Emphysema Respiratory Disease Discussion Paper

coupled with multiple hospitalizations. He was admitted because of severe, worsening
dyspnea. He lived and worked in Pittsburgh, Pennsylvania, for 35 years as a foundry
worker in a steel manufacturing plant. His wife died 10 years prior to this report.
After his wife’s death, he lived alone for 9 years and managed his daily activities with
progressive difficulty.
Approximately 2 years before this admission, he was forced to retire early
because of declining health. His doctor told him that he had chronic obstructive
pulmonary disease (COPD). For the past year, he had been living with his brother’s
family in Chicago, Illinois. The patient’s brother indicated during the interview that
the patient might “have the flu again.” The patient had a 35-pack/year history of
smoking unfiltered cigarettes, but he stopped smoking at the time of his forced
retirement.

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His last hospitalization was 9 weeks before this admission. At that time, he
was hospitalized for 2 days for cough, muscle aches and pains, fever, and respiratory
distress. He underwent a complete pulmonary function study and received airway
clearance therapy, oxygen therapy, and instruction in at-home breathing exercises.
During this hospitalization, hospital personnel noted that the patient’s expiratory flow
rate measurements had declined significantly since his pulmonary function tests
(PFTs) a year earlier. Emphysema Respiratory Disease Discussion Paper
Bedside, spirometry showed an FEV1/FVC ratio of 43% and an FEV1 of 27% of
predicted—GOLD grade 4. The patient’s mMRC was 2 and he now had two
exacerbations in the last 12 months—both leading to hospital admission.

In fact, in the past year his forced expiratory volume in 1 second (FEV1) had declined
from 70% of that predicted to 45% of that predicted. At discharge 9 weeks before this
admission and on 1.5 L per minute oxygen by nasal cannula, the patient’s ABGs were
as follows: pH 7.37, PaCO2 67 mm Hg, HCO3– 36 mEq/L, and PaO2 63 mm Hg. He
had received influenza vaccine 6 months earlier and pneumococcal vaccine 2 years
earlier.
At the time of discharge 9 weeks earlier, he was demonstrating pursed-lip
breathing and using his accessory muscles of inspiration at rest. He demonstrated no
spontaneous cough or sputum production. His bronchodilator therapy was
discontinued 1 year ago because it had been “found to be ineffective” during his PFT.
He was strongly encouraged to perform his pulmonary rehabilitation exercises daily.
A weekly exercise diary was given to him by the respiratory care department at
discharge.

PHYSICAL EXAMINATION
In the emergency room the patient was febrile, cyanotic, and in obvious
respiratory distress. He appeared malnourished at 6-ft tall and weighed 66 kg (146 lb).
His skin was cool and clammy. The patient said, “I’m so short of breath!”
His vital signs were as follows: blood pressure 154/110, heart rate 95 bpm,
respiratory rate 25/minute, and oral temperature 38.3C (101F). He was using his
accessory muscles of inspiration and breathing through pursed lips. An increased
anteroposterior diameter of the chest was easily visible. Percussion revealed that he
had low-lying, poorly mobile diaphragm. Expiration was prolonged, and his breath
sounds were diminished. No wheezes were noted, but crackles could be heard over
the right lower lobe.
A chest x-ray showed hyperinflation, severe apical pleural scarring, a large
bulla in the right middle lobe, and a right lower lobe infiltrate consistent with
pneumonia (see the figure below). On instruction the patient’s forced cough was weak
and productive of a small amount of yellow sputum. On 2 L per minute oxygen by
nasal cannula, his ABGs were as follows: pH 7.59, PaCO2 40 mm Hg, HCO3– 37
mEq/L, and PaO2 38 mm Hg. The physician ordered a pulmonary consult and stated that she did not want to commit the patient to a ventilator if possible. The patient also was started on intravenous doses of methylprednisolone. Emphysema Respiratory Disease Discussion Paper

2 DAYS LATER
At this time, the patient stated that his chest was feeling tighter and that he was
even more short of breath. His vital signs were as follows: blood pressure 160/112,
heart rate 97 bpm, respiratory rate 15/minute and shallow and oral temperature 37.8C
(100F). Expectorated sputum was thick, yellow, and tenacious. He no longer was
using his accessory muscles of inspiration or demonstrating pursed-lip breathing. His
breath sounds were diminished bilaterally, and crackles no longer could be heard over
the right lower lobe. Dull percussion notes were elicited over the right lower lobe. On
4 L per minute oxygen by nasal cannula, his ABGs were as follows: pH 7.28, PaCO2 82 mm Hg, HCO3– 36 mEq/L, and PaO2 41 mm Hg. His hemoglobin oxygen
saturation measured by pulse oximetry (SpO2) was 68%. A repeat chest x-ray showed
more extensive pulmonary infiltrates, particularly in the right lower chest. The
physician ordered subcutaneous terbutaline every 8 hours.

Based on the above clinical data, how would you SOAP this patient? (SOAP 2)

(SOAP 1 IS ALREADY ANSWERED)