Acute exacerbation of chronic obstructive pulmonary disease (COPD) is often characterized by increased cough, yellowish and viscous sputum, or even purulent sputum, and increased shortness of breath, especially at times. In the clinical management of these patients, the treatment is often based on infection control, correction of respiratory failure (including oxygen therapy), anti-inflammatory, antispasmodic and asthma treatment.
In the case of chronic pulmonary heart disease, reducing cardiac load, lowering pulmonary artery pressure, and correcting heart failure are also the focus of treatment. However, the factors causing the exacerbation of dyspnea must not be simply defined as COPD combined with infection, and in the case of ineffective conventional treatment, close attention needs to be paid to.
I. Pulmonary factors
1. Specific types of infections
COPD patients are susceptible to specific pathogens, such as Mycobacterium tuberculosis and fungi, because they are often combined with systemic symptoms that can involve the skeletal muscle, gastrointestinal tract, blood system, immune system, cardiovascular system, etc., which can cause dysfunction of the body’s immune function. Fungal diagnosis and treatment guidelines have clearly listed COPD as a high-risk factor for fungal infection. Special emphasis is placed on history taking and initial determination based on the main concomitant symptoms, which needs to be supported by laboratory tests.
2.Pulmonary embolism
Patients with COPD have increased blood viscosity and are in a hypercoagulable state, coupled with damage to the vascular endothelium, thrombus is easily formed locally, and the embolus is dislodged and blocked to the pulmonary vasculature, which can cause intractable hypoxemia, low or high concentration of oxygen can not raise the partial pressure of oxygen above 60 mmHg, suffocating and wheezing, which can be aggravated at any time, accompanied by cough, hemoptysis, chest pain, syncope and other symptoms, and the blockage area is too large to cause shock or even sudden death. If the blockage area is too large, it may lead to shock or even sudden death, which requires timely diagnosis and rescue.
Pulmonary embolism and lower extremity deep vein thrombosis are different stages of the disease. If there is sudden breathlessness and cyanosis that cannot be relieved by oxygen, and swelling of the lower extremity, especially one of the lower extremities, pulmonary embolism is highly suspected. Patients with low breath sounds and signs of pulmonary embolism are not easily obtained, and D-dimer may help to exclude. Intensive CT should be performed as soon as possible to confirm the diagnosis if possible. The sudden onset of pulmonary embolism and the failure to improve the oxygenation status by increasing the oxygen concentration can be distinguished.
3.Pneumothorax
Pneumothorax is one of the common complications of COPD, especially for patients with COPD combined with pulmonary alveoli, it is necessary to be careful when examining the patient. COPD is a disease of enlarged lung volume, resulting in enlargement of the thorax, widening of the rib space, clear sounds on percussion and low breath sounds on auscultation, while if there is a combination of pulmonary alveoli, the drum sounds and breath sounds may disappear locally. If the patient is in remission, the breath sounds may disappear.
If the patient is in remission, and there is no shortness of breath but sudden aggravation of symptoms, and if there is a sudden aggravation of dyspnea with the above-mentioned signs after the inquiry, then attention should be paid to exclude pneumothorax. At this time, a more careful examination is needed, and the sudden disappearance of unilateral croup can be one of the bases if the patient originally had intrapulmonary croup.
Pneumothorax can be sudden, but not necessarily continuous. Pneumothorax can be a basal state of the patient, in which a little activity increases the oxygen demand and the pulmonary reserve function is insufficient, and then suffocated wheezing occurs. Clinically, this should be distinguished from post-activity shortness of breath caused by heart failure, and needs to be considered in cases where the general treatment of heart failure drugs are not effective.
4. Sputum embolism
Patients with sticky sputum, especially after inappropriate use of diuretics, may cause obstruction of sputum clots, aggravating the ventilation dysfunction of chronic obstructive pulmonary emphysema, and the oxygenation status cannot be improved, and the breathlessness is aggravated.
Second, cardiogenic factors
1.Heart failure
Chronic pulmonary heart disease is the most common complication of COPD, resulting in right heart failure, typically manifested as lower limb edema, hepatic and splenic stasis, further development of slow obstructive pulmonary and right heart failure can lead to total heart failure, pulmonary venous stasis in left heart failure, increased capillary hydrostatic pressure in the lungs, interstitial and alveolar edema, resulting in thickening of diffusion membrane, which can lead to increased dyspnea, typically manifested as exertional dyspnea, night The typical manifestations are exertional dyspnea, nocturnal dyspnea, telangiectatic breathing, and mobile wet rales at the base of both lungs.
Initially, croup can be detected on auscultation. The onset of dyspnea is characterized by worsening after activity, and diagnostic treatment such as cardiopulmonary diuresis and vasodilation is feasible.
2.Pericardial effusion
Dyspnea is caused by pericarditis or other causes of pericardial effusion, compression of the heart or even the left lower lobe of the lung, diastolic dysfunction of the heart, insufficient filling, ineffective ejection of blood resulting in ischemia and hypoxia, and restrictive ventilation dysfunction caused by compression of the lung.
In addition to the manifestations of dyspnea, it may be accompanied by retrosternal and precordial pain, symptoms of pericardial compression such as pallor, irritability, cyanosis, weakness, epigastric pain, swelling and even shock, symptoms of tracheal compression such as hoarseness and cough, esophageal compression may cause dysphagia, systemic symptoms such as palpitations and sweating, tiredness and fatigue, etc. The heart turbinates are enlarged on percussion, the heart sounds are distant and low on auscultation, and the pericardium can be heard. Friction sounds can be heard. The primary cause should be sought and treated symptomatically.
3, heart valve disease, cardiomyopathy and other diseases that can cause heart pumping dysfunction or reduced ejection fraction.
Other factors
Including cardiac diseases and abdominal diseases, chest wall diseases, neurological diseases, musculoskeletal system diseases and other diseases that can cause pathological changes such as reduction of chest volume and respiratory dynamics.
Clinical conditions are complex and variable, so it is important to understand the comprehensive medical history, meticulous physical examination, not to miss the smallest details, timely detection and early treatment.