[vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][ultimate_heading main_heading=”Candidate brief” main_heading_color=”#000000″ sub_heading_color=”#000000″ main_heading_style=”font-weight:bold;” main_heading_font_size=”desktop:36px;”]”This patient has presented to the acute medical unit on account of shortness of breath. Please examine their respiratory system to identify why then tell the examiners what signs you find and discuss your proposed management”[/ultimate_heading][vc_empty_space image_repeat=”no-repeat”][vc_video link=”https://vimeo.com/138191689″][vc_empty_space image_repeat=”no-repeat”][vc_row_inner row_type=”row” type=”full_width” use_row_as_full_screen_section_slide=”no” text_align=”left” css_animation=””][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Station Time” counter_value=”20″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Time for this encounter” counter_value=”10″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Maximum time to examine your patient” counter_value=”6″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Minimum time for discussion and questions” counter_value=”4″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][/vc_row_inner][vc_empty_space image_repeat=”no-repeat”][/vc_column][/vc_row][vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][/vc_column][/vc_row]
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This patient has tar stained fingers. Although he does not appear hyperinflated he does have quiet breath sounds with an audible wheeze and his percussion note is clearly resonant throughout. Overall this combination is most in keeping with a diagnosis of COPD.
Cigarette smoking is the most important risk factor for development of COPD. The causal relationship of smoking and COPD is fully established. Studies have establishes “dose-response relationship” for smoking and lung function but consider variability is present among individuals.
In early stages of COPD, physical examination may be normal. Patients having more severe disease may have a prolonged expiratory phase. Signs of hyperinflation such as barrel shaped chest, increased resonance on percussion may be present. On auscultation, expiratory wheezing, decreased breath sounds, crackles at the base of lungs may be present. Chest x-ray is not required for making a diagnosis of COPD. It is typically performed to look for complication such as pneumonia, pneumothorax, and heart failure during acute exacerbations. Increased hyperlucency, flat diaphragm and long narrow cardiac shadow is visible on postero-anterior view of chest x-ray.
The major components of in-hospital management of exacerbations of COPD include reversing airflow limitation with inhaled short-acting bronchodilators and systemic glucocorticoids, treating infection, ensuring adequate oxygenation. Respiratory status, heart rate and rhythm, and fluid status should be monitored regularly. Arterial blood gas measurement should be performed to check for respiratory acidosis, confirm the oxygen saturation, and to monitor hypercapnia.
Supplemental oxygen therapy is of critical importance in management of acute condition. The target of oxygen therapy should be pulse oxygen saturation (SpO2) of 88 to 92 percent or arterial oxygen tension (PaO2) of approximately 60 to 70 mmHg.
Inhaled short-acting beta adrenergic agonists (e.g., salbutamol (aka albuterol) and levalbuterol) are the mainstay of therapy for an exacerbation of COPD. Onset of action is rapid and effectively produces bronchodilation. Beta adrenergic agonists may be combined with a short acting anticholinergic agent like ipratropium.
Systemic glucocorticoids are added to the bronchodilator therapies to improve symptoms and lung function, and decrease the length of hospital stay. Oral administration of glucocorticoids appears equally efficacious to intravenous glucocorticoids for treating most exacerbations of COPD. Intravenous glucocorticoids should be considered for patients with a severe exacerbation, who respond poorly to oral glucocorticoids, who are unable to take orally or who may have impaired absorption of oral medication.
There are clinical evidences to suggest use of glucocorticoids in patients of COPD both in setting of acute exacerbation and stable COPD. Both systemic and inhaled glucocorticoids are widely prescribed for patients with chronic obstructive pulmonary disease (COPD).
Systemic (oral or intravenous) glucocorticoids improve symptoms, hasten recovery, reduced treatment failure and increased the rate of improvement in lung function. Hospitalized patients with COPD exacerbation also benefit from systemic glucocorticoid therapy. The benefits of glucocorticoids appear to be greatest in the first 72 hours after administration. Oral therapy appears to be equally effective if patients are able to take orally. Intravenous glucocorticoids should be considered in cases of failure to respond with oral regimen, very severe, exacerbation or in patient having poor oral absorption.
The mainstays of drug therapy of stable symptomatic COPD are inhaled bronchodilators (beta agonists and anticholinergics) with or without inhaled glucocorticoids depending upon the severity, risk of exacerbations, and response to therapy.
Inhaled glucocorticoids are part of the stepwise approach to management of stable COPD, which is intended to control symptoms, decrease exacerbations, and improve patient function and quality of life. Inhaled corticosteroids are not recommended as monotherapy for stable COPD patients because inhaled bronchodilators have greater benefits with fewer adverse effects.
There are no laboratory tests which are diagnostic of COPD but certain tests are recommended to exclude other causes of dyspnoea and other co-morbid conditions.
Assessment of oxygen saturation should be done by continuous pulse oximetry. Arterial blood gas should be done in all patients of acute exacerbation of COPD to confirm oxygen saturation obtained from pulse oximetry. A chest radiograph should be obtained to look for signs of pneumonia, acute heart failure, pnemothorax. A full blood count, electrolytes, sometimes a BUN and creatinine should be obtained. An ECG should be obtained to look for arrhythmia, ischemia and cor pulmonale.
Assessment of peak expiratory flow and spirometry should be avoided during acute severe exacerbation of COPD as results are not accurate during acute condition.
Body mass index (BMI) is an independent risk factor in COPD. Decreasing body mass or BMI is associated with higher risk of mortality. Further weight loss increases risk of mortality, whereas weight gain improves prognosis.
The forced expiratory volume in one second (FEV1) is the most commonly used parameter to assess the course of COPD and prognosis of COPD as well as to predict future changes in lung function.
The postbronchodilator FEV1 has also been used to predict survival. Studies have shown the postbronchodilator FEV1 as the best predictor of survival in patient of COPD.
Patients with COPD are frequently hospitalized for acute exacerbations. Respiratory infections are also commonly associated. The effect of these exacerbations on survival is not clear.
Interestingly, the presence of heart failure or cor pulmonale was associated with a longer survival time after adjustment for other variables. This may be the result of the relatively good response of these disorders to acute therapy.
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Question 1 of 19
What clinical sign can be seen on the patient’s hands?CorrectIncorrect
Question 2 of 19
What clinical signs can be heard in the patient’s chest?CorrectIncorrect
Question 3 of 19
What is the unifying diagnosis?CorrectIncorrect
Question 4 of 19
A 55-year male patient presents to emergency department with complaints of dyspnoea at rest for last 2 days. He also mentioned that he is having exertional dyspnoea for last six months which is gradually increasing in severity. History reveals that he used to be a chronic smoker since his young age. On inspection of chest, barrel-shaped chest was visible. Auscultation of chest reveals bilateral wheezing. During work-up of this patient which of the following features favours the diagnosis of COPD?CorrectIncorrect
Question 5 of 19
What is the definition of COPD?CorrectIncorrect
Question 6 of 19
What is the clinical definition of Chronic Bronchitis?CorrectIncorrect
Question 7 of 19
What is the definition of a bullus?CorrectIncorrect
Question 8 of 19
Choose correct statements regarding use of glucocorticoids in treatment of COPD.CorrectIncorrect
Question 9 of 19
Which of the following diagnostic tests should be performed during emergency management of acute exacerbation of COPD patients?CorrectIncorrect
Question 10 of 19
What is the best marker in the assessment of severity in COPD?CorrectIncorrect
Question 11 of 19
Which of the following is not an important prognostic factor in predicting survival in a patient of COPD?CorrectIncorrect
Question 12 of 19
Do macrolide and fluoroquinolone doses need to be increased or decreased with concomitant use of beta2 agonists and anti-muscarinic agents?CorrectIncorrect
Question 13 of 19
What level of deoxygenated blood is required for cyanosis to occur?CorrectIncorrect
Question 14 of 19
Which one of the following conditions does not cause a central cyanosis?CorrectIncorrect
Question 15 of 19
When does alpha 1 antitrypsin tend to manifest? More than one answer may be correct.CorrectIncorrect
Question 16 of 19
Which of the following 12-lead electrocardiogram changes would be consistent with a diagnosis of COPD?CorrectIncorrect
Question 17 of 19
Which one of the following vaccinations should all patients with COPD be recommended to have unless there is a contraindication?CorrectIncorrect
Question 18 of 19
What are the indications for long term oxygen therapy in COPD? There maybe more than one right answer.CorrectIncorrect
Question 19 of 19
In the assessment for long term oxygen therapy, how should you assess a patient’s potential need?CorrectIncorrect