(Disclaimer: This article is for general use only, and the information in the following content has been processed to protect patient privacy)
Abstract: An elderly patient presented with “recurrent cough and sputum for more than 20 years, shortness of breath after activity for more than 10 years, and recurrent exacerbation with fever for 1 week”, and reported a history of smoking for 50 years, so it was not difficult to confirm the diagnosis of emphysema. The patient was given anti-inflammatory and asthma treatment in the hospital, and the patient was given a long-term treatment plan after discharge, and was told that a cold could easily lead to exacerbation of the disease, and if the disease was not well controlled, respiratory distress could gradually appear and even lead to pulmonary hypertension and pulmonary heart disease.
Basic information】Male, 70 years old
Disease Type】Emphysema
Hospital】The Second Hospital of Harbin Medical University
Consultation time】November 2019
Treatment plan】Medication (moxifloxacin hydrochloride tablets, ambroxol hydrochloride tablets, sodium methylprednisolone succinate for injection, doxorubicin tablets, budesonide suspension for inhalation, umebramine vilanterol inhalation powder nebulizer, nifedipine controlled-release tablets)
[Treatment period] Hospitalization for 10 days, regular outpatient follow up
Treatment effect】The disease has been controlled, and all indicators are improving
I. Initial consultation
The patient’s family described: The patient had recurrent cough and sputum for more than 20 years, shortness of breath after activity for more than 3 years, and symptoms worsened with fever for 1 week. The patient had a cough and white sputum every time he had a cold or seasonal change 20 years ago, which lasted for more than 3 months each year; 10 years ago, he developed shortness of breath after activity, and was clearly diagnosed with “chronic obstructive pulmonary disease” in the past, taking oral theophylline tablets for a long time, inhaling bronchodilators intermittently, and applying budesonide formoterol inhalation powder regularly in the past 1 week. 7 days before the cold, the above symptoms worsened, dyspnea, coughing purulent sputum, fever, body temperature up to 38.0 ℃. On examination: body temperature: 37.0 ℃, heart rate: 110 beats/min, respiratory rate: 17 breaths/min, blood pressure: 200/109 mmHg. chronic disease, no obvious cyanosis of lips, no rash and skin edema, no palpable enlargement of lymph nodes, no yellow sclera, soft neck, central trachea, no angry jugular vein, barrel-shaped chest, diminished fibrillation, coarse breath sounds in both lungs, dry and wet rales were heard. The heart rate was 110 beats/min and no murmur was heard. The abdomen was soft, no pressure pain, and the liver and spleen were not enlarged. The patient had a history of smoking for 50 years, with 10-20 cigarettes/day, and had quit smoking for 5 years. He had a 20-year history of hypertension, with a maximum systolic blood pressure of 200 mmHg or more, which was not regularly controlled, no cerebral infarction, no atrial fibrillation and no history of heart disease.
II. Treatment history
The patient had been suffering from the disease for more than 20 years, and the diagnosis was clearly “emphysema”, without regular medication. After admission, the patient’s blood gas analysis was completed: pH: 7.43; PCO2: 50 mmHg; PO2: 65 mmHg, and low-flow oxygen was given. The patient had fever and coughing yellow sputum symptoms, which indicated the exacerbation of COPD induced by infection, so he was given aggressive antibiotic treatment, and moxifloxacin hydrochloride tablets were selected, while sputum-suppressing and wheezing treatment, i.e., amiloride hydrochloride tablets and doxorubicin tablets, were given for the symptoms. After 3 days, it was changed to inhalation of budesonide suspension. Oral nifedipine controlled-release tablets were given to control blood pressure, and the cardiology department was consulted to adjust the medication and improve the cardiac ultrasound.
III. Treatment history
The patient’s acute attack was related to the usual poor control. After giving targeted anti-inflammatory and wheezing treatment, the patient’s symptoms improved significantly. Blood gas analysis also returned to normal. The treatment plan for discharge was formulated according to mMRC score and CAT score, and hormone-free double bronchodilator (umebramine vilanterol inhalation powder) was given. The patient was taught the correct inhalation method and advised to inhale for a long time to control symptoms and reduce acute exacerbations, and the follow-up time and content were formulated. Tell patients how to try to avoid triggering factors, especially the need to quit smoking, and advise them to actively control their blood pressure.
IV. Notes
We are glad that the patient’s symptoms have improved after treatment, but because infection can lead to recurrent attacks, so in order to avoid recurrent infections and prevent disease progression, usual care is very important, and the patient also needs to pay attention to the following points.
1, emphysema belongs to a kind of chronic obstructive pulmonary disease, long-term treatment is very important, regular medication according to the bronchodilator chosen by the doctor, avoid stopping medication at will, establish a self-examination manual, daily observation of the number of coughs and wheezes, heart rate, respiratory rate, finger pulse oxygen, and activity endurance, and at the same time, patients are advised to follow up once every six months.
2. Although emphysema is a disease of the airway, the systemic impact on the whole body should not be ignored. Long-term hypoxia can lead to impaired cardiac function, especially if patients have hypertension, they should pay more attention to treatment in remission and actively control blood pressure to prevent cardiac insufficiency.
3, increase resistance, avoid colds and flu, appropriate daily life exercises, especially pulmonary rehabilitation training is very important, including brisk walking, tai chi, lip reduction breathing, abdominal breathing, etc. Winter and spring climate change faster, pay attention to keep indoor air circulation to increase their ability to resist cold.
4. Quit smoking in order to avoid smoke and dust can increase the burden on the lungs and lead to aggravation of disease symptoms.
V. Personal insight
Because pulmonary function declines rapidly in poorly controlled emphysema patients, patients should pay attention to stabilization treatment, including the following: according to disease guidelines, assess the grading and staging of COPD by symptoms, pulmonary function, and blood tests, and select appropriate bronchodilators: including anticholinergics, hormone-containing or hormone-free bronchodilators, triple bronchodilators, etc. Clinical indications for long-term home oxygen therapy refer to PaO2 ≤ 55 mmHg or Sa02 ≤ 88%, i.e., the presence of hypercapnia, on the one hand, and PaO2: 55-60 mmHg, or Sa02 < 89%, with pulmonary hypertension, heart failure edema, or erythrocytosis, on the other hand. In addition, oxygen is usually administered by nasal cannula, in which the oxygen flow rate is 1.0-2.0 L/min, while the duration of oxygen should be >15 h/d. Currently, the patient’s blood gas analysis in the acute phase is 65 mmHg, and home oxygen therapy is not needed for the time being, but attention should be paid to rehabilitation training.