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Diagnosis and management of COPD: a case study

04 May, 2020

This case study explains the symptoms, causes, pathophysiology, diagnosis and management of chronic obstructive pulmonary disease

This article uses a case study to discuss the symptoms, causes and management of chronic obstructive pulmonary disease, describing the patient’s associated pathophysiology. Diagnosis involves spirometry testing to measure the volume of air that can be exhaled; it is often performed after administering a short-acting beta-agonist. Management of chronic obstructive pulmonary disease involves lifestyle interventions – vaccinations, smoking cessation and pulmonary rehabilitation – pharmacological interventions and self-management.

Citation: Price D, Williams N (2020) Diagnosis and management of COPD: a case study. Nursing Times [online]; 116: 6, 36-38.

Authors: Debbie Price is lead practice nurse, Llandrindod Wells Medical Practice; Nikki Williams is associate professor of respiratory and sleep physiology, Swansea University.

• This article has been double-blind peer reviewed
• Scroll down to read the article or download a print-friendly PDF here (if the PDF fails to fully download please try again using a different browser)

Introduction

The term chronic obstructive pulmonary disease (COPD) is used to describe a number of conditions, including chronic bronchitis and emphysema. Although common, preventable and treatable, COPD was projected to become the third leading cause of death globally by 2020 (Lozano et al, 2012). In the UK in 2012, approximately 30,000 people died of COPD – 5.3% of the total number of deaths. By 2016, information published by the World Health Organization indicated that Lozano et al (2012)’s projection had already come true.

People with COPD experience persistent respiratory symptoms and airflow limitation that can be due to airway or alveolar abnormalities, caused by significant exposure to noxious particles or gases, commonly from tobacco smoking. The projected level of disease burden poses a major public-health challenge and primary care nurses can be pivotal in the early identification, assessment and management of COPD (Hooper et al, 2012).

Grace Parker (the patient’s name has been changed) attends a nurse-led COPD clinic for routine reviews. A widowed, 60-year-old, retired post office clerk, her main complaint is breathlessness after moderate exertion. She scored 3 on the modified Medical Research Council (mMRC) scale (Fletcher et al, 1959), indicating she is unable to walk more than 100 yards without stopping due to breathlessness. Ms Parker also has a cough that produces yellow sputum (particularly in the mornings) and an intermittent wheeze. Her symptoms have worsened over the last six months. She feels anxious leaving the house alone because of her breathlessness and reduced exercise tolerance, and scored 26 on the COPD Assessment Test (CAT, catestonline.org), indicating a high level of impact.

Ms Parker smokes 10 cigarettes a day and has a pack-year score of 29. She has not experienced any haemoptysis (coughing up blood) or chest pain, and her weight is stable; a body mass index of 40kg/m 2 means she is classified as obese. She has had three exacerbations of COPD in the previous 12 months, each managed in the community with antibiotics, steroids and salbutamol.

Ms Parker was diagnosed with COPD five years ago. Using Epstein et al’s (2008) guidelines, a nurse took a history from her, which provided 80% of the information needed for a COPD diagnosis; it was then confirmed following spirometry testing as per National Institute for Health and Care Excellence (2018) guidance.

The nurse used the Calgary-Cambridge consultation model, as it combines the pathological description of COPD with the patient’s subjective experience of the illness (Silverman et al, 2013). Effective communication skills are essential in building a trusting therapeutic relationship, as the quality of the relationship between Ms Parker and the nurse will have a direct impact on the effectiveness of clinical outcomes (Fawcett and Rhynas, 2012).

In a national clinical audit report, Baxter et al (2016) identified inaccurate history taking and inadequately performed spirometry as important factors in the inaccurate diagnosis of COPD on general practice COPD registers; only 52.1% of patients included in the report had received quality-assured spirometry.

Pathophysiology of COPD

Knowing the pathophysiology of COPD allowed the nurse to recognise and understand the physical symptoms and provide effective care (Mitchell, 2015). Continued exposure to tobacco smoke is the likely cause of the damage to Ms Parker’s small airways, causing her cough and increased sputum production. She could also have chronic inflammation, resulting in airway smooth-muscle contraction, sluggish ciliary movement, hypertrophy and hyperplasia of mucus-secreting goblet cells, as well as release of inflammatory mediators (Mitchell, 2015).

Ms Parker may also have emphysema, which leads to damaged parenchyma (alveoli and structures involved in gas exchange) and loss of alveolar attachments (elastic connective fibres). This causes gas trapping, dynamic hyperinflation, decreased expiratory flow rates and airway collapse, particularly during expiration (Kaufman, 2013). Ms Parker also displayed pursed-lip breathing; this is a technique used to lengthen the expiratory time and improve gaseous exchange, and is a sign of dynamic hyperinflation (Douglas et al, 2013).

In a healthy lung, the destruction and repair of alveolar tissue depends on proteases and antiproteases, mainly released by neutrophils and macrophages. Inhaling cigarette smoke disrupts the usually delicately balanced activity of these enzymes, resulting in the parenchymal damage and small airways (with a lumen of <2mm in diameter) airways disease that is characteristic of emphysema. The severity of parenchymal damage or small airways disease varies, with no pattern related to disease progression (Global Initiative for Chronic Obstructive Lung Disease, 2018).

Ms Parker also had a wheeze, heard through a stethoscope as a continuous whistling sound, which arises from turbulent airflow through constricted airway smooth muscle, a process noted by Mitchell (2015). The wheeze, her 29 pack-year score, exertional breathlessness, cough, sputum production and tiredness, and the findings from her physical examination, were consistent with a diagnosis of COPD (GOLD, 2018; NICE, 2018).

Spirometry is a tool used to identify airflow obstruction but does not identify the cause. Commonly measured parameters are:

• Forced expiratory volume – the volume of air that can be exhaled – in one second (FEV1), starting from a maximal inspiration (in litres);
• Forced vital capacity (FVC) – the total volume of air that can be forcibly exhaled – at timed intervals, starting from a maximal inspiration (in litres).

Calculating the FEV1 as a percentage of the FVC gives the forced expiratory ratio (FEV1/FVC). This provides an index of airflow obstruction; the lower the ratio, the greater the degree of obstruction. In the absence of respiratory disease, FEV1 should be ≥70% of FVC. An FEV1/FVC of <70% is commonly used to denote airflow obstruction (Moore, 2012).

As they are time dependent, FEV1 and FEV1/FVC are reduced in diseases that cause airways to narrow and expiration to slow. FVC, however, is not time dependent: with enough expiratory time, a person can usually exhale to their full FVC. Lung function parameters vary depending on age, height, gender and ethnicity, so the degree of FEV1 and FVC impairment is calculated by comparing a person’s recorded values with predicted values. A recorded value of >80% of the predicted value has been considered ‘normal’ for spirometry parameters but the lower limit of normal – equal to the fifth percentile of a healthy, non-smoking population – based on more robust statistical models is increasingly being used (Cooper et al, 2017).

A reversibility test involves performing spirometry before and after administering a short-acting beta-agonist (SABA) such as salbutamol; the test is used to distinguish between reversible and fixed airflow obstruction. For symptomatic asthma, airflow obstruction due to airway smooth-muscle contraction is reversible: administering a SABA results in smooth-muscle relaxation and improved airflow (Lumb, 2016). However, COPD is associated with fixed airflow obstruction, resulting from neutrophil-driven inflammatory changes, excess mucus secretion and disrupted alveolar attachments, as opposed to airway smooth-muscle contraction.

Administering a SABA for COPD does not usually produce bronchodilation to the extent seen in someone with asthma: a person with asthma may demonstrate significant improvement in FEV1 (of >400ml) after having a SABA, but this may not change in someone with COPD (NICE, 2018). However, a negative response does not rule out therapeutic benefit from long-term SABA use (Marín et al, 2014).

NICE (2018) and GOLD (2018) guidelines advocate performing spirometry after administering a bronchodilator to diagnose COPD. Both suggest a FEV1/FVC of <70% in a person with respiratory symptoms supports a diagnosis of COPD, and both grade the severity of the condition using the predicted FEV1. Ms Parker’s spirometry results showed an FEV1/FVC of 56% and a predicted FEV1 of 57%, with no significant improvement in these values with a reversibility test.

GOLD (2018) guidance is widely accepted and used internationally. However, it was developed by medical practitioners with a medicalised approach, so there is potential for a bias towards pharmacological management of COPD. NICE (2018) guidance may be more useful for practice nurses, as it was developed by a multidisciplinary team using evidence from systematic reviews or meta-analyses of randomised controlled trials, providing a holistic approach. NICE guidance may be outdated on publication, but regular reviews are performed and published online.

NHS England (2016) holds a national register of all health professionals certified in spirometry. It was set up to raise spirometry standards across the country.

Assessment and management

The goals of assessing and managing Ms Parker’s COPD are to:

• Review and determine the level of airflow obstruction;
• Assess the disease’s impact on her life;
• Risk assess future disease progression and exacerbations;
• Recommend pharmacological and therapeutic management.

GOLD’s (2018) ABCD assessment tool (Fig 1) grades COPD severity using spirometry results, number of exacerbations, CAT score and mMRC score, and can be used to support evidence-based pharmacological management of COPD.

When Ms Parker was diagnosed, her predicted FEV1 of 57% categorised her as GOLD grade 2, and her mMRC score, CAT score and exacerbation history placed her in group D. The mMRC scale only measures breathlessness, but the CAT also assesses the impact COPD has on her life, meaning consecutive CAT scores can be compared, providing valuable information for follow-up and management (Zhao, et al, 2014).

After assessing the level of disease burden,  Ms Parker was then provided with education for self-management and lifestyle interventions.

Lifestyle interventions

Smoking cessation.

Cessation of smoking alongside support and pharmacotherapy is the second-most cost-effective intervention for COPD, when compared with most other pharmacological interventions (BTS and PCRS UK, 2012). Smoking cessation:

• Slows the progression of COPD;
• Improves lung function;
• Improves survival rates;
• Reduces the risk of lung cancer;
• Reduces the risk of coronary heart disease risk (Qureshi et al, 2014).

Ms Parker accepted a referral to an All Wales Smoking Cessation Service adviser based at her GP surgery. The adviser used the internationally accepted ‘five As’ approach:

• Ask – record the number of cigarettes the individual smokes per day or week, and the year they started smoking;
• Advise – urge them to quit. Advice should be clear and personalised;
• Assess – determine their willingness and confidence to attempt to quit. Note the state of change;
• Assist – help them to quit. Provide behavioural support and recommend or prescribe pharmacological aids. If they are not ready to quit, promote motivation for a future attempt;
• Arrange – book a follow-up appointment within one week or, if appropriate, refer them to a specialist cessation service for intensive support. Document the intervention.

NICE (2013) guidance recommends that this be used at every opportunity. Stead et al (2016) suggested that a combination of counselling and pharmacotherapy have proven to be the most effective strategy.

Pulmonary rehabilitation

Ms Parker’s positive response to smoking cessation provided an ideal opportunity to offer her pulmonary rehabilitation (PR)  – as indicated by Johnson et al (2014), changing one behaviour significantly increases a person’s chance of changing another.

PR – a supervised programme including exercise training, health education and breathing techniques – is an evidence-based, comprehensive, multidisciplinary intervention that:

• Improves exercise tolerance;
• Reduces dyspnoea;
• Promotes weight loss (Bolton et al, 2013).

These improvements often lead to an improved quality of life (Sciriha et al, 2015).

Most relevant for Ms Parker, PR has been shown to reduce anxiety and depression, which are linked to an increased risk of exacerbations and poorer health status (Miller and Davenport, 2015). People most at risk of future exacerbations are those who already experience them (Agusti et al, 2010), as in Ms Parker’s case. Patients who have frequent exacerbations have a lower quality of life, quicker progression of disease, reduced mobility and more-rapid decline in lung function than those who do not (Donaldson et al, 2002).

“COPD is a major public-health challenge; nurses can be pivotal in early identification, assessment and management”

Pharmacological interventions

Ms Parker has been prescribed inhaled salbutamol as required; this is a SABA that mediates the increase of cyclic adenosine monophosphate in airway smooth-muscle cells, leading to muscle relaxation and bronchodilation. SABAs facilitate lung emptying by dilatating the small airways, reversing dynamic hyperinflation of the lungs (Thomas et al, 2013). Ms Parker also uses a long-acting muscarinic antagonist (LAMA) inhaler, which works by blocking the bronchoconstrictor effects of acetylcholine on M3 muscarinic receptors in airway smooth muscle; release of acetylcholine by the parasympathetic nerves in the airways results in increased airway tone with reduced diameter.

At a routine review, Ms Parker admitted to only using the SABA and LAMA inhalers, despite also being prescribed a combined inhaled corticosteroid and long-acting beta 2 -agonist (ICS/LABA) inhaler. She was unaware that ICS/LABA inhalers are preferred over SABA inhalers, as they:

• Last for 12 hours;
• Improve the symptoms of breathlessness;
• Increase exercise tolerance;
• Can reduce the frequency of exacerbations (Agusti et al, 2010).

However, moderate-quality evidence shows that ICS/LABA combinations, particularly fluticasone, cause an increased risk of pneumonia (Suissa et al, 2013; Nannini et al, 2007). Inhaler choice should, therefore, be individualised, based on symptoms, delivery technique, patient education and compliance.

It is essential to teach and assess inhaler technique at every review (NICE, 2011). Ms Parker uses both a metered-dose inhaler and a dry-powder inhaler; an in-check device is used to assess her inspiratory effort, as different inhaler types require different inhalation speeds. Braido et al (2016) estimated that 50% of patients have poor inhaler technique, which may be due to health professionals lacking the confidence and capability to teach and assess their use.

Patients may also not have the dexterity, capacity to learn or vision required to use the inhaler. Online resources are available from, for example, RightBreathe (rightbreathe.com), British Lung Foundation (blf.org.uk). Ms Parker’s adherence could be improved through once-daily inhalers, as indicated by results from a study by Lipson et al (2017). Any change in her inhaler would be monitored as per local policy.

Vaccinations

Ms Parker keeps up to date with her seasonal influenza and pneumococcus vaccinations. This is in line with the low-cost, highest-benefit strategy identified by the British Thoracic Society and Primary Care Respiratory Society UK’s (2012) study, which was conducted to inform interventions for patients with COPD and their relative quality-adjusted life years. Influenza vaccinations have been shown to decrease the risk of lower respiratory tract infections and concurrent COPD exacerbations (Walters et al, 2017; Department of Health, 2011; Poole et al, 2006).

Self-management

Ms Parker was given a self-management plan that included:

• Information on how to monitor her symptoms;
• A rescue pack of antibiotics, steroids and salbutamol;
• A traffic-light system demonstrating when, and how, to commence treatment or seek medical help.

Self-management plans and rescue packs have been shown to reduce symptoms of an exacerbation (Baxter et al, 2016), allowing patients to be cared for in the community rather than in a hospital setting and increasing patient satisfaction (Fletcher and Dahl, 2013).

Improving Ms Parker’s adherence to once-daily inhalers and supporting her to self-manage and make the necessary lifestyle changes, should improve her symptoms and result in fewer exacerbations.

The earlier a diagnosis of COPD is made, the greater the chances of reducing lung damage through interventions such as smoking cessation, lifestyle modifications and treatment, if required (Price et al, 2011).

• Chronic obstructive pulmonary disease is a progressive respiratory condition, projected to become the third leading cause of death globally
• Diagnosis involves taking a patient history and performing spirometry testing
• Spirometry identifies airflow obstruction by measuring the volume of air that can be exhaled
• Chronic obstructive pulmonary disease is managed with lifestyle and pharmacological interventions, as well as self-management

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200506 diagnosis and management of copd – a case study.

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[Physiotherapy during and after acute exacerbation of COPD]

Affiliations.

• 1 Intensive Care Unit, Le Havre Hospital, 76600 Le Havre, France; UVSQ, Erphan, Paris-Saclay University, 78000 Versailles, France; Saint-Michel School of Physiotherapy, 75015 Paris, France.
• 2 ADIR Association, Rouen University Hospital, 76000 Rouen, France; UPRES EA 3830, Haute Normandie Research and Biomedical Innovation, Normandy University UNIROUEN, 76000 Rouen, France. Electronic address: [email protected].
• PMID: 35221161
• DOI: 10.1016/j.rmr.2022.02.056

Introduction: Exacerbations are major events in the course and prognosis of COPD. Following acute exacerbation of COPD (AECOPD), functional recovery is not always complete and the risk of relapse is high, requiring proactive management.

State of the art: Pulmonary and extrapulmonary consequences of AECOPD require comprehensive and individualized care. Muscle function and nutritional status are key elements to target. Pulmonary rehabilitation is an effective strategy designed to deal with these aspects and to facilitate a comprehensive, patient-centered approach.

Perspectives: Access to pulmonary rehabilitation programs is limited, and existing barriers need to be more precisely identified as a first step toward their possible removal. Long-term exercise maintenance strategies likewise warrant further study.

Conclusion: The physiotherapist has a major role to assume in per- and post-exacerbation management of people with COPD; it is up to him to assess the patient and to put into place an individualized pulmonary rehabilitation program; it is also up to him to provide long-term support, helping the patient to maintain an active lifestyle while coping with a chronic pathology.

Keywords: Acute exacerbation; Bronchopneumopathie chronique obstructive; Chronic obstructive pulmonary disease; Exacerbation; Kinésithérapie; Muscle; Physiotherapy; Pulmonary rehabilitation; Réadaptation respiratoire.

Copyright © 2022 SPLF. Published by Elsevier Masson SAS. All rights reserved.

Publication types

• Disease Progression
• Physical Therapy Modalities
• Pulmonary Disease, Chronic Obstructive*

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A COPD Case Study: Jim B.

This post was written by Jane Martin, BA, LRT, CRT, Assistant Director of Education at the COPD Foundation .

We're interested in your thoughts on our latest COPD case study: Jim B., a 68-year-old man here for his Phase II Pulmonary Rehabilitation intake interview.

A bit more about Jim:

Medical history: COPD, FEV1 six weeks ago was 38% of normal predicted, recent CXR shows flattened diaphragm with increased AP diameter, appendectomy age 34, broken nose and broken right arm as a child.

Labs: Lytes plus and CBC all within normal limits.

Physical exam: Breath sounds markedly diminished bilaterally with crackles right lower lobe and wheeze left upper lobe. Visible use of accessory muscles. O2 Saturation 93% room air, 95% O2 on 2lpm. Respiratory rate 24 and shallow, HR 94, BP 150/88, 1+ pitting pedal edema.

Current Medications: Prednisone 10mg q day / DuoNeb q 4 hrs. / Ibuprofen 400mg BID / Tums prn (estimates he takes two per day).

Respiratory history: 80-pack-year cigarette history, quit last year. He has developed a dry, hacking, non-productive cough over the last six months. Had asthma as a child and was exposed to second-hand smoke and cooking fumes while working at family-owned restaurant as a child. Lately, he has noticed slight chest tightness and increased cough when visiting his wife’s art studio.

Family history: Father had emphysema, died at age 69, mother died of breast cancer at 62. Grandfather died at age 57, grandmother died in her 40s of suicide. Six adult children, alive and well.

Previous respiratory admissions: Inpatient admission for six days last winter for acute exacerbation of COPD with bacterial pneumonia requiring 24-hour intubation and mechanical ventilation.

Psych: Jim presents to his Phase II Pulmonary Rehab intake interview appearing disheveled, wearing a sweatshirt, pajama pants and bedroom slippers. He is accompanied by his wife and adult daughter who appear neat, clean and well dressed. Patient states, “I don’t think you people can do anything to help me. I’m only here because they (referring to wife and daughter) made me go.” Jim states that he has been doing less and less at home since discharged from the hospital last winter. Wife states, “He walked outside a little with our grandchildren last Sunday and got so short of breath, he almost collapsed.” Became emotional when saying, “It scared the kids. It tore me up for them to see me that way. Besides that, with this darn shoulder I can’t even pick up the little ones anymore.”

Social: Lives at home with his wife of 43 years who works as an artist. Two out of his six children live within 30 miles of Jim’s home.

Occupation: Building contractor, retired three years ago. Jim states, “I made a good living. All the kids were able to go to college. I was strong. I could work circles around anybody in my crew. And now look at me. I’m tied to that darn breathing machine (referring to nebulizer) and I might as well hang it up.” Wife states, “He used to have all kinds of energy. Now all he does is sit in his chair watching TV, eating potato chips and peanuts.”

Tell us your impressions!

• What co-morbidities should be explored?
• How would you change Jim’s medication regime?
• What psych/social recommendations would you make?
• What other medical disciplines should do a consult on this patient?
• This is a real case. What are your thoughts on what took place following Jim’s pulmonary rehab intake interview?

This page was reviewed on March 3, 2020 by the COPD Foundation Content Review and Evaluation Committee

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COPD - Sarah's story

For one Greenwich resident, a trip to the high street meant regularly stopping and pretending to look in shop windows to hide her embarrassment at being out of breath.

Sarah*, who smoked her first cigarette at age 11, was diagnosed with chronic obstructive pulmonary disease (COPD) in 2008 after a routine health check showed signs of reduced lung function.

COPD includes conditions such as chronic bronchitis, emphysema and some cases of chronic asthma.

The former smoker said it was two years before she noticed symptoms of breathlessness and fatigue which left her gasping for air without warning.

“I used to walk for miles. I used to love walking and I could go out walking for at least two hours,” Sarah said.

“Then I couldn’t even get up out of the chair without being out of breath... it’s very frightening.”

“When it first started I thought I was on my own but you don’t realise the number of other people who are also affected.”

Sarah’s GP encouraged her to attend pulmonary rehabilitation classes at a local leisure centre.

“I thought, ‘What’s that going to do? I can’t breathe, how am I going to exercise?’...but it was marvellous,” she said.

“Physios are there, they monitor you with your exercising and they push you a little further...they gave me my life back.”

When the course ended, Sarah signed up as a volunteer and now helps others twice a week.

She said the classes gave her the skills and confidence to work out at her local gym four days a week and enjoy holidays abroad again.

Plumstead Health Centre specialist physiotherapist Helen Jefford said pulmonary rehabilitation classes aimed to help people with COPD who were becoming increasingly breathless.

“The evidence reports that patients who attend pulmonary rehab feel less breathless, fitter and have an improved quality of life,” Ms Jefford said.

“Physiotherapists are instrumental in delivering the classes. They are experts in the prescription of exercise when managing patients with chronic lung disease,” she said.

Pulmonary rehab classes offer tailored exercise plans and education sessions presented by a range of healthcare professionals, she said.

* Name has been changed at patient request

Find Out More

How physiotherapy may help with copd, being active with a respiratory condition.

COPD Case Study: Patient Diagnosis and Treatment (2024)

by John Landry, BS, RRT | Updated: May 16, 2024

Chronic obstructive pulmonary disease (COPD) is a progressive lung disease that affects millions of people around the world. It is primarily caused by smoking and is characterized by a persistent obstruction of airflow that worsens over time.

COPD can lead to a range of symptoms, including coughing, wheezing, shortness of breath, and chest tightness, which can significantly impact a person’s quality of life.

This case study will review the diagnosis and treatment of an adult patient who presented with signs and symptoms of this condition.

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COPD Clinical Scenario

A 56-year-old male patient is in the ER with increased work of breathing. He felt mildly short of breath after waking this morning but became extremely dyspneic after climbing a few flights of stairs. He is even too short of breath to finish full sentences. His wife is present in the room and revealed that the patient has a history of liver failure, is allergic to penicillin, and has a 15-pack-year smoking history. She also stated that he builds cabinets for a living and is constantly required to work around a lot of fine dust and debris.

Physical Findings

On physical examination, the patient showed the following signs and symptoms:

• His pupils are equal and reactive to light.
• He is alert and oriented.
• He is breathing through pursed lips.
• His trachea is positioned in the midline, and no jugular venous distention is present.

Vital Signs

• Heart rate: 92 beats/min
• Respiratory rate: 22 breaths/min

Chest Assessment

• He has a larger-than-normal anterior-posterior chest diameter.
• He demonstrates bilateral chest expansion.
• He demonstrates a prolonged expiratory phase and diminished breath sounds during auscultation.
• He is showing signs of subcostal retractions.
• Chest palpation reveals no tactile fremitus.
• Chest percussion reveals increased resonance.
• His abdomen is soft and tender.
• No distention is present.

Extremities

• His capillary refill time is two seconds.
• Digital clubbing is present in his fingertips.
• There are no signs of pedal edema.
• His skin appears to have a yellow tint.

Lab and Radiology Results

• ABG results: pH 7.35 mmHg, PaCO2 59 mmHg, HCO3 30 mEq/L, and PaO2 64 mmHg.
• Chest x-ray: Flat diaphragm, increased retrosternal space, dark lung fields, slight hypertrophy of the right ventricle, and a narrow heart.
• Blood work: RBC 6.5 mill/m3, Hb 19 g/100 mL, and Hct 57%.

Based on the information given, the patient likely has chronic obstructive pulmonary disease (COPD) .

The key findings that point to this diagnosis include:

• Barrel chest
• A long expiratory time
• Diminished breath sounds
• Use of accessory muscles while breathing
• Digital clubbing
• Pursed lip breathing
• History of smoking
• Exposure to dust from work

What Findings are Relevant to the Patient’s COPD Diagnosis?

The patient’s chest x-ray showed classic signs of chronic COPD, which include hyperexpansion, dark lung fields, and a narrow heart.

This patient does not have a history of cor pulmonale ; however, the findings revealed hypertrophy of the right ventricle. This is something that should be further investigated as right-sided heart failure is common in patients with COPD.

The lab values that suggest the patient has COPD include increased RBC, Hct, and Hb levels, which are signs of chronic hypoxemia.

Furthermore, the patient’s ABG results indicate COPD is present because the interpretation reveals compensated respiratory acidosis with mild hypoxemia. Compensated blood gases indicate an issue that has been present for an extended period of time.

What Tests Could Further Support This Diagnosis?

A series of pulmonary function tests (PFT) would be useful for assessing the patient’s lung volumes and capacities. This would help confirm the diagnosis of COPD and inform you of the severity.

Note: COPD patients typically have an FEV1/FVC ratio of < 70%, with an FEV1 that is < 80%.

The initial treatment for this patient should involve the administration of low-flow oxygen to treat or prevent hypoxemia .

It’s acceptable to start with a nasal cannula at 1-2 L/min. However, it’s often recommended to use an air-entrainment mask on COPD patients in order to provide an exact FiO2.

Either way, you should start with the lowest possible FiO2 that can maintain adequate oxygenation and titrate based on the patient’s response.

Example: Let’s say you start the patient with an FiO2 of 28% via air-entrainment mask but increase it to 32% due to no improvement. The SpO2 originally was 84% but now has decreased to 80%, and his retractions are worsening. This patient is sitting in the tripod position and continues to demonstrate pursed-lip breathing. Another blood gas was collected, and the results show a PaCO2 of 65 mmHg and a PaO2 of 59 mmHg.

What Do You Recommend?

The patient has an increased work of breathing, and their condition is clearly getting worse. The latest ABG results confirmed this with an increased PaCO2 and a PaO2 that is decreasing.

This indicates that the patient needs further assistance with both ventilation and oxygenation .

Note: In general, mechanical ventilation should be avoided in patients with COPD (if possible) because they are often difficult to wean from the machine.

Therefore, at this time, the most appropriate treatment method is noninvasive ventilation (e.g., BiPAP).

Initial BiPAP Settings

In general, the most commonly recommended initial BiPAP settings for an adult patient include this following:

• IPAP: 8–12 cmH2O
• EPAP: 5–8 cmH2O
• Rate: 10–12 breaths/min
• FiO2: Whatever they were previously on

For example, let’s say you initiate BiPAP with an IPAP of 10 cmH20, an EPAP of 5 cmH2O, a rate of 12, and an FiO2 of 32% (since that is what he was previously getting).

After 30 minutes on the machine, the physician requested another ABG to be drawn, which revealed acute respiratory acidosis with mild hypoxemia.

What Adjustments to BiPAP Settings Would You Recommend?

The latest ABG results indicate that two parameters must be corrected:

• Increased PaCO2
• Decreased PaO2

You can address the PaO2 by increasing either the FiO2 or EPAP setting. EPAP functions as PEEP, which is effective in increasing oxygenation.

The PaCO2 can be lowered by increasing the IPAP setting. By doing so, it helps to increase the patient’s tidal volume, which increased their expired CO2.

Note: In general, when making adjustments to a patient’s BiPAP settings, it’s acceptable to increase the pressure in increments of 2 cmH2O and the FiO2 setting in 5% increments.

Oxygenation

To improve the patient’s oxygenation , you can increase the EPAP setting to 7 cmH2O. This would decrease the pressure support by 2 cmH2O because it’s essentially the difference between the IPAP and EPAP.

Therefore, if you increase the EPAP, you must also increase the IPAP by the same amount to maintain the same pressure support level.

Ventilation

However, this patient also has an increased PaCO2 , which means that you must increase the IPAP setting to blow off more CO2. Therefore, you can adjust the pressure settings on the machine as follows:

• IPAP: 14 cmH2O
• EPAP: 7 cmH2O

After making these changes and performing an assessment , you can see that the patient’s condition is improving.

Two days later, the patient has been successfully weaned off the BiPAP machine and no longer needs oxygen support. He is now ready to be discharged.

The doctor wants you to recommend home therapy and treatment modalities that could benefit this patient.

What Home Therapy Would You Recommend?

You can recommend home oxygen therapy if the patient’s PaO2 drops below 55 mmHg or their SpO2 drops below 88% more than twice in a three-week period.

Remember: You must use a conservative approach when administering oxygen to a patient with COPD.

Pharmacology

You may also consider the following pharmacological agents:

• Short-acting bronchodilators (e.g., Albuterol)
• Long-acting bronchodilators (e.g., Formoterol)
• Anticholinergic agents (e.g., Ipratropium bromide)
• Inhaled corticosteroids (e.g., Budesonide)
• Methylxanthine agents (e.g., Theophylline)

In addition, education on smoking cessation is also important for patients who smoke. Nicotine replacement therapy may also be indicated.

In some cases, bronchial hygiene therapy should be recommended to help with secretion clearance (e.g., positive expiratory pressure (PEP) therapy).

It’s also important to instruct the patient to stay active, maintain a healthy diet, avoid infections, and get an annual flu vaccine. Lastly, some COPD patients may benefit from cardiopulmonary rehabilitation .

By taking all of these factors into consideration, you can better manage this patient’s COPD and improve their quality of life.

Final Thoughts

There are two key points to remember when treating a patient with COPD. First, you must always be mindful of the amount of oxygen being delivered to keep the FiO2 as low as possible.

Second, you should use noninvasive ventilation, if possible, before performing intubation and conventional mechanical ventilation . Too much oxygen can knock out the patient’s drive to breathe, and once intubated, these patients can be difficult to wean from the ventilator .

Furthermore, once the patient is ready to be discharged, you must ensure that you are sending them home with the proper medications and home treatments to avoid readmission.

Written by:

John Landry is a registered respiratory therapist from Memphis, TN, and has a bachelor's degree in kinesiology. He enjoys using evidence-based research to help others breathe easier and live a healthier life.

• Faarc, Kacmarek Robert PhD Rrt, et al. Egan’s Fundamentals of Respiratory Care. 12th ed., Mosby, 2020.
• Chang, David. Clinical Application of Mechanical Ventilation . 4th ed., Cengage Learning, 2013.
• Rrt, Cairo J. PhD. Pilbeam’s Mechanical Ventilation: Physiological and Clinical Applications. 7th ed., Mosby, 2019.
• Faarc, Gardenhire Douglas EdD Rrt-Nps. Rau’s Respiratory Care Pharmacology. 10th ed., Mosby, 2019.
• Faarc, Heuer Al PhD Mba Rrt Rpft. Wilkins’ Clinical Assessment in Respiratory Care. 8th ed., Mosby, 2017.
• Rrt, Des Terry Jardins MEd, and Burton George Md Facp Fccp Faarc. Clinical Manifestations and Assessment of Respiratory Disease. 8th ed., Mosby, 2019.

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Case studies in respiratory physiotherapy

CHAPTER FIVE Case studies in respiratory physiotherapy Lead author Janis Harvey, with contributions from Sarah Ridley, Jo Oag, Elaine Dhouieb, Billie Hurst Case study 1: Respiratory Medicine – Bronchiectasis Out-patient 34 Case study 2: Respiratory Medicine – Lung Cancer Patient 36 Case study 3: Respiratory Medicine – Cystic Fibrosis Patient 38 Case study 4: Respiratory Medicine – COPD Patient 41 Case study 5: Surgical Respiratory – Anterior Resection 43 Case study 6: Surgical Respiratory – Division of Adhesions 44 Case study 7: Surgical Respiratory – Hemicolectomy 46 Case study 8: Surgical Respiratory – Bowel Resection 48 Case study 9: Intensive Care – Patient for Extubation 50 Case study 10: Intensive Care – Surgical Patient 51 Case study 11: Intensive Care – Medical Patient 52 Case study 12: Intensive Care – Patient Mobilisation 54 Case study 13: Cardiothoracic Surgery – Self Ventilating Patient 55 Case study 14: Cardiothoracic Surgery – Intensive Care Patient 57 Case study 15: Paediatric Respiratory Care – Medical Patient 59 Case study 16: Paediatric Respiratory Care – Intensive Care Patient 61 Introduction The area of respiratory physiotherapy reaches a number of patient groups, both in the in-patient and out-patient settings. The case studies that follow are based predominantly in the in-patient environment; however, the components of a respiratory assessment and the subsequent identification of physiotherapy problems and treatment plan could be applied to any patient with respiratory compromise in any clinical setting. Like all other areas of physiotherapy practice, respiratory physiotherapy involves accurate patient assessment in order to identify patient problems. Respiratory assessment should include certain key elements: general observations of the patient; consideration of trends in physiological observations (e.g. HR, BP, oxygen saturations); patient position; auscultation, palpation and, where available, analysis of arterial blood gases and chest X-ray (CXR). Patient problems identified from the assessment generally fall into three main categories: loss of lung volume, secretion retention and increased work of breathing. The extent of any resulting respiratory compromise can vary greatly between patients and may not always be reflected by the ward area in which the patient is being treated. On occasion the most acutely unwell patients are in the general ward areas and not within critical care as expected. A problem-orientated treatment plan may include a combination of a number of interventions such as mobilisation, positioning, breathing techniques (e.g. ACBT, AD), manual techniques (percussion, vibrations), mechanical aids (e.g. IPPB, CPAP) or more invasive measures (e.g. airway suctioning). A respiratory assessment is mainly indicated for patients who have undergone surgery, those with medical respiratory conditions, e.g. exacerbation of COPD, and those requiring critical care. Cardiothoracic surgery and paediatrics are other specialist clinical areas that physiotherapists are involved in providing respiratory care. However, it must be remembered that patients requiring such care may not be in these ward areas exclusively. Physiotherapists working in any clinical area may be required to undertake a respiratory assessment and provide respiratory care. For example, assessment of a stroke patient who has aspirated or an oncology patient who develops respiratory failure following chemotherapy. It is important, therefore, that all physiotherapists are familiar with respiratory assessment and intervention. Another key area of work where physiotherapists are required to undertake respiratory care is in the provision of emergency duty/on-call services. Such services are available to patients who have a condition amenable to physiotherapy, which has either deteriorated or is likely to deteriorate without intervention before daytime service resumes ( Scottish Intercollegiate Guideline Network 2004 ). This can be a very challenging area of work for the physiotherapist on-call, who needs to think clearly while being faced with an acutely unwell patient who is in need of their attention, whatever the time of day. Guidance is available to support the clinician involved in providing such care and to aid ongoing assessment of competence ( Chartered Society of Physiotherapy 2002 ). CASE STUDY 1 Respiratory medicine – bronchiectasis out-patient Subjective assessment PC 35-year-old female Attending routine multidisciplinary bronchiectasis clinic appointment HPC Diagnosed 6/12 ago with bronchiectasis following an in-patient admission with community-acquired pneumonia (CAP) in her right lower lobe. This resulted in the development of bronchiectatic changes. Since diagnosis the patient reports daily production of mucopurulent secretions with excessive coughing and feelings of fatigue PMH CAP Gastric oesophageal reflux SH Married with two children Lifelong non-smoker Full-time employment as drug company representative, involving frequent travel around the United Kingdom Normally leads an active lifestyle with two to three visits a week to the gym, although this has decreased over the past 3/12 DH Omeprazole Consultant handover Patient is currently stable but is concerned about the impact of her cough and increased sputum on everyday life, especially in relation to her work, where she frequently does formal presentations Objective assessment Respiratory Ventilation SV room air SpO 2 99% RR 12 CXR Bronchiectatic changes present in right lower lobe ABG Not appropriate to be taken as stable CVS Temp 37°C HR 70 BP 120/70 CNS Nil of note Renal Nil of note MSK Nil of note Microbiology Staphylococcus aureus in sputum sample 6/12 ago Patient position Sitting in chair Observation Looks well, good colour, breathing pattern normal Patient actively trying to suppress cough and noise of secretions Auscultation Breath sounds throughout both lung fields with mid inspiratory crackles right lower lobe Questions 1. You feel this lady seems a little vague regarding her diagnosis, how will you deal with this issue? 2. Following discussion it is now evident that the patient’s knowledge about her condition is sparse. How will you resolve this issue? 3. What is the range of airway clearance techniques commonly taught to this group of patients? 4. Considering this patient’s condition and lifestyle what would be the advantages and disadvantages to each of the treatments mentioned in the previous question? 5. Your patient seems reluctant to undertake airway clearance management, how will you motivate your patient to undertake regular treatment? 6. What frequency and duration may you suggest to this patient for performing airway clearance techniques? 7. What signs and symptoms would you highlight to your patient to recognize at the start of an exacerbation? 8. Your patient asks what she should do if she has an exacerbation, what advice do you give her? 9. Why would you consider asking this patient if she has any urinary stress incontinence problems? CASE STUDY 2 Respiratory medicine – lung cancer patient Subjective assessment PC 70-year-old male Non-small-cell lung cancer (NSCLC) in the right main bronchus Admitted with an acute deterioration in condition and the family are no longer able to cope with the patient at home HPC Diagnosed 9/12 ago following a 3/12 history of increasing shortness of breath and cough. Two episodes of frank haemoptysis also reported. Following diagnosis, patient was deemed appropriate for a course of chemotherapy, but had limited response to intervention. As an out-patient he had a CT scan, which showed brain and spinal metastases, and he has been suffering uncontrollable pain. As a result he has been bed bound for the past month and has required increasing support from Macmillan oncology nurse specialists PMH Nil of note SH Lives with wife in a bungalow Smokes 40 cpd Retired teacher Close family network Until 2/12 ago independent with walking stick, able to walk to local shops approximately 100 m DH Paracetamol Co-codamol Oramorph Lactulose Build up drinks Handover Patient admitted with a decreased GCS, frail, emaciated Family very concerned, emotional and distressed by patient’s breathing pattern and audible secretions Pain management sub-optimal Objective assessment Respiratory Ventilation SV 4L O 2 via non-venturi system mask, unhumidified SpO 2 95% RR 10–22 CXR No CXR taken on admission Previous CXR (1/12 ago): white out of right lung field, secondary to bronchus obstruction ABG None available CVS Temp 39°C HR 120 BP 105/65 CNS GCS fluctuating between 5 and 8 Renal Catheterised on admission MSK Pain at lower back region in keeping with spinal metastases Microbiology None Patient position Supine Observation Flushed, drowsy, intelligible speech with audible secretions. Agitated at times, with arms flailing and pulling at oxygen mask Normal chest shape with altered breathing pattern illustrated by Cheyne–Stoking Auscultation Breath sounds diminished throughout right lung field with widespread coarse inspiratory/expiratory crackles transmitting throughout left lung field Palpation Decreased chest excursion on right with palpable secretions over trachea and left apex Questions 1. How would you describe Cheyne–Stoking? 2. If a patient is performing a Cheyne–Stoke breathing pattern, what does this indicate? 3. Prior to assessing and treating this patient, what further information do you require? 4. What are the main physiotherapy problems? 5. What are the associated problems for this patient that may affect your physiotherapy intervention? 6. How will you treat the problems that you have highlighted? 7. What outcome measures will you use to evaluate the effectiveness of your intervention? 8. In this scenario, which medical and physiotherapy interventions are inappropriate and why? 9. What do you see as the role of the palliative care team in this scenario? CASE STUDY 3 Respiratory medicine – cystic fibrosis patient Subjective assessment PC 19-year-old female Admitted with acute exacerbation of cystic fibrosis (CF) HPC Diagnosed at birth. Multiple hospital admissions over last 3 years due to exacerbation of CF. On admission patient reporting 1/52 history of increased breathlessness, sputum volume and cough. These symptoms have not responded to a 2/52 course of intravenous antibiotics. In respiratory distress. Dehydrated. Recent weight loss and current BMI 17. Under review for lung transplantation assessment. Patient previously agreed to perform twice daily ACBT in alternate side lying/supine for 20 minutes, but generally non-compliant with suggested airway clearance programme and prescribed medications PMH Asthma Osteoporosis SH Lives at home with parents and sister (non-CF) Unemployed and sedentary lifestyle due to health status DH Ventolin via nebuliser Becotide via inhaler Dnase via nebuliser Colomycin via nebuliser Azithromycin Creon Alendronate Vitamins A, D, E, K Long-term oxygen therapy Handover Patient exhausted and only able to clear small amounts of very thick, purulent bronchial secretions with difficulty. Pyrexial and requiring intravenous fluids. C/O nausea following overnight feed via PEG tube Objective assessment Respiratory Ventilation SV 28% O 2 via venturi system mask SpO 2 85% RR 34 CXR ( Figure 5.1 ) Hyperinflated, chronic bronchiectatic/fibrotic changes throughout upper and mid zones bilaterally Intravenous access device in situ Figure 5.1 X-ray for Case Study 3 showing hyperinflated, chronic bronchiectatic/fibrotic changes throughout upper and mid zones bilaterally. Intravenous access device in situ . ABG H + 50 nmol/L pCO 2 13 kPa pO 2 7 kPa HCO 3 − 30 mmol/L BE −9.0 CVS Temp 38.5°C HR 129 BP 100/85 CNS Nil of note Renal Nil of note MSK Kyphotic with history of osteoporosis Microbiology Pseudomonas in sputum Patient position Sitting upright in bed holding onto cot sides Observation Pale with signs of central cyanosis. Unable to speak due to SOB and excessive cough. Looks distressed. Breathing pattern shallow, apical with active expiration Auscultation Coarse inspiratory crackles transmitting throughout chest on background of high-pitched expiratory wheeze Palpation Limited chest excursion on inspiration (right = left) Secretions palpable upper, anterior chest wall Questions 1. Considering the above information, list this patient’s physiotherapy problems. 2. What information from the objective assessment led you to this problem list? 3. What does the ABG result tell you? 4. What are the specific signs of hyperinflation on this patient’s X-ray ( Figure 5.1 )? 5. During this admission, how might you initially modify this patient’s normal daily routine of alternate side lying and ACBT for 20 minutes twice a day? 6. Having decided on an acceptable airway clearance technique, what else would you include in your initial treatment plan? 7. Following two physiotherapy sessions with modified ACBT that morning, you feel that the patient is becoming more exhausted and unable to clear her secretions effectively. How might you change your physiotherapy management and with whom would you want to discuss these potential changes? 8. How might your treatment/management change if your patient was commenced on NIV? 9. Why would it be inappropriate to introduce activity/exercise at this stage? CASE STUDY 4 Respiratory medicine – copd patient Subjective assessment PC 65-year-old male Admitted to respiratory ward with acute exacerbation of COPD HPC Diagnosed 5 years ago with severe emphysema. Recent viral illness that has resulted in a dry cough, wheeze and breathlessness for 1/52. Has been house bound last few days. Normally 1–2 exacerbations per year that are managed by GP. No previous hospital admissions for COPD PMH Hypertension SH Retired engineer. Lives alone in third-floor flat. No lift. Normally manages all ADL independently. Exercise tolerance 50 m on flat – no aid required. Drives a car. No family living locally. No social services required. Smokes 30 cpd DH Salbutamol inhaler Becotide inhaler Atenolol GP letter states that patient has not picked up repeat prescription for inhalers from 1/12 ago Handover Admitted overnight. Patient noted to be drowsy but able to be roused for short periods. When awake, able to talk in short sentences but appears slightly disorientated. Breathing pattern laboured and has a dry, spontaneous cough. Dehydrated but receiving IV fluids Objective assessment Respiratory Ventilation SV 6 L O 2 via a simple face mask SpO 2 97% RR 9 CXR Hyperinflated lung fields with flattened diaphragms Emphysematous bullae upper zones No focal signs of collapse/consolidation ABG H + 58 mmol/L pCO 2 12 kPa pO 2 12 kPa HCO 3 − 30 mmol/L BE +9 CVS Temp 37.5°C HR 115 BP 130/90 CNS Drowsy but able to be roused for short periods Disorientated and confused. Moving all four limbs Renal Nil of note MSK Nil of note Microbiology None available Patient position Slumped lying in bed Observation Obese man with barrel shaped chest and large abdomen. Colour – flushed. Breathing through an open mouth. Predominately a shallow, apical breathing pattern with increased use of accessory muscles. Also demonstrating in-drawing of his lower chest wall on inspiration. Active expiration Auscultation Quiet BS generally with end expiratory polyphonic wheeze throughout Palpation Decreased expansion bi-basally (right = left). No palpable secretions Questions 1. The patient is drowsy with a RR of 9. What may be the contributing factors? 2. What is the difference between fixed and variable oxygen therapy? 3. Which type of oxygen therapy would be more suitable for the patient at this point? 4. What is this patient’s main physiotherapy problem? 5. What led you to this conclusion? 6. What factors may be contributing to this increased WOB? 7. How might your initial treatment plan address this problem of increased WOB? 8. Consider this patient’s CXR report, chest shape and breathing pattern. Would he benefit from lower lateral costal breathing exercises to improve basal chest excursion once he was less drowsy? 9. What goals would you hope to have achieved before this patient was discharged home? CASE STUDY 5 Surgical respiratory – anterior resection Subjective assessment PC 63-year-old male Day 2 post-laparotomy for anterior resection (end to end anastomosis) HPC Emergency admission yesterday with increasing abdominal pain 2/12 altered bowel habit PMH Nil of note- previously fit and well SH Lives with wife, recently retired, independent with ADL, plays golf three times a week, smoker 5 cpd DH Nil of note Handover Acute desaturation this morning. Patient has been coughing – effective and occasionally moist, nil expectorated. Otherwise stable Not been out of bed as yet Objective assessment Respiratory Ventilation SV 4 L O 2 via nasal cannulae SpO 2 90% RR 12 CXR Right basal collapse ABG None available CVS Temp 37.4°C HR 80 BP 130/60 CNS GCS E4 V5 M6 Pain score VAS 2/10 at rest 4/10 on movement/coughing Morphine PCA Renal UO 20–30 mL/hr +1.5 L cumulative balance to date MSK Nil of note Microbiology Nil of note Patient position Slumped in bed Observation Talking freely Auscultation Breath sounds throughout, fine end inspiratory crackles right base Palpation Reduced expansion right base, no secretions palpable Questions 1. Is this patient adequately oxygenated? What suggestions might you make? 2. List this patient’s physiotherapy problem(s). 3. What information from the objective assessment led you to this problem list? 4. Why are patients who have undergone surgery/anaesthetic at risk of developing respiratory compromise? 5. What are the treatment options for this patient? 6. What would your initial treatment plan include? 7. How would you progress this patient? 8. HDU patients can have many attachments including monitoring (ECG, sats probe), oxygen therapy, catheter and wound drains. What considerations would you have to give before mobilising such a patient? CASE STUDY 6 Surgical respiratory – division of adhesions Subjective assessment PC 74-year-old female Day 3 post-laparotomy and division of adhesions HPC Existing ileostomy – no output for 48 hours, vomiting and no significant fluid intake PMH Small bowel resection and formation of ileostomy 2 years previous for incarcerated hernia COPD Right axillary node clearance Previous pulmonary TB SH Lives alone, housebound, home help three times/day, smokes 10 cpd DH Ventolin inhaler Seretide inhaler Handover Initially in intensive care, intubated and ventilated. Extubated yesterday and transferred to HDU. Stable overnight, difficulty clearing secretions Objective assessment Respiratory Ventilation SV FiO 2 0.28 via face mask cold humidification RR16 SpO 2 89% CXR – taken prior to extubation ( Figure 5.2 ) Scoliosis, rotated, hyperinflated, nil focal Figure 5.2 X-ray for Case Study 6 taken prior to extubation showing the patient has a scolosis with hyperinflated lungs and nil focal in lung fields. ABG H + 36.35 nmol/L pCO 2 5.91 kPa pO 2 7.42 kPa HCO 3 − 28.2 mmol/L BE + 4.7 CVS Temp 36.5°C HR 85 BP 110/50 Noradrenaline 8 mL/hr CNS GCS E4 V5 M6 Pain score VAS 3/10 at rest 8/10 on movement/coughing Morphine PCA Renal UO 50 mL/hr +3.2 L cumulative balance to date MSK Nil of note Microbiology Nil of note Patient position Sitting upright in bed, frail Observation Hyperinflated chest, looks well, chatting freely, dry mouth Auscultation Breath sounds throughout, coarse expiratory crackles throughout Palpation Expansion equal, palpable secretions bilateral upper zones Questions 1. Describe the advantages and disadvantages of patient-controlled analgesia (PCA). 2. Considering this patient’s CXR ( Figure 5.2 ), what additional hardware/monitoring is visible? 3. List this patient’s physiotherapy problem(s). 4. What information from the assessment led you to this problem list? 5. From the assessment information, what suggestions should the physiotherapist make before physiotherapy care commences? 6. What would be your initial treatment plan? 7. Given this patient’s present condition and past history, how might you need to modify the treatments delivered? 8. How would you know if your treatment had been effective (outcome measures)? 9. If the initial treatment plan were to be unsuccessful in clearing secretions, how would you modify your treatment? CASE STUDY 7 Surgical respiratory – hemicolectomy Subjective assessment PC 55-year-old male Day 2 post laparotomy for right hemicolectomy (end to end anastomosis) HPC Elective admission for bowel resection – investigated 6/12 ago due to altered bowel habit and weight loss. Tumour identified and biopsy taken during colonoscopy PMH Nil of note SH Lives alone, independent with ADL, non-smoker DH Nil of note Handover Acute desaturation this morning requiring increased FiO 2 , not been out of bed as yet due to reduced blood pressure, otherwise stable Objective assessment Respiratory Ventilation SV FiO 2 0.6 via face mask cold humidification RR 12 SpO 2 96% CXR Left lower lobe collapse ABG None available CVS Temp 37.4°C HR 80 BP 80/45 CNS GCS E4 V5 M6 Pain score VAS 2/10 at rest 3/10 on movement/coughing Epidural analgesia (Bupivacaine and Morphine mix) Renal UO 30 mL/hr +1.5 L cumulative balance to date MSK Nil of note Microbiology Nil of note Patient position Slumped in bed Observation Looks well, talking freely Auscultation Breath sounds throughout, reduced at left base Palpation Reduced expansion left base, no secretions palpable Questions 1. What does the procedure of a right hemicolectomy involve? 2. Why can the presence of an epidural lead to hypotension? 3. List this patient’s physiotherapy problem(s). 4. What information from the objective assessment led you to this problem list? 5. What would be your initial treatment plan? 6. After identifying an appropriate treatment plan, what information/instructions would you handover to the nursing staff caring for the patient? 7. How would you determine if your treatment plan had been effective (outcome measures)? 8. What goals would you hope to have achieved before this patient was discharged home? CASE STUDY 8 Surgical respiratory – bowel resection Subjective assessment PC 80-year-old male Day 3 post-laparotomy for bowel resection HPC Presented to A&E with painful distended abdomen. Bowels not opened for 2/7 previous. Distended loops of bowel and sigmoid volvulus on AXR. Attempted decompression by colonoscopy unsuccessful therefore proceeded to theatre for open procedure PMH Hypertension SH Lives with wife, independently mobile DH Atenolol Handover Patient confused and drowsy since return from theatre. Has a moist, ineffective cough that is not productive Objective assessment Respiratory Ventilation SV 2L O 2 via nasal cannulae RR 17 SpO 2 94% CXR ( Figure 5.3 ) Reduced lung volume bibasally Figure 5.3 X-ray for Case Study 8 showing reduced lung volume bi-basally. ABG H + 49.8 nmol/L pCO 2 4.87 kPa pO 2 10.16 kPa HCO 3 − 18.0 mmol/L BE –8 CVS Temp 37°C HR 100 BP 160/70 CVP +9 CNS GCS E3 V4 M5 Pain score – unable to score reliably Renal UO 35 mL/hr +6 L cumulative fluid balance to date MSK Nil of note Microbiology Nil of note Patient position Slumped in bed Observation Drowsy, audible added sounds at mouth Auscultation Breath sounds throughout reduced bibasally, expiratory crackles upper zones Palpation Expansion equally reduced bilaterally, no secretions palpable Questions 1. Explain the patient’s drug history in relation to the past medical history. 2. Why do post-operative patients tend to have a significant positive fluid balance? 3. Why is metabolic acidosis a common finding when analysing the ABG of a post-operative patient? 4. List this patient’s physiotherapy problem(s). 5. What information from the objective assessment led you to this problem list? 6. Systematically analysing this patient’s CXR ( Figure 5.3 ), what signs do you find that would confirm bibasal loss of lung volume? 7. What would be your initial treatment plan? 8. What could be suggested as a management strategy if the patient required regular suctioning and why? CASE STUDY 9 Intensive care – patient for extubation Subjective assessment PC 55-year-old female Day 7 post-laparotomy for subtotoal colectomy and extensive bowel resection, formation of ileostomy HPC Emergency admission from A&E in shock with reduced BP, abdominal pain Unwell for 3–4 days, intermittent diarrhoea and vomiting Theatre findings – patchy infarction of small and large bowel PMH Hypertension SH Lives with son, 10 cpd smoker DH Bisoprolol Handover Stable overnight Possibly for extubation. Just weaned to ASB from SIMV Objective assessment Respiratory Ventilation ASB (PEEP 5 PS 5) ETT size 7.0 FiO 2 0.35 RR 19 Tv 0.46 L SpO 2 97% M1 secretions CXR Nil focal ABG H + 39.7 nmol/L pCO 2 5.06 kPa pO 2 14.15 kPa HCO 3 − 23.1 mmol/L BE –1.5 CVS Temp 38.6°C HR 135 BP 169/88 CVP +11 CNS GCS E3 VT M4 Propofol 10 mL/hr Alfentanil 2 mL/hr Renal UO 50 mL/hr overall +500 mL MSK Nil of note Microbiology Sputum and urine – no growth Patient position Head-up tilt in bed Observation Intubated and ventilated, settled, relaxed breathing pattern Auscultation Breath sounds throughout, no added sounds Palpation Expansion equal, no secretions palpable Questions 1. Define and explain the difference between SIMV and ASB modes of ventilation. 2. What would you look for in a patient assessment that might indicate to you a patient is ready for extubation? 3. The Glasgow Coma Scale (GCS) is used to assess level of consciousness. What are the components of the scoring system? 4. On assessment this patient GCS is E3 VT M5. What is the patient ‘doing’ and what are the implications of this for the patient with regard to readiness to extubate? 5. List this patient’s physiotherapy problem(s). 6. What information from the objective assessment led you to this problem list? 7. What would be your initial treatment plan? 8. How would you assess as to whether the deep breaths the patient was attempting to take were effective? CASE STUDY 10 Intensive care – surgical patient Subjective assessment PC 51-year-old female Day 1 post laparotomy – drainage of pelvic abscess and over sew of serosal tears HPC Admitted previous day with abdominal pain and distension. CT revealed free gas, fluid and faeces in the abdomen and a pelvic collection PMH Ischaemic colitis Hartmans procedure 1 year ago SH Lives with husband Independent with all ADL DH Nil Handover Problems with cuff leak on repositioning. Aiming to place NG tube then reduce sedation Objective assessment Respiratory Ventilation SIMV ETT size 7.0 FiO 2 0.35 PEEP 5 PS 10 Tv 0.419 L RR 14 SpO 2 92% HMEF brown secretions CXR Nil focal ABG H + 52.19 nmol/L pCO 2 4.6 kPa pO 2 10.96 kPa HCO 3 − 16.6 mmol/L BE –9.8 CVS Temp 36.5°C HR 100 BP 140/90 CVP +10 CNS GCS E3 VT M5 Propofol 7 mL/hr Alfentanil 2 mL/hr Renal UO 35 mL/hr +2.5 L cumulative balance MSK Nil of note Microbiology Nil of note Patient position Head-up tilt in bed Observation Intubated, ventilated, settled Auscultation Breath sounds throughout, coarse expiratory crackles right upper/middle zones Palpation Expansion equal, palpable secretions right upper zone Questions 1. Analyse the ABG presented. 2. On handover the presence of a cuff leak has been highlighted. What is the significance of this information? 3. List this patient’s physiotherapy problem(s). 4. What information from the objective assessment led you to this problem list? 5. Positioning is integral to all respiratory physiotherapeutic input. Which position would you choose for this patient and why? 6. What would be your initial treatment plan? 7. If your initial treatment was unsuccessful in clearing the secretions, how might you modify your treatment? 8. What are the potential hazards associated with endotracheal suctioning? CASE STUDY 11 Intensive care – medical patient Subjective assessment PC 72-year-old male Bilateral pneumonia and sepsis, 4 hours post ICU admission HPC Presented to Acute Receiving Unit today. Poor oral intake for 1/52 – dehydrated and weak PMH Mild learning difficulties, irritable bowel syndrome SH Lives with partner, home help twice a week, otherwise independent DH Nil of note Handover Stable since admission; plan to keep sedated for at least 24 hours Objective assessment Respiratory Ventilation Uncut ETT size 8.0 SIMV FiO 2 0.65 PEEP 10 SpO 2 96% RR 25/0 mandatory/spontaneous Tv 0.55 L nil-M1 secretions CXR Collapse consolidation left lower zone, patchy changes right middle zone ABG H + 53.8 nmol/L pCO 2 6.9 kPa pO 2 10.7 kPa HCO 3 − 24 mmol/L BE –1.2 CVS Temp 38°C HR 90 BP 95/55 CVP +12 Noradrenaline 26 mL/hr CNS Pupils 2+ 2+ GCS E2 VT M4 Sedation – Propofol 10 mL/hr, Alfentanil 2 mL/hr Renal UO 30+ mL/hr +1 L balance MSK Nil of note Microbiology No result as yet, commenced on broad-spectrum antibiotics Patient position Head-up tilt in bed Observation Intubated, ventilated, sedated Auscultation Breath sounds throughout, bronchial breathing left lower zone Palpation Reduced expansion left base, no secretions palpable Questions 1. The patient is septic. What information from the objective assessment indicates this? 2. Analyse the ABG presented. 3. Describe bronchial breathing. 4. List this patient’s physiotherapy problems(s). 5. What information from the objective assessment led you to this problem list? 6. What could be your initial treatment plan for each of these problems? 7. Clinically reason through whether MHI would be appropriate for this patient. 8. What would be your short-term goals for this patient? CASE STUDY 12 Intensive care – patient mobilisation Subjective assessment PC 50-year-old male Community-acquired pneumonia Day 41 in ICU HPC Admitted via A&E drowsy, sweaty and ‘unwell’. Quickly deteriorated with respiratory failure, requiring intubation and ventilation Complicated ICU stay with ARDS and two failed extubations PMH Alcohol excess (½ bottle vodka a day) Previous IV drug abuser Previous ICU admission with pneumonia SH Lives alone, first floor flat DH Nil of note Handover Been on CPAP overnight via tracheostomy, now on speaking valve Patient is keen to mobilise Objective assessment Respiratory Ventilation Trache size 8.0 (with inner tube, non-fenestrated) Speaking valve in situ. 2 L O 2 SpO 2 96% RR 20 MP2 secretions on suction CXR No recent ABG H + 39.42 nmol/L pCO 2 5.34 kPa pO 2 11.5 kPa HCO 3 − 24.1 mmol/L BE –0.2 CVS Temp 36.5°C HR 80 BP 140/80 CNS GCS E4 V5 M6 Renal UO 100 mL/hr overall negative balance MSK Nil of note Microbiology MRSA +ve in sputum Patient position High sitting in bed Observation Looks well, strong clear voice Auscultation Breath sounds throughout, no added sounds Palpation Expansion equal, no secretions palpable Questions 1. This patient developed ARDS due to severe pneumonia. What is ARDS? 2. This patient failed two attempts at extubation and so had a tracheostomy inserted to facilitate weaning. What other indications are there for tracheostomy tube insertion?

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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StatPearls [Internet].

Case study: 33-year-old female presents with chronic sob and cough (archive).

Sandeep Sharma ; Muhammad F. Hashmi ; Deepa Rawat .

Affiliations

Last Update: February 20, 2023 .

• Case Presentation

History of Present Illness:  A 33-year-old white female presents after admission to the general medical/surgical hospital ward with a chief complaint of shortness of breath on exertion. She reports that she was seen for similar symptoms previously at her primary care physician’s office six months ago. At that time, she was diagnosed with acute bronchitis and treated with bronchodilators, empiric antibiotics, and a short course oral steroid taper. This management did not improve her symptoms, and she has gradually worsened over six months. She reports a 20-pound (9 kg) intentional weight loss over the past year. She denies camping, spelunking, or hunting activities. She denies any sick contacts. A brief review of systems is negative for fever, night sweats, palpitations, chest pain, nausea, vomiting, diarrhea, constipation, abdominal pain, neural sensation changes, muscular changes, and increased bruising or bleeding. She admits a cough, shortness of breath, and shortness of breath on exertion.

Social History: Her tobacco use is 33 pack-years; however, she quit smoking shortly prior to the onset of symptoms, six months ago. She denies alcohol and illicit drug use. She is in a married, monogamous relationship and has three children aged 15 months to 5 years. She is employed in a cookie bakery. She has two pet doves. She traveled to Mexico for a one-week vacation one year ago.

Allergies:  No known medicine, food, or environmental allergies.

Past Medical History: Hypertension

Past Surgical History: Cholecystectomy

Medications: Lisinopril 10 mg by mouth every day

Physical Exam:

Vitals: Temperature, 97.8 F; heart rate 88; respiratory rate, 22; blood pressure 130/86; body mass index, 28

General: She is well appearing but anxious, a pleasant female lying on a hospital stretcher. She is conversing freely, with respiratory distress causing her to stop mid-sentence.

Respiratory: She has diffuse rales and mild wheezing; tachypneic.

Cardiovascular: She has a regular rate and rhythm with no murmurs, rubs, or gallops.

Gastrointestinal: Bowel sounds X4. No bruits or pulsatile mass.

• Initial Evaluation

Laboratory Studies:  Initial work-up from the emergency department revealed pancytopenia with a platelet count of 74,000 per mm3; hemoglobin, 8.3 g per and mild transaminase elevation, AST 90 and ALT 112. Blood cultures were drawn and currently negative for bacterial growth or Gram staining.

Chest X-ray

Impression:  Mild interstitial pneumonitis

• Differential Diagnosis
• Aspiration pneumonitis and pneumonia
• Bacterial pneumonia
• Immunodeficiency state and Pneumocystis jiroveci pneumonia
• Carcinoid lung tumors
• Tuberculosis
• Viral pneumonia
• Chlamydial pneumonia
• Coccidioidomycosis and valley fever
• Recurrent Legionella pneumonia
• Mediastinal cysts
• Mediastinal lymphoma
• Recurrent mycoplasma infection
• Pancoast syndrome
• Pneumococcal infection
• Sarcoidosis
• Small cell lung cancer
• Aspergillosis
• Blastomycosis
• Histoplasmosis
• Actinomycosis
• Confirmatory Evaluation

CT of the chest was performed to further the pulmonary diagnosis; it showed a diffuse centrilobular micronodular pattern without focal consolidation.

On finding pulmonary consolidation on the CT of the chest, a pulmonary consultation was obtained. Further history was taken, which revealed that she has two pet doves. As this was her third day of broad-spectrum antibiotics for a bacterial infection and she was not getting better, it was decided to perform diagnostic bronchoscopy of the lungs with bronchoalveolar lavage to look for any atypical or rare infections and to rule out malignancy (Image 1).

Bronchoalveolar lavage returned with a fluid that was cloudy and muddy in appearance. There was no bleeding. Cytology showed Histoplasma capsulatum .

Based on the bronchoscopic findings, a diagnosis of acute pulmonary histoplasmosis in an immunocompetent patient was made.

Pulmonary histoplasmosis in asymptomatic patients is self-resolving and requires no treatment. However, once symptoms develop, such as in our above patient, a decision to treat needs to be made. In mild, tolerable cases, no treatment other than close monitoring is necessary. However, once symptoms progress to moderate or severe, or if they are prolonged for greater than four weeks, treatment with itraconazole is indicated. The anticipated duration is 6 to 12 weeks total. The response should be monitored with a chest x-ray. Furthermore, observation for recurrence is necessary for several years following the diagnosis. If the illness is determined to be severe or does not respond to itraconazole, amphotericin B should be initiated for a minimum of 2 weeks, but up to 1 year. Cotreatment with methylprednisolone is indicated to improve pulmonary compliance and reduce inflammation, thus improving work of respiration. [1] [2] [3]

Histoplasmosis, also known as Darling disease, Ohio valley disease, reticuloendotheliosis, caver's disease, and spelunker's lung, is a disease caused by the dimorphic fungi  Histoplasma capsulatum native to the Ohio, Missouri, and Mississippi River valleys of the United States. The two phases of Histoplasma are the mycelial phase and the yeast phase.

Etiology/Pathophysiology 

Histoplasmosis is caused by inhaling the microconidia of  Histoplasma  spp. fungus into the lungs. The mycelial phase is present at ambient temperature in the environment, and upon exposure to 37 C, such as in a host’s lungs, it changes into budding yeast cells. This transition is an important determinant in the establishment of infection. Inhalation from soil is a major route of transmission leading to infection. Human-to-human transmission has not been reported. Infected individuals may harbor many yeast-forming colonies chronically, which remain viable for years after initial inoculation. The finding that individuals who have moved or traveled from endemic to non-endemic areas may exhibit a reactivated infection after many months to years supports this long-term viability. However, the precise mechanism of reactivation in chronic carriers remains unknown.

Infection ranges from an asymptomatic illness to a life-threatening disease, depending on the host’s immunological status, fungal inoculum size, and other factors. Histoplasma  spp. have grown particularly well in organic matter enriched with bird or bat excrement, leading to the association that spelunking in bat-feces-rich caves increases the risk of infection. Likewise, ownership of pet birds increases the rate of inoculation. In our case, the patient did travel outside of Nebraska within the last year and owned two birds; these are her primary increased risk factors. [4]

Non-immunocompromised patients present with a self-limited respiratory infection. However, the infection in immunocompromised hosts disseminated histoplasmosis progresses very aggressively. Within a few days, histoplasmosis can reach a fatality rate of 100% if not treated aggressively and appropriately. Pulmonary histoplasmosis may progress to a systemic infection. Like its pulmonary counterpart, the disseminated infection is related to exposure to soil containing infectious yeast. The disseminated disease progresses more slowly in immunocompetent hosts compared to immunocompromised hosts. However, if the infection is not treated, fatality rates are similar. The pathophysiology for disseminated disease is that once inhaled, Histoplasma yeast are ingested by macrophages. The macrophages travel into the lymphatic system where the disease, if not contained, spreads to different organs in a linear fashion following the lymphatic system and ultimately into the systemic circulation. Once this occurs, a full spectrum of disease is possible. Inside the macrophage, this fungus is contained in a phagosome. It requires thiamine for continued development and growth and will consume systemic thiamine. In immunocompetent hosts, strong cellular immunity, including macrophages, epithelial, and lymphocytes, surround the yeast buds to keep infection localized. Eventually, it will become calcified as granulomatous tissue. In immunocompromised hosts, the organisms disseminate to the reticuloendothelial system, leading to progressive disseminated histoplasmosis. [5] [6]

Symptoms of infection typically begin to show within three to17 days. Immunocompetent individuals often have clinically silent manifestations with no apparent ill effects. The acute phase of infection presents as nonspecific respiratory symptoms, including cough and flu. A chest x-ray is read as normal in 40% to 70% of cases. Chronic infection can resemble tuberculosis with granulomatous changes or cavitation. The disseminated illness can lead to hepatosplenomegaly, adrenal enlargement, and lymphadenopathy. The infected sites usually calcify as they heal. Histoplasmosis is one of the most common causes of mediastinitis. Presentation of the disease may vary as any other organ in the body may be affected by the disseminated infection. [7]

The clinical presentation of the disease has a wide-spectrum presentation which makes diagnosis difficult. The mild pulmonary illness may appear as a flu-like illness. The severe form includes chronic pulmonary manifestation, which may occur in the presence of underlying lung disease. The disseminated form is characterized by the spread of the organism to extrapulmonary sites with proportional findings on imaging or laboratory studies. The Gold standard for establishing the diagnosis of histoplasmosis is through culturing the organism. However, diagnosis can be established by histological analysis of samples containing the organism taken from infected organs. It can be diagnosed by antigen detection in blood or urine, PCR, or enzyme-linked immunosorbent assay. The diagnosis also can be made by testing for antibodies again the fungus. [8]

Pulmonary histoplasmosis in asymptomatic patients is self-resolving and requires no treatment. However, once symptoms develop, such as in our above patient, a decision to treat needs to be made. In mild, tolerable cases, no treatment other than close monitoring is necessary. However, once symptoms progress to moderate or severe or if they are prolonged for greater than four weeks, treatment with itraconazole is indicated. The anticipated duration is 6 to 12 weeks. The patient's response should be monitored with a chest x-ray. Furthermore, observation for recurrence is necessary for several years following the diagnosis. If the illness is determined to be severe or does not respond to itraconazole, amphotericin B should be initiated for a minimum of 2 weeks, but up to 1 year. Cotreatment with methylprednisolone is indicated to improve pulmonary compliance and reduce inflammation, thus improving the work of respiration.

The disseminated disease requires similar systemic antifungal therapy to pulmonary infection. Additionally, procedural intervention may be necessary, depending on the site of dissemination, to include thoracentesis, pericardiocentesis, or abdominocentesis. Ocular involvement requires steroid treatment additions and necessitates ophthalmology consultation. In pericarditis patients, antifungals are contraindicated because the subsequent inflammatory reaction from therapy would worsen pericarditis.

Patients may necessitate intensive care unit placement dependent on their respiratory status, as they may pose a risk for rapid decompensation. Should this occur, respiratory support is necessary, including non-invasive BiPAP or invasive mechanical intubation. Surgical interventions are rarely warranted; however, bronchoscopy is useful as both a diagnostic measure to collect sputum samples from the lung and therapeutic to clear excess secretions from the alveoli. Patients are at risk for developing a coexistent bacterial infection, and appropriate antibiotics should be considered after 2 to 4 months of known infection if symptoms are still present. [9]

Prognosis 

If not treated appropriately and in a timely fashion, the disease can be fatal, and complications will arise, such as recurrent pneumonia leading to respiratory failure, superior vena cava syndrome, fibrosing mediastinitis, pulmonary vessel obstruction leading to pulmonary hypertension and right-sided heart failure, and progressive fibrosis of lymph nodes. Acute pulmonary histoplasmosis usually has a good outcome on symptomatic therapy alone, with 90% of patients being asymptomatic. Disseminated histoplasmosis, if untreated, results in death within 2 to 24 months. Overall, there is a relapse rate of 50% in acute disseminated histoplasmosis. In chronic treatment, however, this relapse rate decreases to 10% to 20%. Death is imminent without treatment.

• Pearls of Wisdom

While illnesses such as pneumonia are more prevalent, it is important to keep in mind that more rare diseases are always possible. Keeping in mind that every infiltrates on a chest X-ray or chest CT is not guaranteed to be simple pneumonia. Key information to remember is that if the patient is not improving under optimal therapy for a condition, the working diagnosis is either wrong or the treatment modality chosen by the physician is wrong and should be adjusted. When this occurs, it is essential to collect a more detailed history and refer the patient for appropriate consultation with a pulmonologist or infectious disease specialist. Doing so, in this case, yielded workup with bronchoalveolar lavage and microscopic evaluation. Microscopy is invaluable for definitively diagnosing a pulmonary consolidation as exemplified here where the results showed small, budding, intracellular yeast in tissue sized 2 to 5 microns that were readily apparent on hematoxylin and eosin staining and minimal, normal flora bacterial growth. 

• Enhancing Healthcare Team Outcomes

This case demonstrates how all interprofessional healthcare team members need to be involved in arriving at a correct diagnosis. Clinicians, specialists, nurses, pharmacists, laboratory technicians all bear responsibility for carrying out the duties pertaining to their particular discipline and sharing any findings with all team members. An incorrect diagnosis will almost inevitably lead to incorrect treatment, so coordinated activity, open communication, and empowerment to voice concerns are all part of the dynamic that needs to drive such cases so patients will attain the best possible outcomes.

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Histoplasma Contributed by Sandeep Sharma, MD

Disclosure: Sandeep Sharma declares no relevant financial relationships with ineligible companies.

Disclosure: Muhammad Hashmi declares no relevant financial relationships with ineligible companies.

Disclosure: Deepa Rawat declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Sharma S, Hashmi MF, Rawat D. Case Study: 33-Year-Old Female Presents with Chronic SOB and Cough (Archive) [Updated 2023 Feb 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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