A 74 Year Old Chronic Smoker Presents With Fatigue And Shortness Of Breath

A 74-year-old man who is a chronic smoker presents with fatigue and shortness of breath. He has not seen a physician for many years and says he has been basically healthy.
On physical examination, he is found to be pale, mildly cachectic, and his lips are cyanotic.
His breath sounds are distant, although crackles can be heard in both lung bases. His heart sounds are best heard in the epigastrium; and a third heart sound is present. He has mild peripheral edema.
His resting pulse oximetry is 74%.
The chest X-ray (CXR) shows emphysema and his echocardiogram confirms heart failure.
The X Ray is shown below:

Case Discussion:

Emphysema:
is a chronic obstructive pulmonary disease characterized by airflow limitation that is usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases
Emphysema is pathologically defined as an abnormal permanent enlargement of air spaces distal to the terminal bronchioles, accompanied by the destruction of alveolar walls and without obvious fibrosis.

Pathology: Mediated by chronic inflammatory responses to environmental factors,especially cigarette smoke, that results in recruitment of inflammatory cells in terminal air spaces and release of elastolytic proteinases that damage the extracellular lung matrix and cause ineffective repair of elastin and other matrix components.
Gas exchange abnormalities result in hypoxemia and hypercapnia. Pulmonary hypertension may occur as a result of hypoxic vasoconstriction of small pulmonary arteries.

Clinical Features: Most patients seek medical attention late in the course of disease since the disease starts slowly and progresses gradually.
Most patients present in fifth decade of life with a productive cough or acute chest illness. This cough is often called as 'smokers cough'.
On physical examination the hallmark is the limitation of expiratory flow with relative preservation of inspiratory flow.

Differential Diagnosis: include:

• Congestive heart failure
• Chronic asthma
• Bronchiectasis 
• Bronchitis.
• Bronchiolitis obliterans.

Diagnosis:

1. Postbronchodilator spirometry secures the diagnosis and provides the severity classification.

2. A serum level of α1-antitrypsin should be measured if you suspect a genetic mutation.

3. A CXR is not useful for diagnosis but is helpful for excluding other diseases or identifying comorbidity.

Management: Management of COPD is based on symptoms, risk or history of exacerbations,

1. Patient education about the disease and avoiding the risk factors. 

2. Influenza and pneumococcal vaccination, are most effective in the elderly.

3.For patients with stable COPD, only smoking cessation and oxygen therapy has shown significant improvement. 

4. For symptomatic relief following are recommended:

• Short-acting inhaled bronchodilators.
• Inhaled long-acting β-agonists.
• Combination long-acting β-agonists with inhaled anticholinergic agents. 
• Inhaled long-acting anticholinergic.I
• Inhaled glucocorticoids. 
• Theophylline
• Mucolytic agents (e.g., guaifenesin, carbocysteine, potassium iodide)