Diagnosis And Management Of Chronic Obstructive Pulmonary Disease (COPD)

Symptoms and Diagnosis of COPD

Discuss About The Global Strategy For Diagnosis Management?

The patient came into the management unit and was diagnosed with Chronic obstructive pulmonary disorder stage II (COPD). The patient was visibly distressed and could not speak in sentences. The patient could only breathe with the help of accessory muscle and had prolonged expiratory phase (Miravitlles, 2014). The Spirometric results showed that the patient’s respiratory rate was 28 beats per minute (bpm). The oxygen saturation of the patient was very low, about 75%,. The pulse rate was 12bpm with sinus tachycardia. The blood pressure was 183/97mmHg, which is very high, and the thermal temperature was hypothermic; about 38.1°C. The auscultation results also revealed inspiratory and expiratory wheezing and presence of crackles on the lower side of the right lung (Seeger et al., 2013). It is commonly observed symptoms of people with COPD. COPD is also characterized by chronic bronchitis like symptoms and emphysema in lungs. The patient’s tongue seemed bluish which is a symptoms of the “blue bloater” variant of COPD.  The patient was administered with Bilevel positive airway pressure. Which would allow the patient to inhale oxygen under the pressure of the systems and exhale without difficulty. 

The analysis of arterial blood gas analysis reveals the hemodynamic condition of the respiratory compartment. The test results of Arnold showed that his pulmonary compartment pH was 7.23 which is a little high and the CO2 saturation is 78mmHg, which is quite high and partial oxygen pressure in lungs is 55mmHg. This causes the imbalance in the CO2 release (Byrne et al., 2014). The oxygen was not being able to compensate for the excess of carbon dioxide, which created an acidic environment in the pulmonary cavity. The base excess signifies that there not many non-carbonic ions to compensate the excess CO2 which further enhances the acidity of the compartment (Vestbo et al., 2013). The breathing trouble is induced by the acidic condition of the respiratory cavity since the hypoxic condition is pressurizing the pulmonary myocytes and that creates shortness of breath. The hemodynamic load present in the pulmonary cavity causes the respiratory vessel to constrict and disruption of erythrocytes occurs, which causes the overload to fluid in the respiratory cavity. The hemodynamic overload also causes the pulmonary and arterial hypertension condition as seen in case of Arnold. The right ventricle of the heart fails in this condition due to excess overload and that causes the jugular vein hypertension, peripheral oedema, hepatic congestion and auscultations (Nasis et al., 2015).

The triage assessment of the patient in the emergency department showed that Arnold seemed visibly distressed and drowsy. The patient had no sense of time or place. Assessment of the  Glasgow Coma score was 13/15 with the eye opening score: 3; verbal response: 4; motor response: 6. The eye opening response of the patient suggested spontaneity, the verbal response indicated confusion and motor response showed that the patient was able to follow the command of the prompter. The overall score of the patient was analysed to be cause mild disorientation in brain function (Reith et al., 2016). Even after arrangement of the intravenous line to improve the patient’s health, the patient’s consciousness started to deteriorate and the coma score was then 10/15. The eye opening was 3; verbal response was 2 and motor response was 5. The significance of the score was that the eye opening was possible only after hearing the prompter’s voice, verbal response of the patient agitated and gutted and the motor response was localised and reluctance to touching.  The overall analysis of the GCS was found to be 10, which is moderately disoriented and progressive loss of consciousness. The indication of these symptoms is that the hypoxic condition is proceeding into the brain and causing cerebral hypoxia and impairing the cognition, function and creates confusion and distress (Dal Negro et al., 2016). 

Treatment Options for COPD such as BiPAP Therapy and NIV

Arnold is suffering from Chronic obstructive pulmonary disease (COPD) where there is shortness of breath and wheezing. Bi-level Positive Airway Pressure (BiPAP) therapy has a positive role in overcoming this disease. During respiratory cycle, BiPAP gives two pressure levels. This includes higher pressure level which means IPAP (inspiratory positive airway pressure) and lower pressure level which means EPAP ( expiratory positive airway pressure). The physiological effect of BiPAP specifically increases the comfort for patient suffering from breathing problem. In the given case study, Arnold is suffering from the same difficulty. BiPAP therapy works by splinting of upper airway and thus IPAP has been achieved. It decreases the venous return and results in increasing lung volume. It also increases the cardiac output (Hakim&Camporesi2015). NIV is considered as an effective treatment in pulmonary disease for respiratory disease. The physiological effects of noninvasive ventilation (NIV) on work of breathing primarily improves gas exchange by augmenting tidal volume and by increasing enough alveolar ventilation. This in turn helps in the improved aeration of under-ventilated alveoli and stabilization of collapsed alveoli (Köhnlein et al., 2014). This mechanical increase of tidal volume results in lowering the intensity and duration of inspiratory muscle contraction. This in turn shows a positive effect in decreasing the patient’s work of breathing.

V/Q ratio denotes ventilation/perfusion (V/Q) ratio that can be defined as the ratio between the amount of air and blood reaching alveoli per minute. In lung disease this ratio decreases and causes destruction of alveoli that results in creation of some large air spaces and some capillary lose. This results in V/Q mismatch (Emery, Anderson & Swenson2016).Non invasive ventilation increases ventilation by bringing in more oxygen to alveoli and pushing out more CO2 from the lungs. It decreases the blood perfusion rate and hence blood takes away less oxygen and supplies less CO2. This in turn helps in the increase of partial pressure of O2 and decrease in the partial pressure of CO2 (Hajian et al., 2018).

There are many noted benefits of BiPAP therapy (Brown et al., 2018).

• This therapy is effective in patient who are suffering from COPD since this is involved in improving blood gas levels.
• With the advancement of technology, a new type named expiratory pressure relief (C-flex) has been discovered. This works by reducing the pressure according to the patient needs and response, thus monitors patient’s airflow during expiration. The pressure is increased again in order to prevent airway collapse.
• BiPAP machine consists of two distinct types of pressure that is inhalation and exhalation pressure. It works by reducing the pressure during exhalation that helps sleeper to sleep more deeply.

• Infection may occur when facemask is fitted too tightly.
• Sometimes local skin damage can also be seen
• Due to leaking from mask, pressure delivered may be less.
• It may also lead to irritation in eye.
• Mouth seldom becomes dry.
• Mild stomach bloating may occur
• It may be also associated with pain in sinus and sinus congestion as well.

1. b) Hypoxaemia is a condition where there is a deficiency of oxygen level in the blood and Hypercapnia is a condition where the concentration of carbon dioxide increases in blood. Arnold is suffering from COPD and requires a controlled oxygen therapy, since there is a risk of respiratory acidosis due to the accumulation of CO2 in blood. Correction of hypoxaemiacan be done by treating patient with high concentration of oxygen. In the given case study, Arnold’s report on arterial blood gas done by BiPAPsuggested that the level of pCO2 is 78 mmHg, that means it is higher than the normal range which is 38-42 mm Hg. His pO2 is 55 mm Hg that is again lower than the normal range of pO2 that is 75 to 100 mm Hg.

 Correction of hypoxaemiacan help the patient to achieve normal parameters of oxygenation. This treatment increase the level of oxygen. He can breathe easily without any discomfort. His respiratory rate will increase (Miguel-Montanes et al.,2015).

Correcting hypercapnia will enable the reduction of accumulated CO2 in blood that will again help him to breathe freely. Reduction in CO2 level will also cure respiratory acidosis as well. His report suggested appearance of some bluish tinge in lips and tongue. After proper treatment this will go away.

Oxygen therapy for correction of both hypoxaemia and hypercapnia has some risks as well. These include:

• skin irritation and nasal dryness. This results due to continuous supply oxygen that has a drying effect on nasal passages.
• Smoking or use of petroleum while oxygen is in use has lethal effect.
• Oxygen toxicity may result due to high concentration of oxygen supply for longer period.

References

Brown, J. P., Bauman, K. A., Kurili, A., Rodriguez, G. M., Chiodo, A. E., Sitrin, R. G., &Schotland, H. M. (2018). Positive airway pressure therapy for sleep-disordered breathing confers short-term benefits to patients with spinal cord injury despite widely ranging patterns of use. Spinal cord, 1.

Byrne, A. L., Bennett, M., Chatterji, R., Symons, R., Pace, N. L., & Thomas, P. S. (2014). Peripheral venous and arterial blood gas analysis in adults: are they comparable? A systematic review and meta?analysis. psychology, 19(2), 168-175.

Dal Negro, R. W., Aquilani, R., Bertacco, S., Boschi, F., Micheletto, C., & Tognella, S. (2016). Comprehensive effects of supplemented essential amino acids in patients with severe COPD and sarcopenia. Monaldi Archives for Chest Disease, 73(1).

Emery, M. J., Anderson, J., & Swenson, E. R. (2016). Ventilation Heterogeneity Is Substantially Decreased When Breathing 5% Carbon Dioxide. In C75. IMPROVING AND ASSESSING RESPIRATORY FUNCTION (pp. A5960-A5960). American Thoracic Society.

Hajian, B., De Backer, J., Vos, W., van Geffen, W. H., De Winter, P., Usmani, O., … & De Backer, W. (2018). Changes in ventilation–perfusion during and after an COPD exacerbation: an assessment using fluid dynamic modeling. International journal of chronic obstructive pulmonary disease, 13, 833.

 Hakim, T. S., &Camporesi, E. M. (2015). Expiratory and Inspiratory Positive Airway Pressures in Obstructive Sleep Apnea: How Much Pressure is Necessary. A Different Point of View. J Lung PulmRespir Res, 2(6), 00065.

Köhnlein, T., Windisch, W., Köhler, D., Drabik, A., Geiseler, J., Hartl, S., …&Schucher, B. (2014). Non-invasive positive pressure ventilation for the treatment of severe stable chronic obstructive pulmonary disease: a prospective, multicentre, randomised, controlled clinical trial. The Lancet Respiratory Medicine, 2(9), 698-705.

Miguel-Montanes, R., Hajage, D., Messika, J., Bertrand, F., Gaudry, S., Rafat, C., …&Dreyfuss, D. (2015). Use of high-flow nasal cannula oxygen therapy to prevent desaturation during tracheal intubation of intensive care patients with mild-to-moderate hypoxemia. Critical care Nursing, 43(3), 574-583.

Miravitlles, M., Worth, H., Cataluña, J. J. S., Price, D., De Benedetto, F., Roche, N., … & Ribera, A. (2014). Observational study to characterise 24-hour COPD symptoms and their relationship with patient-reported outcomes: results from the ASSESS study. Respiratory research, 15(1), 122.

Nasis, I., Kortianou, E., Vasilopoulou, Μ., Spetsioti, S., Louvaris, Z., Kaltsakas, G., … & Vogiatzis, I. (2015). Hemodynamic effects of high intensity interval training in COPD patients exhibiting exercise-induced dynamic hyperinflation. Respiratory physiology & neurobiology, 217, 8-16.

Reith, F. C., Van den Brande, R., Synnot, A., Gruen, R., & Maas, A. I. (2016). The reliability of the Glasgow Coma Scale: a systematic review. Intensive care medicine, 42(1), 3-15.

Seeger, W., Adir, Y., Barberà, J. A., Champion, H., Coghlan, J. G., Cottin, V., … & Martinez, F. J. (2013). Pulmonary hypertension in chronic lung diseases. Journal of the American College of Cardiology, 62(25), D109-D116.

Vestbo, J., Hurd, S. S., Agustí, A. G., Jones, P. W., Vogelmeier, C., Anzueto, A., … & Stockley, R. A. (2013). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. American journal of respiratory and critical care medicine, 187(4), 347-365.