CASE STUDY ON COPD, RESPIRATORY FAILURE & COR PULMONALE

1. CASE STUDY ON COPD, RESPIRATORY FAILURE & COR PULMONALE BY: MANEESHA DOMINIC, REG. NO. : 132820199.

2. COPD: A BRIEF INSIGHT

3. DEFINITION: “ COPD refers to a group of LUNG DISEASES, that block airflow, and make breathing difficult(includes CHRONIC BRONCHITIS & EMPHYSEMA)”. . .

4. EPIDEMIOLOGY: • TWO-THIRDS of men, and ONE-FOURTH of women have emphysema at death(as per US statistics) • COPD is the FOURTH LEADING CAUSE of DEATH in the US • It is the sixth leading cause of death worldwide. . .

5. ETIOLOGY: • Tobacco abuse • ALPHA-1-ANTITRYPSIN DEFICIENCY • CYSTIC FIBROSIS • Air pollution • Occupational exposure • Bronchiectasis. . .

6. PATHOPHYSIOLOGY: • OF CHRONIC BRONCHITIS: • Chronic Bronchitis is defined as “excessive mucus production, with airway obstruction and hyperplasia of mucus-producing glands” • Endothelial damage impairs mucociliary response(that clears bacteria and mucus)  increased inflammation and secretions occur  body responds by REDUCING VENTILATION and INCREASING CARDIAC OUTPUT causes HYPOXEMIA, POLYCYTHEMIA  HYPERCAPNIA and respiratory acidosis develops  leads to PULMONARY ARTERY CONSTRICTION and COR PULMONALE. • Increased CO retention occurs • Such people are known as “BLUE BLOATERS”. . .

7. B. OF EMPHYSEMA: • EMPHYSEMA is defined as “destruction of airways, that are distal to terminal bronchiole”. • Gradual destruction of alveolar septae & pulmonary capillary bed  reduces ability of lungs to OXYGENATE BLOOD  Body compensates by reducing CARDIAC OUTPUT & causing HYPERVENTILATION Causes LIMITED BLOOD FLOW Rest of the body suffers from tissue hypoxia and pulmonary cachexia causes muscle wasting and weight loss such people are identified as “PINK PUFFERS”. . .

8. CLINICAL MANIFESTATIONS: • SOB(especially during EXERTION) • Chest-tightedness • Wheezing • Chronic productive cough • Cyanosis • Weight loss. . .

9. DIAGNOSTIC MEASURES: • PFTs • Chest X-RAY • ABG ANALYSIS • SPUTUM TESTS. • HEMATOLOGICAL TESTS.

10. GOALS OF THERAPY: • To ALLEVIATE the disability associated with AIRWAY OBSTRUCTION • To reduce ADRs associated with the therapy given • To reduce MORBIDITY & MORTALITY • To avoid PROGRESSION into COMPLICATIONS • To improve HRQoL. . .

11. PHARMACOTHERAPY: • BETA-2 AGONISTS: • Drugs  potentiate beta-2-receptors on bronchial smooth muscles reduce muscle tone in lungs, along with relieving of BRONCHOSPASM, by relaxing smooth muscles of bronchi improves ventilation, and reduces airway resistance • ADRs: • Tremor • Nervousness • Tachycardia • Drugs include: • TERBUTALINE SULPHATE(BRICANYL) • ALBUTEROL(PROVENTIL)

12. iii. SALMETEROL iv. FORMOTEROL . . . II. METHYLXANTHINES: • Drug  increases CYCLIC-AMP LEVELS by blocking PDE-3 relaxes bronchial smooth muscles(bronchodilatation) • ADRs: • Tremor • Tachycardia • Drugs include: • THEOPHYLLINE(THEO-24) iv. AMINOPHYLLINE. . . • ETIDOPHYLLINE • ACEBROPHYLLINE

13. III. ANTI-CHOLINERGICS: • Usually have slow effects, and used in combination with corticosteroids, or beta-agonists for LONG TERM MAINTENANCE THERAPY OF COPD • Drug  blocks action of ACETYLCHOLINE  causes relaxation of bronchial smooth muscle • ADRs: • Constipation • Blurred vision • Drugs include: • IPRATROPIUM BROMIDE(ATROVENT) • TIOTROPIUM BROMIDE(SPIRIVA). . .

14. IV. CORTICOSTEROIDS: • Used to ACCELERATE RECOVERY from COPD EXACERBATION • ANTI-INFLAMMATORY PROPERTY of drugs in concern is EXPLOITED HERE • ADRs: • Cataract • Glaucoma • Weight gain • High risk of infections, etc . . . • Drugs include: • METHYLPREDNISOLONE(MEDROL) • PREDNISOLONE • BUDESONIDE(INHALATION)

15. V. PHOSPHODIESTERASE-4 INHIBITORS: • Reduce exacerbations, and improve dyspnea • Improve lung function in patients with severe COPD • Drug includes ROFLUMILAST(DALIRESP) • ROFLUMILAST  blocks PDE-4 increases CYCLIC AMP in lung cells  reduces frequency of exacerbations and worsening of symptoms from severe COPD • ADRs: • Weight loss • Anorexia • Backache. . .

16. VI. ELECTROLYTE SUPPLEMENTS: • MAGNESIUM  replenishes stores that become depleted in periods of ADRENERGIC EXCESS(like asthma, COPD, etc) • MAGNESIUM SULPHATE is used • Drug  counteracts CALCIUM-MEDIATED SMOOTH MUSCLE CONTRACTION produces BRONCHODILATATION, • ADRs: • Hypothermia • Flushing • Hypocalcemia. . .

17. VII. ANTIMICROBIAL THERAPY: • Mainly effective in COPD exacerbation, under the following CONDITIONS: • Increased dyspnea • Increased sputum volume • Increased sputum purulence • Treatment is based on MOST LIKELY OFFENDING MICROBES • ORGANISMS include: • H.influenzae • Moraxella catarrhalis • S.pneumoniae • H.parainfluenzae - Therapy should be started within 24 HOURS OF SYMPTOMS, and INITIATED FOR 7-10 DAYS.

18. For UNCOMPLICATED COPD EXACERBATIONS, use the following: • MACROLIDES( AZITHROMYCIN, CLARITHROMYCIN) • 2nd / 3rd GENERATION CEPHALOSPORINS • DOXYCYCLINE • For COMPLICATED COPD EXACERBATIONS(including RESISTANCE), use the following: • AMOXICILLIN+ CLAVULANATE • FLUOROQUINOLONES(LEVOFLOXACIN, GEMIFLOXACIN, MOXIFLOXACIN). . .

19. VII. NEWER DRUGS FOR COPD: • ACLIDINIUM(TUDORZA PRESSAIR): • LONG ACTING SELECTIVE M3-ANTAGONIST (LAMA) 2. INHALED INDACATEROL(ARCAPTA NEOHALER): • LABA(LONG ACTING BETA-2-AGONIST) 3. UMECLIDINIUM BROMIDE(ANDRO ELLIPTA): • LAMA 4. VILANTEROL INHALED(ANDRO ELLIPTA): • LABA 5. GLYCOPYRROLATE INHALED(SEEBRI NEOHALER): - LAMA. . .

20. NON-PHARMACOTHERAPY: • LUNG THERAPIES: • Oxygen therapy • Pulmonary rehabilitation programs II. SURGERY: • Lung volume reduction therapy • Lung transplantation III. HOME REMEDIES FOR COPD: • FOR EMPHYSEMA: • Stop smoking • MUSTARD OIL+ CAMPHOR chest massage combination, to reduce chest tightedness and breathing difficulties

21. FOR CHRONIC BRONCHITIS: • Onion juice consumption • Turmeric powder+ a glass of milk every morning • Almonds(crushed)+ lemon juice. . . IV. PATIENT COUNSELLING TIPS: • Avoid smoking • Avoid exposure to allergens & pollution • Avoid fermented foods • Have raisins+ honey • Focus on eating well, with justifiable diet • Avoid oily& fried foods • Annual vaccination with inactivated influenza vaccine. . .

22. PROBLEMS LIST: • SEVERE COPD • EMPHYSEMA • RESPIRATORY FAILURE • COR PULMONALE. . .

23. PATIENT DETAILS: Name: Mrs.X Age: 65 yrs Sex: Female IP NO.: 198044 Department: Pulmonology Weight: 48 kgs Height: 160 cm BMI: 18.92 DOA : 15/10/2017 DOD: 21/10/2017. . .

24. II. REASON FOR ADMISSION: Patient had c/o : 1.Breathlessness(for 2 days) 2. Fever(For 1 week) 3. Cough(For 1 week) 4. 1 episode of vomiting. . . III. PAST MEDICAL HISTORY: • K/C/O COPD(on DOMICILIARY OXYGEN for 25 years) • K/C/O RESPIRATORY FAILURE. . . 3. H/O TB (15 years back, took Rx for 1 year). . . IV. FAMILY HISTORY: Nil. . . V. KNOWN ALLERGIES: Allergic to cold. . .

25. VI. FOOD HABITS: Non-vegetarian VII. SOCIAL HABITS: Non-smoker, non-alcoholic. . .

26. VITALS CHART:

27. II. HEMATOLOGICAL ANALYSIS: • Hb: 8 g/dl • TLC: 12,600 cells/cumm • ESR: 80 mm/hr • Platelets: 6,50,000 cells/cumm • RBC : 4,21,000 cells/cumm • DLC: • Polymorphs: 73% • Lymphocytes: 20% • Eosinophils: 7%. . .

28. III. LFT ANALYSIS: • Total bilirubin: 0.49 mg% • Albumin: 3 g/dl • Globulin: 3.9 g/dl • Total protein: 6.9 g/dl • SGPT: 35 IU/L • SGOT: 53 IU/L. . .

29. IV. RFT ANALYSIS: • Urea: 14 mg% • Uric acid: 1.5 mg/dl • Serum creatinine: 0.9 mg/dl. . . V. ELECTROLYTES: • Sodium: 134 mEq/L • Potassium: 3.4 mEq/L • Calcium: 7.52 mEq/L. . .

30. VI. OTHERS: • Edema: positive • Pallor: positive • JVP: Increased • RS: Crepts(++) • Clubbing: +ve • B/L wheeze: +ve • HR-CT of thorax: - Shows diffuse emphysematous changes in B/L lung field, & pleural thickening in left lower lobe & right middle lobe. . .

31. DIAGNOSIS: • Severe COPD • Emphysema • Respiratory failure • Cor pulmonale. . . 2. ASSESSMENT, IF THERAPY INDICATED: • To treat current conditions of severe COPD, emphysema and Cor-pulmonale • To improve HRQoL

32. 3. ASSESSMENT OF CURRENT MEDICATIONS: • INJ. LASIX(FUROSEMIDE); 40 mg i.v; stat(D1): • INDICATION: Diuretic, to treat edema & right ventricular volume filling changes(for Cor Pulmonale) ii. INJ. EFCORLIN( HYDROCORTISONE); 100 mg i.v; stat(D1): • INDICATION: Corticosteroid, to treat inflammation associated with COPD • Also reduces COPD exacerbations iii. INJ.PAN (PANTOPRAZOLE); 40 mg i.v; stat(D1): • INDICATION: PPI, that works to reduce gastric irritation(generalized). iv. INJ. EMESET(ONDANSETRON); 4 mg i.v; stat(D1): • INDICATION: Anti-emetic, that works to reduce emesis(N&V) v. INJ. IVPRED(METHYLPREDNISOLONE); 4 mg i.v, (D1-D6): - INDICATION: Corticosteroid, to attenuate COPD exacerbations; anti-inflammatory.

33. vi. T.MUCINAR(ACETYLCYSTEINE); 5 mg OD; (D1-D7): • INDICATION: Potent MUCOLYTIC, that reduces mucus viscosity. vii. T. MONTEK-AB( MONTELUKAST+ACEBROPHYLLINE); 5 mg OD; (D2-D4): • INDICATION: Leukotriene receptor antagonist+ bronchodilator combination, that work to reduce inflammatory processes, and enhance bronchodilatation, by relaxation of bronchial smooth muscles. viii. T. DULCOLAX(BISACODYL SULFATE) ; 5 mg OD; (D3-D4): • INDICATION: Increases laxative property, helps to treat constipation. ix. NEB. SALBAIR-I(SALBUTAMOL+ IPRATROPIUM BROMIDE); (500+2.5 mcg) Q6H; (D1-D7): • INDICATION: Combination of beta-2-agonist and anticholinergic medications, used for LONG TERM MAINTENANCE OF COPD. x. T. ZOLFRESH(ZOLPIDEM); 5 mg OD, HS; (D3-D7): - INDICATION: Produces SEDATION(induces sleep).

34. xi. INJ. MONOCEF(CEFTRIAXONE), 1 g i.v, BD; (D1): • INDICATION: 3RD generation cephalosporin, used to treat COPD EXACERBATION. xii. C. LIVOGEN(FERROUS FUMARATE+ FOLIC ACID), 1500 mcg OD; (D4-D7): • INDICATION: To treat ANEMIA(justifiable in this patient, who is with 8g/dl Hb count). xiii. NEB.FORACORT(BUDESONIDE+ FORMOTEROL), (400+6 mcg) BD; (D1-D7): • INDICATION: Bronchodilator+ corticosteroid combination, used in the long term management of COPD xiv. T. AZEE(AZITHROMYCIN), 500 mg OD, (D2-D5) • INDICATION: Macrolide antibiotic, that is bacteriostatic, and exploited for COPD exacerbation • Use of this drug is justified here, since the patient is not resistant to this drug, which is a major complicationof antimicrobial therapy in COPD patients.

35. xv. ATPRO DHA POWDER(PROTEIN POWDER); 2 tsp TID; (D3-D7): • INDICATION: Protein supplement, justifiable in COPD patients, since patients with SEVERE COPD will be malnourished. . . xvi. BIPAP (NON-INVASIVE VENTILATOR); (D1-D7): - INDICATION: Used in respiratory failure and COPD exacerbation. . .

36. TREATMENT CHART:

38. PROGRESS CHART: 15/10/2017: • Edema (+ve), crepts(+ve), B/L wheezing(+ve) 16/10/2017: • Patient felt better, reduced edema, crepts(+ve) 17/10/2017: • Persistent cough, blood transfusion done, slept well 18/10/2017: • Persistent cough, reduced breathlessness, c/o no motions for 2 days 19/10/2017: • Symptomatically better, crepts(+ve) 20/10/2017: • Patient felt better and no fresh complaints 21/10/2017: - Patient felt better, and was discharged appropriately. . .

39. DISCHARGE SUMMARY: A 65 yr old female, with k/c/o COPD, respiratory failure, emphysema, H/O TB, allergic to cold, was presented with high breathlessness, exacerbation for 2 days, cough & fever for 1 week, with 1 episode of vomiting. Patient was diagnosed to have severe COPD, emphysema, respiratory failure, Cor-pulmonale, and anemia. Patient was treated with i.v antibiotics, steroids, inhalers and bronchodilators. Patient felt symptomatically better at the time of discharge. . .

40. DISCHARGE ADVICE: • DUOLIN(R/C) , TID for 1 week • T. PAN (DSR), 40 mg OD, for 1 week • Cap. Livogen , 800 mcg for 1 week • T. Montek, 5 mg OD, for 1 week 5. Increase protein and calorie intake 6. Avoid exposure to allergenic environments 7. Review after 1 week. . .

41. DRUG-BASED COUNSELLING: • Patient should have proper knowledge on how to use ROTAHALERS • Avoid dose missing • Use ROTAHALERS TID, with a time interval of 4 hrs, between each administration • Avoid overdosing, since the contents in ROTAHALERS have potentiality to cause severe ADRs • Consume PAN-DSR 30 mins before food • Medication adherence is necessary to prevent disease worsening. . .

42. DISEASE-BASED COUNSELLING: • Avoid contact with allergens & polluted environment • Avoid fermented foods • Avoid dairy products • Avoid stress • Do breathing exercises(especially deep breathing) • Avoid oily& fried foods • Steam inhalation with eucalyptus/lavender essential oils • Chest massage with mustard oil+ camphor • Increase intake of calories • Keeping air purifiers also helps • Consume raisins with honey • Drink ginger tea/ green tea with little black pepper powder+ honey daily. . .

43. THANK YOU!!!!!