumothorax
● Pneumonia
● Pulmonary hypertension
● Cor Pulmonale
● Exacerbations of COPD
● Respiratory failure

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 REFERENCES
● Ralston, S. H., Penman, I. D., Strachan, M. W. J., & Hobson, R. (Eds.). (2018). Davidson’s
principles and practice of medicine (23rd ed.). Elsevier Health Sciences.

● Kumar, P. J., & Clark, M. L. (2002). Kumar & Clark clinical medicine. Edinburgh: Saunders.

● Guidelines In The Management Of Chronic Obstructive PUlmonary Disease-A Consensus

Statement Of The Ministry Of Health Of Malaysia, Academy Of Medicine Of
Malaysia And Malaysian Thoracic Society. Med J Malaysia 1999; 54:387-400.

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 THANK YOU

“ COPD IS THE 3rd LARGEST KILLER AFTER CANCER AND HEART DISEASE “
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