Newly diagnosed COPD - obstructive ventilatory impairment

Presented case report documents an example of a patient with an accidentally diagnosed chronic obstructive pulmonary disease (COPD) based on clinical signs. Diagnosis was confirmed by a pneumologist using spirometry. A bronchodilation test was carried out to confirm the irreversibility of detected obstructive ventilatory impairment. The patient was given combined bronchodilator treatment with ß2-mimetics and anticholinergics to relieve symptoms, improve functional parameters and prevent subsequent exacerbations.

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Anamnesis:

A 75-year-old patient with a history of arterial hypertension in dual anti-hypertensive therapy was examined by an outpatient pneumologist on recommendation of general practitioner. The reason for reference to specialist was an auscultation finding of chest wheezing in a preventive exam.
Personal history: 9 years of treatment for hypertension
History of allergies: no allergy
Used medicines: Lokren, Accuzide
Addictive history: Active smoker for 50 yrs., on average 10 cigarettes daily. Overall 25 packyears
Current disease: Patient says he was sick three weeks ago. He was coughing, expectorated green sputum, he had breathing difficulties, his general practitioner put on antibiotic amoxicillin clavulanate (Amoksiklav). Now he feels better, his cough improved but he still feel dyspnea when going to hill and stairs and sometimes during walk.

Status praesens:
Patient was conscious, oriented, eupnoic, normostenic habitus, well nutrified, saturation: 96 percent.
Lung: alveolar breathing, without prolongation of expirium, without side phenomena, percussion full bright
Cor: Hearg action regular, 80/min, Blood pressure: 130/80 torr
Abdomen: free, painless, no palpation sensitivity, no resistance
Lower limbs: without oedema, calfs free, symmetrical, no varices

Imaging methods:

Chest X-ray: documented lung parenchyme without nodular shadows or infiltrates. Lung was slightly hyperinflated, both hili were vascularly magnified, pleura was intact. Heart shadow was not enlarged, mediastinum was without pathologic finding. Diaphragm was flattened bilaterally with sharp contour, diaphragmatic angles were free without pathologic filling. Bone structures were without pathology (Figure 1).

Spirometric assessment:
Spirometry revealed obstructive ventilatory impairment with severe obstruction and reduced volumes (see Table 1). Visual display of flow-volume curve had a typical obstructive pattern (see Figure 2). Bronchodilation test after administration of 4x100 ug of Salbutamol did not show positivity (demonstrated by improving of forced expiratory volume /FEV1/ by 200 ml and 12 %). FEV1 and forced vital capacity (FVC) ratio (Tiffeneau index) was 0.6 (60 %) and postbronchodilation FEV1 was 47 %.
Based on spirometry, case history, risk factors, age, and absence of allery or bronchial asthma (proven also by negativity of bronchodilation test) a chronic obstructive pulmonary disease (COPD) was diagnosed. Severity of disorder was evaluated according GOLD classification based on postbronchodilatation value of FEV1, symptoms and history of exacerbations in previous year (patient underwent 1 ambulatory antibiotic therapy) (see Figure 3 - Classification of COPD according GOLD 2017).

Diagnosis:

Chronic obstructive pulmonary disease (COPD)- GOLD III/B

Diferential diagnosis:

Astma bronchiale
ACO(S) - Asthma-COPD overlap (syndrome)

Treatment:

Long-acting muscarine antagonist (LAMA) Tiotropium in Respimat inhalator (showed on Figure 4) in dose of 5 ug 2 inhalation in the morning was adminiseterd as bronchodilator therapy. Salbutamol from group of short-acting ß2- agonists (SABA) in dose of 100 ug 1 inhalation on demand was prescribed as a rescue medication. Patient was educated about inhalation of drugs. On next visit he reported mild improving of dyspnea, repeated spirometry proven improving on 49 percent of FEV1. Persistance of severe obstructive ventilatory impaiment and symptoms was a reason for administering of dual bronchodilation treatment LAMA/LABA (long-acting muscarine antagonist/ long-acting ß2-agonist) with titropium-olodaterol. Treatment was effective in relieving of dyspnea. Smoking cessation, improving of regimen, sufficiency of exercise and pulmonary rehabilitation was recommended to patient of course.

Authors declare the case report will not be published in any national or international publications.

Classification ICD-10:

J44.8 Other specified chronic obstructive pulmonary disease

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