Chest Infection in COPD patient

Puan RD 63 y.o malay woman with history of COPD presented to emergency department in Hospital Machang with shortness of breath and cough for one week duration.

The S.O.B is on and off and not relief by taking rest. The S.O.B is increase in intensity which brings her to ED. Meanwhile, the cough produces yellowish sputum. On further questioning, she is an ex smoker

BP: 120/80 (normal)

PR: 110 bpm (normal 60-80)

Temperature: 37⁰C

Approach to this patient.

1) This patient has acute exacerbation of shortness of breath due to COPD.

2) Nasal prong to give oxygenation. (nebulizer is not indicated)

3) Arterial blood gas need to be carried out.

4) Chest examination need to be performed

5) Full blood count is compulsory indicated by yellowish sputum. In elderly, fever usually not present in infection.

6) Chest infection needs to be ruled out due to history of COPD which predispose patient to chest infection.

7) BUSE

8) Take AP chest X-ray as patient is ill and cannot stand up properly. Mobile X-ray was called.

On physical examination

1) Reduce air entry to the left side of lung

2) Decrease lung expansion

3) Crackles on lower lung field.

ABG Result (on high flow mask)

pH: 7.37 (7.35- 7.45)

PCO₂ : 68 mmHg (35-45)

PO₂: 161 mmHg (75-100)

HCO₃- : 39 mmol/L (25-35)

1) This patient has type II respiratory failure in which pCO2 is high (oxygen high due to hi flow mask)

2) To correct this condition, respirator may be used to assist ventilation

Full blood count

WBC: 17.3 X 10⁹/L (4-11) with elevated neutrophil count

Hg: 13.4 g/dL

1) Elevated WBC indicates Infection.

BUSE result

Urea: 5.4 mmol (1.7-8.3)

Na⁺ : 138 (125-154)

K⁺ : 4.4 (3.5-5.4)

CL^- : 94.6 (98-108)

Creatinine: 56.6 µmol/L (53-100)

Uric acid: 393.2 µmol/L 9150-360)

AP Chest X-Ray

1) Hyperinflated lung

2) Visible hilar marking with peripheral opacity (not consolidation)

Management to this patient

1) Admit to the ward

2) Sputum culture

3) Antibiotics

4) IV fluid

5) Respirator to assist breathing.