Name: Yvonne Ybarra Date: January 21, 2021 Course No: RSPT 2363-T02 Case Study 1: Chronic Bronchitis Key Terms Alpha 1-Antitrypsin Deficiency- blood test useful for individuals with a family history of Panlobular emphysema due to the deficiency of the protease inhibitor alpha 1-antitrypsin “Blue Bloater”- Type B COPD, derived from the cyanosis or bluish color of the lips and skin seen in patients with chronic bronchitis Centriacinar Emphysema- most common form of emphysema and strongly associated with cigarette smoking Centrilobular Emphysema- one type of emphysema characterized by enlargement of air spaces in the proximal portion of the acinus Chronic Bronchitis- chronic cough for 2 months in each 2 successive years in a patient Emphysema- presence of permanent enlargement of the air spaces distal to the terminal bronchioles accompanied by destruction of the bronchiole wall and without obvious fibrosis Hoover’s Sign- inward movement of the lower lateral chest wall during each inspirationindicates severe hyperinflation Panacinar Emphysema- one type of emphysema characterized by uniform enlargement of air spaces throughout the terminal bronchioles and alveoli Panlobular Emphysema- type of emphysema characterized by the uniform enlargement of air spaces throughout the terminal bronchioles and alveoli. It is commonly found in the lower parts of the lung “Pink Puffer”- Type A COPD, derived from the reddish complexion and the pursed-lip breathing seen in patients with emphysema S: A 71- year-old male was admitted into South Carolina Medical Center after being assessed and informed that he has had a chronic cough. The male works has been working at a cotton mill for the past 37 years. Upon admission, the man informed us that he has been smoking 40 cigarettes a day for the past 30 years which suggests that he has a 60-pack year history. Aside from smoking 40 cigarettes a day, he chew tobacco regularly as well. The male described his cough as a “smoker’s cough” that has been present for 4-5 months out of the year. He recently went to get medical assistance from a chest clinic in South Carolina for the chronic cough and was told to stop smoking, but the man has not followed medical advice and the cough has not improved, only worsened. He also mentioned that for the past 3 years, his cough has produced grayish-yellow sputum occasionally during the winter months that is also thick. He has been feeling shorter of breath during moderate exercise and occasional occupational movements like walking upstairs, but it could also be because he is only getting older and is old. It was also explained that he has not been taking any pulmonary medications or over the counter medications. O: On physical observation, the patient was in mild respiratory distress. The patient weighed in at 270 lbs. which is 122.5 kg. and measured 5 ft. 6 in. tall. Occasionally, the patient would cough, and it was a strong, productive cough that produced gray-yellowish sputum just like the patient had described producing for the past 3 years. Auscultation revealed medium bilateral crackles with scattered wheezing heard over the chest. Due to the man being in obvious respiratory distress, he was placed on a nasal cannula at 1 LPM (FIO2 of 0.24). An arterial blood gas (ABG) was drawn 30 minutes after he was given oxygen and it showed a pH of 7.36, PaCO2 Name: Yvonne Ybarra Date: January 21, 2021 Course No: RSPT 2363-T02 Case Study 1: Chronic Bronchitis 88 mm Hg. HCO3 49 mEq/L, PaO2 65 mm Hg, and an SaO2 of 90%. A chest radiograph was also obtained after it was requested by his doctor and it showed hyperinflation. His vital signs upon admission were a heart rate of 110 beats/min, respiratory rate of 20 breaths/min, a temperature of 98.8F, and a blood pressure of 141/72. After oxygen was given there was very slight improvement, and his heart rate was 108 beats/min and a respiratory rate of 18 breaths/min. The hospital had gotten his pulmonary function tests (PFT’s) transferred from the chest clinic and they showed a decrease in FEV1/ FVC (65%) and a decrease FEV1 (55% of predicted). The patient’s mMRC came out to 1. He had also reported that he had not had any exacerbations during the past 12 months (year). Based on the Combined Assessment of COPD Rubric Scoring System, he was placed into the GOLD (Global Initiative for Chronic Obstructive Lung Disease) Group A classification which are low risk, and less symptoms patients. A: It is based upon my assessment that the patient has Chronic Bronchitis but is a low-risk patient at the moment. Chronic Bronchitis is also known as Type B Chronic Obstructive Pulmonary Disease (COPD) and some of these patients are also known as “Blue Bloaters” because of the characteristics the disease causes. They are called this because the patient appears overweight and cyanotic especially at the lips hence the name “blue bloater”. They have a low ventilation-perfusion ratio and a depressed respiratory drive that reduces their arterial oxygenation level and causes the cyanosis. The patient has had a chronic cough that has produced thick, gray-yellow sputum and crackles were heard upon auscultation. Scattered wheezing was also heard over the chest area. The patient has a strong cough, so he is able to mobilize secretions and expectorate the sputum. Under his classification, he was a low risk and placed under Group A based off the questionnaire and because the patient himself mentioned that he had not had any exacerbations within the past year. His PFT results showed that the patient also had moderate airflow limitation with a decreased FEV1/ FVC of 65%. His ABG results also showed that he has chronic ventilatory failure with mild hypoxemia based on his pH being on the low end and him retaining so much CO2 which is seen at 87 mm Hg. Most COPD patient’s pH appears to be normal, but they will retain a lot of CO2 which is seen in this case as well as his chest radiograph which revealed hyperinflation. There is a decrease in his respiratory drive which will then increase carbon dioxide levels. P: The patient is a COPD patient, and he has already been given oxygen therapy at 1 LPM (FIO2 of 0.24). This is important because oxygen therapy should be kept below 0.28 FIO2 and no greater due to the fact that they are hypercarbic. COPD patients retain CO2 and don’t respond to high oxygen stimulus when it is given which can make them delusional and tired and further worsen their respiratory drive. His vital signs also showed that the patient had some improvement with the oxygen therapy given at 1 LPM and it needs to continue to be monitored. Aerosolized medication protocol should also begin because the patient has bronchospasm and wheezing as well as crackles that were heard upon auscultation. He is to be given DuoNeb (Albuterol 3.0 mg & Ipratropium Bromide 0.5 mg) via SVN. The patient already is able to mobilize secretions, but cough and deep breathing (C&DB) techniques can help the patient breathe and mobilize secretions better. When the patient is to be discharged from the hospital, he should continue his aerosolized medication protocol of Advair Diskus (Fluticasone & Salmeterol) via DPI 100 mcg fluticasone/50 mcg salmeterol, 1 inhalation twice daily 12 hours apart since the patient will still continue working at an occupational hazardous area and on the Name: Yvonne Ybarra Date: January 21, 2021 Course No: RSPT 2363-T02 Case Study 1: Chronic Bronchitis go. The patient needs to be educated on smoking cessation since smoking is a huge risk factor to his health and advised to retire from the cotton mill ASAP if he wants to manage his health better. He is also to be referred to a smoking cessation clinic and program to help with his condition and help him quit smoking. The patient should be referred to a nutritionist to help with his diet and exercise to lose weight since he is obese that could affect his health. Lastly, the patient should be given the pneumococcal vaccine since he is at high risk of contracting the pneumococcal disease because he of his age at 71-years-old. Follow-Up Assessment S: A male patient arrived at the emergency room of South Carolina Medical Center. He informed the medical staff that he was here 10 months prior to today and he was not feeling or doing well. After his discharge the patient did go to a smoking cessation program that helped him stay off of smoking cigarettes for a month, but after that he was back to his 3-packs-per-day smoking habit and stopped attending the program. The patient did not follow through on a diet or exercise and has gained weight. The patient had stated that he got enough exercise at work climbing the stairs and that was more than enough because he would be out of breath getting to the top. He also let the staff know that he was coughing a lot more frequently and it would be troublesome in the mornings. He would expectorate 3-4 tablespoons of thick yellowish-green sputum every day. Despite being short of breath at work, he also complained that sometimes just by walking he has an increased work of breathing. The patient denied having chest pain, orthopnea, fever, chills, leg edema, and hemoptysis. One thing the patient has been compliant with his taking his medication of Advair Diskus (Fluticasone & Salmeterol) via DPI 100 mcg fluticasone/50 mcg salmeterol, 1 inhalation twice daily 12 hours apart because he says it has helped him breathe better now that he has had an increased work of breathing more frequently than before on some days. O: It is based upon my observation that the patient was still obese and has in fact gained 30 lbs. increasing his weight to 300 lbs. now (136 kg) in the past 10 months. Despite the patient denying having leg edema, his ankles were indeed swollen and noted moderate pitting edema at 3+. It also took 1 ½ minutes to refill after it was touched. The patient’s neck veins were also distended, and he did appear to be cyanotic and have cyanosis around his lips as well which are all common signs of Chronic Bronchitis. When he was auscultated, bilateral posterior basilar wheezing was heard as well as course crackles which would clear with some coughing. When he would cough, he would expectorate copious, purulent, sputum that was yellow green in color. A chest radiograph was obtained, and it showed fibrotic lung markings that were diffused and an enlarged right side of the heart. His vital signs were a blood pressure of 165/90, heart rate of 116 beats/min, respiratory rate of 26 breaths/min, and an oral temperature of 98.4F. A bedside spirometry was done and his FEV1/FVC ratio was at 51% and his FEV! Was 37% making a GOLD 3. His mMRC scale was at a 2 due to the fact that he had an exacerbation the last time he was admitted into the hospital 10 months prior and one at the time of admissions now showing he has had 2 total exacerbations at this point. He is also now placed in GOLD Group D which is a higher risk and symptom patient. A CBC was also taken, and his hemoglobin (Hb) was at 17.8 g%, red blood count (RBC) at 9.5 mill/mm3, hematocrit (Hct) 52%, and white blood count Name: Yvonne Ybarra Date: January 21, 2021 Course No: RSPT 2363-T02 Case Study 1: Chronic Bronchitis (WBC) was at 14,000 cells/mm3. Thirty-minutes after the patient was placed on oxygen therapy at 2 LPM (FIO2 0.28) via nasal cannula, an arterial blood gas was obtained and it showed a pH of 7.51, PaCO2 51 mm Hg, HCO3 39 mEq/L, PaO2 41 mm Hg, and SaO2 at 84%. With a pulse ox monitor, his SpO2 on room air was at 83% and increased to 89% with the oxygen therapy at an FIO2 at 0.28. A: Based on all the objective and subjective information gathered, it is my assessment that the patient has increased his severity of Type B Chronic Bronchitis. He has now become a high-risk patient and came to the emergency room due to the fact that he had an exacerbation and couldn’t control it with medications. He has also not followed through on his care plan at home and has continued smoking and worsening his health. He has also gained weight and made it harder for him to control his condition. The patient has a 90 pack-year smoking history as of date and has stopped attending his smoking cessation program. He has signs and symptoms such as a chronic cough, sputum production that shows signs of infection, cyanosis, and even his acute exacerbations. An infection is assessed because he has a low-grade fever of 99.2ºF and his sputum is purulent and of yellow-green color. According to his CBC results, his white blood count is also elevated at 14,000 cells/mm3 which indicative of them fighting off an infection. Crackles and wheezing were heard upon auscultation over both lung bases and indicate bronchospasm and excessive mucus accumulation. Although the patient has a strong cough, he is producing tablespoons amount of sputum daily and could eventually tire out and not be able to expectorate the sputum eventually. There is evidence of cor pulmonale based off of his chest radiograph, but it is a moderate enlargement. Along with that, pitting edema was noted, and the patient also has polycythemia with an elevated RBC of 9.5 mill/mm3. The patient went from Group A to GOLD Group D in the matter of 10 months which classifies him as a high-risk patient with more symptoms that he has presented from that of a less risk patient. Based on his ABG, the patient also has chronic ventilatory failure with moderate-severe hypoxemia and is impeding ventilatory failure with a PaO2 at 41 mm Hg. P: I would recommend that the patient continue his oxygen therapy protocol at 2 L/min (FIO2 0.28) but change to a Venturi mask instead of a nasal cannula so that he can precisely receive oxygen. This should also be done because he has already showed signs of improvement in his SpO2 to 89%. The patient should also have his SpO2 continuously monitored because the patient is impeding ventilatory failure and can reach severe hypoxemia soon. An ABG should be drawn in the next 20 minutes again to see if the patient’s condition has improved or not. A mechanical ventilator should be set up and placed on standby just in case it is needed as well as being prepared for intubation. Due to the patient having bronchospasm and crackles heard in both bases of the lungs, he should be given aerosolized medication of DuoNeb (Albuterol 3.0 mg & Ipratropium Bromide 0.5 mg) via SVN. He should also be given an oral corticosteroid of 40 mg Prednisone for 5 days to help with his exacerbation. According to guidelines since the patient is also a GOLD 3 patient, Rofumilast should be given because he now has a history of having exacerbations. Despite the patient having his strong cough, we can see that there is excessive mucus accumulation that was heard with crackles upon auscultation, so he needs to begin cough & deep breathing (C&DB) techniques 4 times daily after he improves from his exacerbation to help expectorate his sputum. CPT t.i.d should also help mobilize the secretions but should be done with caution and if the patient can tolerate it. If the patient ends up intubated, closed Name: Yvonne Ybarra Date: January 21, 2021 Course No: RSPT 2363-T02 Case Study 1: Chronic Bronchitis suctioning should be done PRN. Since the patient has a possible infection, a sputum and culture sensitivity test (S&C) should be done. It is possible that the patient has a Pseudomonas aeruginosa infection since his sputum his purulent and of greenish-yellow color. In the meantime, the patient should begin antibiotic therapy of Amoxicillin 500 mg every 12 hours since it is a broad-spectrum antibiotic and when the results of the S&C are obtained, proper antibiotic medication should be given and switched to target that certain bacillus infection. The patient has shown signs of cor pulmonale which is also right sided heart failure so an echocardiogram should be acquired. The patient should also be given Aspirin (300 mg q.6.h) since it is a vasodilator and can also treat the patient’s low-grade fever from the infection. Since the patient also has shown pitting edema 3+, Furosemide (Lasix) 80 mg should be given to decrease excess fluid that’s collecting in the patient’s legs. Due to the initiation of this drug and the patient holding fluid, his intake and output (I&O) should be measured closely. The patient has been given medications that can alter electrolyte balance so an electrolyte panel test should be taken as well as the fact that COPD patients can have hypokalemia and hyponatremia and that should be monitored. The patient needs to be educated on his condition and what Chronic Bronchitis entails and how serious of a matter it is on his health along with cor pulmonale. His condition has only worsened, and he needs to take every piece of advice and recommendations seriously. He is to be educated on smoking cessation and nutritional diet and exercise. He is also to be referred to a nutritionist again as well as a smoking cessation clinic and follow through on his smoking cessation entirely not just for 1 month. He also needs to be readvised that he needs to retire because working at a cotton mill is also not improving his health only worsening it and even if he does stop smoking, his occupation is still a big risk to his health. When he is to be discharged, he needs to continue taking his Advair Diskus (Fluticasone & Salmeterol) via DPI 100 mcg fluticasone/50 mcg salmeterol, 1 inhalation twice daily 12 hours apart. Works Cited Appendix 2: Pathology. Brownsville, 1 July 2020. "Chronic Obstructive Pulmonary Disease, Chronic Bronchitis, and Emphysema." Terry Des Jardins, George G. Burton. Clinical Manifestations and Assessment of Respiratory Disease. St. Louis: Elsevier, 2016. 171-194. "Corticosteriods in Respiratory Care." Gardenhire, Douglas S. RAU's Respiratory Care Pharmacology. St. Louis: Elsevier, 2016. 185. Drugs.com. Amoxicillin Dosage. 10 December 2019. 6 July 2020. —. Aspirin Dosage. 24 February 2020. 7 July 2020. —. Furosemide Dosage. 5 June 2019. 22 June 2020.
