Emphysema and chronic bronchitis are clinically grouped together and called chronic obstructive pulmonary disease (COPD). Both have overlapping features with damage at acinar level (emphysema) and bronchial level (bronchitis) and most commonly occur in smokers. In COPD there is chronic inflammation of airways, lung parenchyma and pulmonary vasculature. According to protease-antiprotease and oxidant-antioxidant theories heavy smoking results in imbalance between these enzymes result in damages to lung parenchyma and alveolar wall (Kumar, Abbas & Fausto, 2005). Clinical manifestations appear when one third of lung parenchyma is already damaged. Initial symptoms are dyspnoea, (progressive in nature) but cough and wheezing may also be the first. Pink puffers (primarily having emphysema) have mild hypoxia and normal PCO2. Blue bloaters (primarily having chronic bronchitis) have severe hypoxia with cyanosis and have hypercapnia. Acute respiratory tract infection makes situation worse and signs and symptoms of infection with hypoxia and hypercapnea and right heart failure (at latter stage of COPD) become apparent and patient need urgent treatment (Talley & Connor, 2006). In this case study patient is an eighty four year old man with COPD who has got respiratory tract infection and his disease has become severe. Ambulance has been called and ambulance crew has to reach the scene, conduct primary survey, secondary survey, manage the case and shift it to hospital if appropriate. In this essay this process is described.
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Ambulance crew approaches the patient
The ambulance crew arrives at the site safely. They are wearing personal protective equipment including safety boots, high visible clothing and vest and a portable two-way radio is in the hand of one of the staff. He introduces himself and carries staff to the patient. The patient is eighty four years old elderly black male of average built sitting forward in hunched-over position on bed and breathing through pursed lips. The room is well lit but untidy. Nothing in the environment appears harmful for the patient or ambulance staff. The crew gets consent from the patient and approaches patient for quick Primary Survey. Both of the crew wear latex gloves because they themselves do not have any latex allergy and proceeded calmly and confidently to conduct primary survey of the patient.
Primary survey
This is a preliminary assessment of the patient. The ambulance crew quickly examines patient for any injury. There is no injury. The patient is alert and responds to verbal stimulus. Then ambulance crew examines patient’s airway, and find lips and tongue blue due to cyanosis and secretions in the throat. The crew use sucker and clear secretions to ensure patency of airway. Next he examines patient’s breathing. The respiratory rate is 33 per minute and bilateral chest movements are reduced. He quickly percusses and auscultates chest and finds it hyper-resonant all over. He gives patient oxygen through nasal cannulae to decrease cyanosis. The radial pulse rate is 100 per minute, regular but bounding; blood pressure 125/90. He checked capillary refill by pressing finger nails of the patient and found it normal <2 sec. There is no evidence of haemorrhage. Then he assesses if patient has any disability and finds no disability. He examines pupils of both eyes and find normal in size and reaction to light. Then crew then exposes patient from head to toe examination. There is no injury or deformity but ankle oedema is present and patient is using accessory muscles of respiration. (Longmore, Wilkinson & Rajagopalan, 2007).
The ambulance crew has considered a number of psychosocial and disease factors. The patient is living alone, unable to cope at home and confused. The general condition of patient is poor, his disease is getting worse and he is confined to bed. He is cyanosed and has peripheral oedema indicating chances of co-morbidity like heart disease (Simon, Everitt & Kendrick, 2005). Ambulance crew decide to transport the patient to the hospital for in-hospital treatment
Secondary Survey
A further focused history and physical examination is required to identify injury or disease that has not been identified during the primary survey.
History
The patient has certain Presenting complaints (PC).These include worsening cough with sputum since seven days, breathlessness on Exertion since four days, Wheezing since four days, generalised weakness since two days, temperature since two days and breathlessness at rest since six hours. His history of these presenting complaints spans to last three months. Patient is a heavy smoker, smoking one pack of twenty cigarettes a day. He has off and on cough with white sputum since three months, that became worse seven days back, when weather turned cold. The amount of sputum is increasing day by day. The sputum has gradually become purulent. Mild wheezing was present since one month but it became more prominent four days back. Breathlessness on exertion started four days back that gradually increased and he developed breathlessness at rest 6 hours back. Patient developed mild fever two days back, before that he gives no history of fever. Patient used to do light house-hold work, but since last two days he is unable to do that due to weakness.
There is no history of allergy. The patient gives history of medication prescribed by local general practitioner. The medicine patient is using is Salbutamol inhaler taking two puffs three times a day. Salbutamol is bronchodilator (Haslett, Chilver, Boon & College, 2002). The medication was working up to some extent till ten days back when current symptoms started. The medication is prescription only and the patient been taking it since three years. It within the expiratory date and has been taken correctly.
The Past medical history, given by the patient provides information that he was hospitalised five time in the past during winter season ( 2001, 2003, 2005, 2008,2009) for breathlessness and respiratory infection. He stayed in the hospital for one day each time then was discharged. He was diagnosed with COPD and chest infection each time. Current complaint is a direct result exacerbation of previously existing COPD (Longmore, Wilkinson & Rajagopalan, 2007).
The social history of patient is important. He is eighty four years old male migrant from Jamaica living alone in a two bed room flat with no one looking after him. His wife died in a car accident ten years back. He is a pensioner and poor man. The neighbor once or twice a week visits him and gives him some company. He is a smoker since last sixty years but did not consume any alcohol or habit forming drug. He used to prepare food for himself but buying from a take away shop since last three day as he does not feel good to prepare it at home. There was no pet in the house. Patient gives Family history of no significant disease in his parents and two children. His wife died in a car accident. The patient had his last meal three hours back.
Physical Examination
The ambulance crew recorded four basic vital signs consisting of pulse, respiration,
temperature and blood pressure(Warrell, Cox & Firth, 2005). Pulse rate is 100/min, regular and bounding. Respiration rate is 33/minute, deep with forced expiration. Blood pressure is 125/90, diastolic blood pressure slightly high. Temperature on Tympanic temperature 100.5 F. Capillary refill in <2 seconds shows normal tissue perfusion. Some laboratory signs for this patient include Glasgow Coma Score; level of consciousness is 14/15, with patient little confused. Random Blood Glucose level was 120mg/ dl. Skin is warm to touch. Pupils equal in size in both eyes with normal reaction to light (Warrell, Cox & Firth, 2005).
Systemic Examination
Respiratory system
On inspection ambulance crew noted a number of signs including pursing of lips, tachypnia, accessory muscles of respiration in use, tracheal tug and shortening of trachea, deepening of supraclavicular and suprasternal fossa, decreased movement of chest wall, audible wheeze and barrel shaped chest. Shape and movements of chest are symmetrical; no flail segment and no injury present. On palpation there were no crepetations on neck and chest so no subcutaneous emphysema. On percussion, chest is hyper resonant and dullness over liver and cardiac area is reduced. On auscultation breath sounds are reduced and rhonchi are present in the chest. All these signs are due to increased air-trapping in the lungs, narrowing of bronchi and use of accessory muscles of respiration (Talley & Connor, 2006).
Cardiovascular system and other body system examination
There is right ventricular heave, ankle oedema, raised JVP and increased diastolic blood
pressure (90mmHg) showing right ventricular failure called cor- pulmonale (Sam, Baker &
Hameed, 2003). On examination of abdomen and pelvis no wounds or painful areas found.
There are no fractures or wounds in extremities. Sensory and motor functions are normal.
Investigations for COPD
In this case both FVC and FEV1 are reduced and ratio FEV1/FVC is decreased to 1.1 L / 3.0 L (Costanzo, 2007). With spirometry the disease is mild when FEV1 was 60-79%, moderate when FEV1 40-59% and severe when FEV1 is lesser than 40%. In this case Peak expiratory flow FEV1 is 40% of predicting obstructive lung disease thus can be classified as moderate at this stage. X-ray chest shows hyper-inflated lungs and CT scan shows lung bullae (Haslett, Chilver, Boon & College, 2002). SpO2 i.e. Oxygen saturation levels is found 88% (Normal=95%) ECG shows tachycardia, P- pulmonale and Right axis deviation (right ventricular failure). PO2 =6.6 KPa
Management of COPD
The aim of management is to treat infection, reduce cyanosis, increase oxygen saturation in blood, decrease carbon dioxide saturation in blood and provide symptomatic relief to patient.
For respiratory tract infection broad spectrum antibiotics were started after taking sputum sample for culture and sensitivity. Amoxicilline 250 mg 8-hourly for seven days was given as patient is not sensitive to penicillin. For Penicillin sensitive patients Clarithromycin 250 mg 12-hourly is used. Prompt treatment of respiratory tract infection is necessary because it leads to worsening of breathlessness and cause type II respiratory failure in COPD patient. Bronchodilators such as β2 — adrenoceptor agonist ( Salbutamol ) inhaler used as two inhalations four times a day and anticholernegic ( ipratropium bromide) inhaler as two inhalations four times a day relieve bronchspasm and give symptomatic relief. Low dose steroid inhaler (Beclomethasone Dipropionate inhaler) two inhalations three times a day act as an anti inflammatory agent to reduce bronchial inflammation thus reducing symptoms. Low oxygen therapy (24-28% of O2) was given to the patient by using nasal cannulae to deliver 1-2 litres of oxygen per minute. The aim is to maintain PaO2 level of 7 kPa or more to reduce hypoxaemia and hypercapnia. Nasal connulae is preferred in this patient so that he can expectorate and eat or drink. This oxygen therapy is aimed to reduce a cyanosis, pulmonary hypertension, cerebral hypoxia, hypotension and tachycardia. Raised JVP and oedema of lower legs show right heart failure thus a thiazide diuretic Chlorthalidone 25 mg once daily, which is minimum daily dose, is started as initial therapy. Kidneys of elderly patients have reduced drug clearance so toxic effects of drugs appear with minor overdose. Chlorthalidone dose may be increased if oedema is not relieved Physiotherapy of chest help expectorate and clear bronchial recreations (Haslett, Chilver, Boon & College, 2002).
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Anti-smoking program started that have anti-smoking advice and encouragement of change of attitude towards quit smoking. After patient achieves good motivation, nicotine replacement therapy will be started that included Bupropion 150mg once daily for 6 days then doubling it to 150mg bid for seven weeks. Stopping smoking slows down average rate of decline in FV1 from 50-70ml/ year to 30ml/year that is equal to non-smokers (Warrell, Cox & Firth, 2005).
Pre-alert was sent to the hospital that an elderly patient with acute on chronic type II respiratory failure is on the way to hospital. Unmanaged COPD can lead to death due to respiratory acidosis, coma, right sided heart failure and massive collapse of lungs due to pneumothorax (Kumar, Abbas & Fausto, 2005).
Conclusion
As an observer with the ambulance crew I have gained useful knowledge about safely driving an ambulance, safe arrival at the scene, safety equipments used by the ambulance crew and how to approach the patient safely. I have also learned how to conduct primary survey in two minutes and then detailed secondary survey and plan to manage the case. But this is my first experience and I think I need to have more experiences similar to or different from this experience to learn more about dealing with different kind of patients and different situations. The ambulance crew behaved quite professionally with few exceptions. He did not park their ambulance very correctly and left little space for other cars. When taking history of the patient they asked some leading questions from the patient. They were also talking with each other during history taking and physical examination. I think more refresher courses need to be held to teach professional behavior in crew and build their academic knowledge.
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