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Airway Diseases: COPD - Case

Airway Diseases: COPD - Case. Prof. Dr. Müzeyyen Erk IU Cerrahpaşa Medical Faculty Pulmonary Diseases Department. Symptoms. 78-M Dyspnea with minimal exertion Cough Sputum Dyspnea in exertion for 6-7 years, cough and sputum present but not severe, symptoms progressive

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Airway Diseases: COPD - Case

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  1. Airway Diseases: COPD - Case Prof. Dr. Müzeyyen Erk IU Cerrahpaşa Medical Faculty Pulmonary Diseases Department

  2. Symptoms • 78-M • Dyspnea with minimal exertion • Cough • Sputum • Dyspnea in exertion for 6-7 years, cough and sputum present but not severe, symptoms progressive • Dyspnea has become significant with minimal exertion for the last 3 months • The patient is treated with BD for 6 years, receives ICS for 2 years

  3. Past medical history, family hist. • Left femur fracture (15 years ago) • Inguinal hernia operation (2 years ago) • Mass excision from left breast: Gynecomastia (1.5 years ago) • Operation for catract • Glaucoma in the left eye • Benign prostate hyperplasia • GIS complaints • Peripheral arterial disease (stent in the right femoral artery) • Coronary artery disease (3 vessels, stent in 1 vessel) • Anemia

  4. Habits • Smoking history: 90 p-y • The patient does not smoke for 6 years • Alcohol: rarely

  5. Clinical findings-1 • Cachectic appearence • 50 kg 10 years previously, lost weight in the last 10 years, inadequate food intake for 2 years (because of dental prothesis) • BMI: 15.2 (38 kg, 1.52 m) • Peripheral edema (+) • Cyanosis (+) • JVD (+) • Decreased skin turgor

  6. Clinical findings-2 • Respiratory system • RR: 20/m • Hyperresonance • Decrased breath sounds • No adventitious sounds

  7. Clinical findings-3 • Cardiovascular • HR:90/min, regular rhythm, BP:130/70 mm Hg • Normal heart sounds • Decreased pulse in the peripheral arteries • Physical examination of other body systems are normal

  8. Spirometry, arterial blood gases

  9. QUESTION What is your preliminary diagnosis? • Severe COPD+cor pulmonale • Severe COPD - stabile • Severe COPD - execarbation • Severe COPD + CHF • Severe COPD + PE

  10. EKG

  11. CBC Leukocyte: 9600/mm3 P: %75 L: %11 M: %12 Eo: %1 B: %1 Erythrocyte: 4.33x106 Hb: 12 g/dl Ht: %36 MCV: 83 fL MCH: 28 pg MCHC: 33 g/dl PLT: 377.000/mm3 Urin analysis : normal Biochemistry ESR: 57 mm/h CRP: 64 mg/L Glucose: 70 mg/dl Urea: 44 mg/dl Creatinine: 1.4 mg/dl AST: 15 U/L ALT: 13 U/L Na: 139 mEq/L K: 4.8 T Protein: 6.5 g/dl Albumin: 3.1gr/dl PSA: 0.727 ng/ml Blood and urine

  12. Follow-up The patient was given optimal treatment (BD, CS,O2, diuretics, other drugs), drug education and respiratory physical threapy was started. The treatment was not completely useful and pulmonary function test was performed again

  13. QUESTION What do you plan to do at this stage ? • Echocardiography • V/Q sintigraphy • HRCT • Blood analysis • Lung volumes, DLco

  14. CBC and biochemistry

  15. Endoscopy • GIS complaints: endoscopy last year (gastroscopy, colonoscopy) • Hiatus hernia, sliding type • Dilated cardia • Erosive pangastritis • Severe duodenitis • Gastro-duodenal bile reflux

  16. Question Which is false for COPD and anemia? • 10-15% of COPD patients have anemia • Anemia is defined as a Hct level <%39 (in M) and <%36 (in F) • In COPD patients, HCT is an independent and major predictor of survival • Raised cytokines and chemokines have a key role in ACD • RBC life is not shortened in ACD of COPD patients

  17. ACD is immune driven and mainly inflammatory in nature • From a pathophysiological point of view, there are three putative mechanisms that are thought to lead to ACD, namely: • Shortened RBC survival • Iron homeostasis dysregulation • Impaired bone marrow erythropoietic response • Shortened RBC survival is thought to occur as a result of raised IL-1 and TNF in COPD KOAH ve anemi konusundaki ifadelerden yanlış olanı bulunuz • 10-15% of COPD patients have anaemia • Anaemia is defined as a Hct level <%39(in M) and <%36 (in F) • In COPD patients, HCT is an independent and major predictor of survival • Raised cytokines and chemokines have a key role in ACD • There is not the shortened RBC life seen in ACD in Similowski T, Agusti A, MacNee W, Schönhofer B. The potential impact of anaemia of chronic disease in COPD. Eur Respir J. 2006; 27: 390-396

  18. ACD Fe: ↓ IBC: N Ferritin: >10 MCV: 80 – 100 AID Fe: ↓ IBC ↑ Ferritin: <10 MCV: < 80

  19. Bone mineral density • Lumbar spine L1-L4 • T score: -5.11 • Z score: -4.00 • Left femoral neck • T score: -2.46 • Z score: -0.21 • (Therapy: Ca, vit D, calcitonin)

  20. Question Which statement is wrong for osteoporosis in COPD patients? • 1SD reduction in BMD increases the fracture risk by 1,5-3 fold • PTs with COPD are at risk to develop osteoporosis due to a reduced muscle mass and strength • Hypogonadism and other endocrine abnormalities can contribute to the development of osteoporosis • For COPD pts with osteopenia those on long-term KS, BMD should be undertaken • For prevention, daly intake of 1000 mg Ca should be ensured

  21. Vrieze A, de Greef MH, Wijkstra PJ, Wempe JB. Low bone mineral density in COPD patients related to worse lung function, low weight and decreased fat-free mass. Osteoporos Int 2007; 18:1197–1202. Which statement is wrong for osteoporosis in COPD patients? • 1SD reduction in BMD increases the fracture risk by 1,5-3 fold • PTs with COPD are at risk to develop osteoporosis due to a reduced muscle mass and strength • Hypogonadism and other endocrine abnormalities can contribute to the development of osteoporosis • For COPD pts with osteopenia those on long-term KS, BMD should be undertaken • For prevention, the daly intake of 1000 mg Ca should be ensured Potential risk factors of osteoporosis Smoking Increased alcohol intake Vitamin D levels Genetic factors Treatment with corticosteroids Reduced skeletal muscle mass and strength Low BMI and changes in body composition Hypogonadism Reduced levels of insulin-like growth factors Chronic systemic inflammation Potential risk factors of osteoporosis Bolton ,2004 osteoporosis/osteopenia of COPD pts 69%: FEV1>50% 89%: FEV1<50% 45%: controls. For prevention, the daly intake of 1200-1500 mg Ca and 400 IU vitD should be ensured Ionescu AA, Schoon E. Osteoporosis in chronic obstructive pulmonary disease. Eur Respir J 2003; 22 (46): 64s-75s

  22. DLco, Static volumes

  23. spiral

  24. PE probability • D-dimer: 256 mcg/L (51-285) • Pulmonary V/Q sintigraphy: low-probability

  25. QUESTION Patient BMI is 15.2 kg/m2. Which one of the following statements is false ? • About 25% of patients with chronic obstructive pulmonary disease (COPD) will develop cachexia • Incidence of cachecsia correlates with airway obstruction • Decrease in muscle mass increases the mortality risk • Increase in basal metabolic rate, tissue hypoxia, smoking, inflammation, drugs are etiopathogenetic factors • PR is contrindicated at this stage

  26. Patient BMI is 15.2 kg/m2. Which one of the following statements is false ? • About 25% of patients with chronic obstructive pulmonary disease (COPD) will develop cachexia • Incidence of cachecsia correlates with airway obstruction • Decrease in muscle mass increases the mortality risk • Increase in basal metabolic rate, tissue hypoxia, smoking, inflammation, drugs are etiopathogenetic factors • PR is contrindicated at this stage This must be balanced against the findings that exercise training does in fact lead to a substantial improvement in exercise capacity, even in cachectic patients.

  27. Wagner PD.Possible mechanisms underlying the development of cachexia in COPDEur Respir J 2008; 31: 492–501 BMI values and weight loss ATS-ERS Pulmonary Rehabilitation 2006

  28. Schols et al. ARRD 1993; 147: 1151-6

  29. BMI and FFMI for COPD prognosis • COPD patients: 1898 patients, 7 years follow-up (Copenhagen…) • BMI normal, low FFMI patients: %26.1 • All causes of mortality: FFMI risk rate: 1.5 • Mortality due to COPD: FFMI risk rate: 2.4 FFMI and BMI are mortality predictors Vestbo J ve ark. AJRCCM 2006; 173: 79

  30. Wagner PD.Possible mechanisms underlying the development of cachexia in COPDEur Respir J 2008; 31: 492–501

  31. ?

  32. QUESTION When the COPD level of the patient is considered, what is the one-year mortality risk? • % 5 • %10 • %30 • %50 • %100

  33. BODE Index

  34. ECHOCARDIOGRAPHY (31.01.08) • Degenerative changes in aorta and mitral valves, calcification • Left ventricular hypertrophy • Paradoxical septal movement • Mass attached to the the right atrial free wall with a stalk, measuring 9X11 mm approximately • Left and right ventricular diastolic disfunction

  35. QUESTION Which one of the following statements is true for the pulmonary hypertension in this patient ? (0.61x55 +2 = 35.5 mm Hg) • Systemic inflammation does not have a role in the etiology of PH • PAPm value of PH due to COPD is generally over 40 mm Hg • PAPm value of PH due to COPD is generally less than 40 mm Hg • Hypercarbia should also be present in this patient • At this stage pulmonary vazodilators may be useful

  36. QUESTION Which of the following statements is true for performing sleep study in this patient ? • It should be performed in every cor pulmonale patient • There is no indication, CP is the usual prognosis • It should be performed, because ABG values do not correlate with the functional level • It would have been performed if the patient had mild to moderate obstruction along with hypoxemia and PH • It would have been performed if the patient had daytime somnolence

  37. Cardiac MR • A mass of 1 cm with contrast enchancement attached to the right atrial free wall • Mild thickening of mitral valves • Minimal prominence at the aortic supra valvular level

  38. Kardiyak MR

  39. QUESTION What can be the pathologic mass that is seen on the echocardiogram and MRI? • Thrombus • Mixoma • Rhabdomyom • Other cadiac tumour • Hydatid cyst

  40. Cardiac myxoma Autopsy series: 1/10 000 Right and left myxomas compromise %2.5-4 of all myxomas % 17-27 in the right atrium May grow slowly or rapidly Can be seen by TTE and TEE Surgery indications Emboli Hemodynamic problem Valvular obstruction Ayan F, Koldaş L, Karpuz H. J Clin Basic Cardiol 2000; 3: 197

  41. Clinical characteristics of right atrial myxoma • Systemic reactions (early stage): Anemia due tumoral degeneration, fever, weight loss, leukocytosis, high ESR and CRP, hyperglobulinemia, local cutaneous pigmentations, acromegali, proteinuria • Emboli:by tumour fragments or by thrombus, micro or macro pulmonary emboli (if patent foramen ovale exists systemic embolism) • Hemodynamic changes: mechanical obstruction and valve destruction Ayan F, Koldaş L, Karpuz H. J Clin Basic Cardiol 2000; 3: 197

  42. UPLIFT Study - Associated comorbidities 44.9 30.6 Organ /systems 28.3 26.5 25.5

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