Case Study – Chronic Bronchitis

Admitting History A 68 year old retired geologist arrived in the emergency room with his daughter. Well known to the respiratory care consult team, he has a 40 year history of smoking 1.5 packs of cigarettes a day, is widowed, lives alone, and has difficulty managing his daily activities. For the past week the man has experienced increased dyspnea and cough and has been unable to care for himself. On observation, his personal hygiene appeared to have deteriorated. The man stated that he has been unable to get his breath or inhale deep enough to cough up secretions. He complained of mild nausea without abdominal pain or vomiting. His physician had given him an unknown oral antibiotic 3 days before this admission.
The man was diagnosed with severe chronic bronchitis approximately 6 years ago and had an acute myocardial infarction 2 years ago. His pulmonary function studies 1 year before this admission showed severe airway obstruction and air trapping. He has a history of high blood pressure, congestive heart failure, chronic dyspnea on exertion, and chronic cough and he experienced two episodes of pneumonia within the last year. In recent months, according to a neighbor, he has become increasingly depressed. According to his daughter, his physical activity is minimal. He generally spends most of his days watching television, smoking, and napping. All his children, none of whom live in the immediate area, have tried to coax him to move to a boarding house environment, but he has adamantly refused. During his last admission, the advantages of pulmonary rehabilitation were discussed with him. The patient said that he had no need for pulmonary education, nor for the services of other agencies or organizations to check up on him in his home.

Physical Examination (Time: 1730) Inspection revealed a barrel chest, clubbing of his fingers and toes, cyanotic skin, and pitting edema (2+) around his ankles. His breathing was labored; he was pursed-lip breathing, using his accessory muscles of respiration, and he appeared weak. He had a frequent, weak cough productive of large amounts of thick, yellow sputum. Vital signs were as follows: blood pressure 190/115, heart rate 125 bpm, respiratory rate 30/min, and oral temperature 37 C (98.6F). Tactile fremitus was present over both lung fields, and hyperresonant perussion notes were produced both anteriorly and posteriorly. Bilateral rhonchi were auscultated. His abdomen was soft and not tender. Bowel sounds were active. On room air his arterial blood gas values were as follows: pH 7.53, PaC02 56 mmHg, Pa02 64 mmHg, HC03 33 mmol/L. review of his chart showed that on his last hospital discharge, his baseline ABG’s on 2 L/min 02 were as follows: pH 7.39, PaC02 85, mmHg, Pa02 64 mmHg, HC03 38 mmol/L. His carboxyhemoglobin level was 6%. His chest x-ray on this admission showed severe hyperinflation with depressed hemidiaphragms (refer to page 183 for reference). No acute infiltrates were apparent. His heart size was normal. His CBC values were all normal except for hct of 58% and hgb of 16.5. The attending physician ordered a respiratory care consult. The following order was written in the patient’s chart: “All efforts should be made to keep the patient off the ventilator.

Classify his baseline ABG stated in the previous information.

Classify his current ABG stated in the previous information.

Using the terms from chapter 4 of your Respiratory Disease textbook, which term would be used to describe his current ABG?

SOAP chart based on the previous information:
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What are the most common causes of chronic bronchitis?

Are the clinical manifestations of cough and sputum production characteristic of this disorder? If so, why?

State how secretions are normally cleared from the airway.

State how these mechanisms are impaired with chronic bronchitis.

Respiratory Therapists identify smoking history based on ‘pack years of smoking’. To perform this calculation you must take the # of packs per day (20 cigarettes/pack) and multiply by years patient has been smoking.
Calculate this patient’s pack year history.

How does smoking cessation improve the symptoms of chronic bronchitis?

Early Morning, Next Day (Time: 0230) The respiratory care practitioner on duty was called by the floor nurse to evaluate the patient. The nurse reported that the patient had said that he was having a bad period. The nurse further thought that the patient appeared restless and short of breath and was coughing excessively. On inspection the patient could be seen using his accessory muscles of respiration. He demonstrated pursed-lip breathing. In addition, he demonstrated a weak, productive cough and expectorated large amounts of thick, yellow secretions. The patient’s vital signs were as follows: blood pressure 185/135, heart rate 130 bpm, respiratory rate 28/min, and oral temperature 37 C. Bilateral rhonchi were auscultated over the lung bases. His ABG’s were as follows: pH 7.55, PaC02 53 mmHg, Pa02 41 mmHg, HC03 32 mmol/L. His Sp02 was 83%.

Classify his recent ABG.

Using the terms from chapter 4 of your Respiratory Disease textbook, which term would be used to describe his recent ABG?

Based on this patient’s ABG assessment and level of oxygenation, 02 therapy is warranted. We must be cautious with 02 administration in the patient who exhibits chronic hypercapnia. Read ‘Control of Breathing During Chronic Hypercapnia’ in Egan pg 303. Explain how providing 02 therapy to this patient can lead to ‘oxygen induced hypoventilation’.

SOAP chart based on the previous information:
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Late Afternoon, Same Day (Time: 1415) Although the patient had been resting comfortably for several hours, he suddenly became short of breath and difficult to arouse directly before a scheduled bronchial hygiene treatment. The respiratory therapist on duty noted that the patient said that he was “doing worse again”. He was sitting up in bed and using his accessory muscles of respiration and pursed-lip breathing. His breathing was rapid and shallow. His cough continued to be weak. No sputum production was noted at this time. Expiration was prolonged. His vital signs were as follow: blood pressure 150/95, heart rate 140 bpm, respirations 25/min, and temperature 37 C. He had bilateral wheezes and rhonchi. A recent chest x-ray was unavailable. His ABGs were as follows: pH 7.28, PaC02 105 mm Hg, HC03 41 mmol/L, and Pa02 44 mmHg, Sp02 78%. His CO level was 2.6%. A toxic drug blood screen was negative.

Classify his recent ABG.

Using the terms from chapter 4 of your Respiratory Disease textbook, which term would be used to describe his recent ABG?

SOAP chart based on the previous information:
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