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COPD + Pneumonia

A Case Study

by Mike Painter

INTRODUCTION

Introduction

The patient was a 67-year-old, Caucasian, male patient came to the Emergency Department by ambulance with a chief complaint of increased shortness of breath with productive cough. He was re-admitted for “Severe End Stage COPD Exacerbation” as well as a secondary diagnosis of “Right Upper Lobe Hospital-Acquired Pneumonia” and had tested positive for Methicillin-resistant Staphylococcus aureus (MRSA). Per hospital records, he had just been discharged from Enloe for a similar admission two days prior. The patient has had multiple previous admissions for similar respiratory problems within the past 12 months.

Medical History

Medical History

  • Chronic Obstructive Pulmonary Disease
  • HTN
  • Anxiety
  • Depression
  • Insomnia
  • Pneumonia
  • Pulmonary Embolism
  • Lung Cancer
  • Skin Cancer

Assessment

  • Not wearing O2 due to accidental removal while sleeping
  • BP 142/92, P102, RR30, Temp 36.7C, SpO2 78% (room air)
  • Wheezes and coarse crackles in lower lobes
  • Ronchi in right upper lobe
  • Increased work of breathing
  • Intercostal retractions

Assessment

What is COPD?

COPD

Pathophysiology

COPD is an umbrella term used to describe Chronic Bronchitis and Emphysema which are both diseases that limit gas exchange at the alveoli in the lungs by limiting expiratory air flow.

CAUSES

  • SMOKING!!! 85-90% of ALL COPD cases!
  • Environmental Factors
  • Chemical Inhalation
  • Pollutants
  • Camp fires???
  • Genetic Factors
  • Alpha-1 Antitrypsin Deficiency

Chronic Bronchitis

  • Characterized as an overproduction of mucus
  • Mucus glands and goblet cells undergo hypertrophy and hyperplasia and secrete excessive amounts of mucus
  • Celia begin to shorten and become less motile
  • Narrowing of airways from "mucus plugging"

CHRONIC BRONCHITIS

Emphysema

  • Characterized by the destruction of the walls of the lower airway and alveoli.
  • Phagocytosis --> the activated macrophages release proteins called cytokines which in turn activate neutrophils.
  • Macrophages and neutrophils start releasing protease enzymes called elastase.
  • Elastase breaks down elastin
  • Airways begin to collapse during exhalation
  • "Air trapping" begins to occur
  • Leads to destruction of walls of alveoli
  • LESS AREA FOR GAS EXCHANGE!!!

EMPHYSEMSA

Cor Pulmonale

  • Under normal circumstances the body requires a somewhat even amount of perfusion to ventilation in order for gas exchange to effectively occur between the alveoli and pulmonary capillary membranes.
  • Uneven perfusion to ventilation = V/Q mismatch
  • Blood vessels constrict in areas where ventilation is poor
  • Can lead to increased pulmonary artery pressure
  • Can lead to right ventricle hypertrophy
  • Can cause Right HF or cor pulmonale

COR PULMONALE

Pneumonia

Pneumonia

Pathophysiology

  • Acute infection of lung parynchema
  • Often a complication of COPD due to decreased celia motility
  • Foreign pathogens invade lung tissue and release endotoxins that cause tissue damage
  • Alveolar tissue becomes damaged it releases leukotrienes and prostaglandins into the bloodstream.
  • In the immune response, leukotrienes attract neutrophils and eosinophils to sites of infection and increase the permeability of small blood vessels
  • Prostaglandins act by vasodilating the blood vessels
  • Mast cells activate and increase inflammation
  • Alveoli begin to fill with exudative fluid at sight of infection
  • Exudate is absorbed via lymph system or coughed up

CAUSES

  • Inhaled bacterial pathogen - most causes
  • Viral infection
  • Hematogenous spread
  • Most common through IV drug use
  • Blood brings infection to lung tissue
  • Aspiration

CAUSES

MEDICATIONS

  • Prednisone - anti-inflammatory
  • Ipratropium Bromide/Albuterol Sulfate - bronchodilator
  • Insulin - pts on corticosteroids experience increased BG
  • Carvedilol - blood pressure
  • Lisinopril - blood pressure
  • Duloxetine HCl - anti-depressive
  • Apixaban - anti-thrombus
  • Vancomycin - for MRSA pneumonia

Medications

Labs and Treatment

Clinical diagnostics involve a thorough evaluation and physical exam of patient as well as their background including risk factors such as smoking or family history of COPD.

  • Chronic bronchitis = productive cough for at least 3 consecutive months in 2 consecutive years
  • Emphysema = pulmonary function test. The test evaluates the ratio of Forced Expiratory Volume (FEV) to Force Vital Capacity of the patient. If FEV/FVC is less than 75%, it indicates the patient has COPD

Labs & Treatment

DIAGNOSTICS

LABS

  • CBC
  • Determine presence of infection
  • CMP
  • Electrolyte imbalances?
  • ABG!!!
  • The patients ABG was as follows:
  • pH 7.47
  • pCO2 55
  • HCO3- 36.1
  • pO2 57
  • What do these levels indicate and what is the reason for them?
  • EKG - to rule out heart failure
  • Chest X-Ray
  • Sputum cultures - for pneumonia

TREATMENT

  • COPD
  • STOP SMOKING!!!
  • Annual influenza and pneumonia vaccine
  • Supplemental O2 (if SpO2 <90%)
  • Bronchodilators
  • Corticosteroids
  • Pneumonia
  • Breathing treatments when needed
  • IV fluid administration
  • Medicine for pain and/or fever
  • Supplemental O2 (if indicated)
  • Antibiotics!!! (but not for viral)

TREATMENT

CONCLUSION

  • COPD is PREVENTABLE!!!
  • COPD = Emphysema & Chronic Bronchitis
  • Both diseases = decreased gas exchange at alveoli
  • Destruction of cilia + increased mucus = pneumonia
  • Pneumonia
  • Infection of lung parynchema
  • Usually caused by bacteria
  • Treatment of choice = antibiotic therapy

CONCLUSION

References

Claeys, K. C., Lagnf, A. M., Hallesy, J. A., Compton, M. T., Gravelin, A. L., Davis, S. L., & Rybak, M. J. (2016). Pneumonia Caused by Methicillin-Resistant Staphylococcus aureus: Does Vancomycin Heteroresistance Matter?. Antimicrobial agents and chemotherapy, 60(3), 1708–1716. doi:10.1128/AAC.02388-15

Cowley, G. (2018) What is the link between prednisone and diabetes? Retrieved from https://www.medicalnewstoday.com/articles/317015.php

Garrison DM, Memon J. Cor Pulmonale. (Updated 2019 Feb 15). Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK430739/

Hine, R., & Martin, E. (2016). Leukotrienes. A Dictionary of Biology, A Dictionary of Biology.

How Serious Is COPD. (2019). Retrieved April 14, 2019, from https://www.lung.org/lung- health- and-diseases/lung-disease-lookup/copd/learn-about-copd/how-serious-is- copd.html

Kitaguchi, Y., Yasuo, M., & Hanaoka, M. (2016). Comparison of pulmonary function in patients with COPD, asthma-COPD overlap syndrome, and asthma with airflow limitation. International journal of chronic obstructive pulmonary disease, 11, 991–997. doi:10.2147/COPD.S105988

Lewis, S.L., Dirksen, S.R., Heitkemper, M.M., Bucher, L., & Harding, M.M. (2017). Medical- Surgical Nursing: Assessment and Management of Clinical Problems (10th ed.). St. Louis: Elsevier.

Ramos, F. L., Krahnke, J. S., & Kim, V. (2014). Clinical issues of mucus accumulation in COPD. International journal of chronic obstructive pulmonary disease, 9, 139–150. doi:10.2147/COPD.S38938

Sattar SBA, Sharma S. Bacterial Pneumonia. (2019 Feb 11) Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK513321/?report=classic

What Causes COPD. (2019, April 19). Retrieved April 19, 2019, from: https://www.lung.org/lung-health-and-diseases/lung-disease-lookup/copd/symptoms-causes-risk-factors/what-causes-copd.html

Fin

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