2. GROUP MEMBERS
Gladys L. Dumayas, 25
BS Medical Technology
Florece Angela Dejacto, 24
BS Pharmacy
Milee Julien G. Coliamar, 25
BS Physical Therapy
Lynn Marie I. Delgado, 23
BS Food Technology
Sophia Jeanine Caneda, 24
BS Nursing
Carl Gerard Cuyos, 27
BS Biology
3. Objectives
1. To present a case of a 41 year old male who came in due to
dyspnea.
2. To discuss the different types of breathing and breath
sounds.
3. To discuss the Pathophysiology of ARDS in relation to
COVID 19 Infection
4. To discuss the different types of Obstructive Lung Diseases.
5. To discuss the treatment and management of Obstructive
Lung Disease.
5. GENERAL DATA:
● Mr. AA
● 41 years old
● Male
● Filipino
● Married
● Roman Catholic
● from Urgello Cebu City
CHIEF COMPLAINT:
difficulty in breathing
6. HISTORY OF PRESENT ILLNESS
● Patient noted
onset of cough,
non-productive,
associated with
sore throat.
● No fever nor
difficulty in
breathing was
noted.
● No consultation
was done, no
medications were
taken.
● Patient noted
persistence of cough
now associated with
undocumented fever,
body malaise, and
loss of smell. Patient
took paracetamol
500mg as needed for
fever with no relief.
● Still, no consultation
was done.
1 week PTA 5 days PTA
7. HISTORY OF PRESENT ILLNESS
● Patient now noted difficulty
in breathing especially
with exertion.
● Patient associated the
symptoms with his COPD.
Started with Salbutamol
nebulization every six
hours with partial relief of
dyspnea.
● Consulted with SWU – out
patient department and
was advised for RT-PCR
testing for SARS-COV2.
While awaiting swab
results, patient was
advised quarantine.
● Patient noted
increasing
difficulty in
breathing even at
rest. He was
rushed to SWU –
MC emergency
room, thus
admitted.
3 days PTA Few hours PTA
8. PAST MEDICAL HISTORY:
Admitted last July 2018 at SWU medical center due to an exacerbation of chronic
obstructive pulmonary disease. He was discharged improved with unrecalled take
home medications.
PERSONAL / SOCIAL HISTORY:
Mr. AA is a smoker, consuming 1 pack of cigarettes per day (25 pack years), started
smoking at the age of 16, he is an occasional alcoholic beverage drinker, denies
history of illicit drug use.
Patient works as a street vendor outside of SWU – MC. Since the pandemic, he has
continued selling in front of the hospital. He wears a cloth mask while outside and
seldom washes his hands.
FAMILY HISTORY:
No history of hypertension, diabetes, nor malignancy in both maternal and paternal
sides.
9. PERTINENT PHYSICAL EXAMINATION
GENERAL:
examined drowsy, coherent, in respiratory distress, with the ff vital signs:
BP: 90/60 mmHg HR: 120 BPM RR: 42 CPM T: 39 C
PERTINENT PHYSICAL FINDINGS:
Chest and lungs: equal chest expansion, decreased fremitus, generalized
hyperresonance, fine rales in
both basal lung fields, expiratory wheezing in all lung fields.
Cardiovascular: tachycardic, regular rhythm, no murmurs
Extremities: strong pulses, no clubbing nor edema noted.
11. 1. Vesicular
- or soft and low pitched
- are heard throughout inspiration,
continue without pause through
expiration, and then fade away
about one third of the way through
expiration.
Normal breath sounds are:
12. 2. Bronchovesicular
- with inspiratory and expiratory
sounds about equal in length,
at times separated by a silent
interval.
- Detecting differences in pitch
and intensity is often easier
during expiration.
13. 3. Bronchial
- or louder, harsher and higher in
pitch, with a short silence
between inspiratory and
expiratory sounds.
- Expiratory sounds last longer
than inspiratory sounds.
14. 4. Tracheal
- or loud harsh sounds heard
over the trachea in the neck.
18. Slow Breathing
(Bradypnea)
Slow breathing with or without an increase in tidal
volume that maintains alveolar ventilation.
Abnormal alveolar hypoventilation without
increased tidal volume can arise from uremia,
drug-induced respiratory depression, and
increased intracranial pressure.
19. Sighing Respiration
Breathing punctuated by frequent sighs suggests
hyperventilation syndrome—a common cause of
dyspnea and dizziness.
Occasional sighs are normal.
20. Rapid Shallow Breathing
(Tachypnea)
Rapid shallow breathing has numerous causes,
including salicylate intoxication, restrictive lung
disease, pleuritic chest pain, and an elevated
diaphragm.
21. Cheyne–Stokes Breathing
Periods of deep breathing alternate with periods of
apnea (no breathing).
This pattern is normal in children and older adults
during sleep.
Causes include heart failure, uremia, drug-induced
respiratory depression, and brain injury (typically
bihemispheric).
22. Obstructive Breathing
In obstructive lung disease, expiration is prolonged
due to narrowed airways increase the resistance to
air flow.
Causes include asthma, chronic bronchitis, and
COPD.
23. Rapid Deep Breathing
(Hyperpnea, Hyperventilation)
In hyperpnea, rapid deep breathing occurs in
response to metabolic demand.
In hyperventilation, this pattern is independent of
metabolic demand, except in respiratory acidosis.
Light-headedness and tingling may arise from
decreased CO2 concentration.
In the comatose patient, consider hypoxia, or
hypoglycemia affecting the midbrain or pons.
Kussmaul breathing is compensatory overbreathing
due to systemic acidosis. The breathing rate may
be fast, normal, or slow.
24. Ataxic Breathing
(Biot Breathing)
Breathing is irregular—periods of apnea alternate
with regular deep breaths which stop suddenly for
short intervals.
Causes include meningitis, respiratory depression,
and brain injury, typically at the medullary level.
25. General Data Signs and Symptoms PE findings
- 41 years old
- Male
- Filipino
- Married
- (+) smoker (25 pack
years)
- Street Vendor
- Diagnosed with COPD
- Dyspnea
- Cough
- Sore Throat
- Body Malaise
- Fever
- Anosmia
- Drowsy
- Tachycardic at
120bpm
- Tachypneic 42 cpm
- Febrile at 39 C
- Decreased Fremitus
- Generalized
Hyperresonance
- Wheezing in all lung
fields
- Fines rales in both
basal lung fields
SALIENT FEATURES
27. DIFFERENTIAL DIAGNOSIS
RULE IN RULE OUT
COVID 19 Infection - Street Vendor who wears cloth
Mask
- Seldom washes hands
- Fever
- Cough
- Dyspnea
- Anosmia
- Tachypnea
- Sore Throat
- Cannot totally rule out
- Need RT-PCR to
confirm
Pneumonia
- Cough
- Dyspnea
- RR: 42 cpm
- Fever
- Tachypnea
- Fine Rales both basal lung fields
- Cannot totally rule out
28. DIFFERENTIAL DIAGNOSIS
RULE IN RULE OUT
Asthma - Cough,
- Dyspnea
- Generalized
Hyperresonance
- Wheezing
- Onset often in Childhood
- Associated with allergy,
rhinitis, eczema
Heart Failure
- Cough
- Dyspnea
- Fine Rales both basal lung
fields
- Body Malaise
- Wheezing
- Non hypertensive
- No edema
- No murmur
30. DISEASE SEVERITY CLASSIFICATION OF PATIENTS WITH
PROBABLE OR CONFIRMED COVID-19
https://www.psmid.org/interim-management-guidelines-for-covid-19-version-3-1/
Mild Symptomatic patients
NO signs of pneumonia or hypoxia
Moderate Adolescent or adult with clinical signs of non-severe pneumonia
Severe Adolescent or adult with clinical signs of severe pneumonia or severe
acute respiratory infection
Critical manifesting with acute respiratory distress syndrome, sepsis and/or
septic shock
Acute Respiratory Distress Syndrome 1. Severe Dyspnea of Rapid Onset
2. Hypoxemia
3. Diffuse Pulmonary Infiltrates
31. EXACERBATIONS IN COPD
PARAMETER NO RESPIRATORY FAILURE ACUTE RESPIRATORY FAILURE
NON LIFE THREATENING LIFE- THREATENING
Respiratory Rate - 20 to 30 breaths/min
- No use of Accessory
muscles
- >30 breaths/min
- With use of accessory muscles
Change in Mental Status - NONE - Yes (acute changes)
Hypoxemia - Improves with O2 support
at 28-35% FiO2
- Improved with O2 support at 35-
40% FiO2
- Not improved with O2 via
Venturi Mask or
- Requiring FiO2 >40%
PaCO2 - Not Increased - Hypercarbia (Increased from
baseline or elevated at 50-60
mmHg)
- Hypercarbia (Increased from
baseline or elevated
>60mmHg or with acidosis
(ph <_ 7.25)
● Change in Mental Status- most important sign of a severe exacerbation
Source: Global Initiative for Chronic
Obstructive Lung Diseases
32. FINAL DIAGNOSIS
1. Acute Respiratory Distress Syndrome secondary
to COVID 19 - Critical Pneumonia
1. Chronic Obstructive Pulmonary Disease in Acute
Exacerbation
40. Bronchiectasis
● Destruction of smooth
muscle and elastic
tissue by chronic
necrotizing infection
leads to permanent
dilation of bronchi and
bronchioles
● Airways are dilated,
sometimes up to 4 times
normal size
41. Asthma
● A chronic disorder of the
conducting airways, usually
caused by an immunological
reaction, which is marked by
episodic bronchoconstriction
due to increased airway
sensitivity to a variety of stimuli;
inflammation of the bronchial
walls; and increased mucus
secretion
In hyperpnea, rapid deep breathing occurs in response to metabolic demand from causes such as exercise, high altitude,sepsis, and anemia.
IMPRESSION VS DIAGNOSIS
"Diagnostic Impression" is the opinion of the therapist upon initial presentation of the patient's symptoms. "Diagnosis" is the final opinion of illness, used to prescribe a course of treatment.
41 years old
Male
Filipino
Married
(+) smoker (25 pack years)
Street Vendor
Diagnosed with COPD
Dyspnea
Cough
Sore Throat
Body Malaise
Fever
Anosmia
Drowsy
Tachycardic at 120bpm
Tachypneic 42 cpm
Febrile at 39 C
Decreased Fremitus
Generalized Hyperresonance
Wheezing in all lung fields
Fines rales in both basal lung fields
For complaints of cough, pursue a thorough assessment. Establish the duration.
Is the cough acute, lasting less than 3 weeks; subacute, lasting 3 to 8 weeks; or
chronic, more than 8 weeks? Bates 12th edition pg 312
CARDIAC WHEEZE- Cardiac asthma is not a form of asthma. It's a type of coughing or wheezing that occurs with left heart failure. Depending on how severe the symptoms are, this wheezing can be a medical emergency. Heart failure can cause fluid to build up in the lungs (pulmonary edema) and in and around the airways.
Philippine Society for Microbiology and Infectious Diseases Philippine College of Chest Physicians Philippine College of Physicians Philippine Rheumatology Association Philippine College of Hematology and Transfusion Medicine
INTERIM GUIDANCE ON THE CLINICAL MANAGEMENT OF ADULT PATIENTS WITH SUSPECTED OR CONFIRMED COVID-19 INFECTION
Mild: Symptomatic patients presenting with fever, cough, fatigue, anorexia, myalgiasother non-specific symptoms such as sore throat, nasal congestion, headache, diarrhea, nausea and vomiting; loss of smell (anosmia) or loss of taste (ageusia) preceding the onset of respiratory symptoms with NO signs of pneumonia or hypoxia
MODERATE: Adolescent or adult with clinical signs of non-severe pneumonia (e.g. fever cough, dyspnea, respiratory rate (RR) = 21-30 breaths/minute, peripheral capillary oxygen saturation (SpO2) >92% on room air)
Child with clinical signs of non-severe pneumonia (cough ordifficulty breathing and fast breathing [ < 2 months: > 60; 2-11 months: > 50; 1-5 years: > 40] and/or chest indrawing)
SEVERE: Adolescent or adult with clinical signs of severe pneumonia or severe acute respiratory infection as follows: fever, cough, dyspnea, RR>30 breaths/minute, severe respiratory distress or SpO2 < 92% on room air
Child with clinical Signs of pneumonia (coughor difficulty in breathing) plus at least one of the following:
Central cyanosis or SpO2 < 90%; severe respiratory distress (e.g. fast breathing, grunting, very severe chest indrawing); general danger sign: inability to breastfeed or drink, lethargy or unconsciousness, or convulsions.
b. Fast breathing (in breaths/min): < 2 months: > 60; 2-11 months: > 50; 1-5 years: > 40.
CRITICAL: manifesting with acute respiratory distress syndrome, sepsis and/or septic shock
ARDS: Patients with onset within 1 week of known clinical insult (pneumonia) or new or worsening respiratory symptoms, progressing infiltrates on chest
X-ray or chest CT scan, with respiratory failure not fully explained by cardiac failure or fluid overload
Source: Global Initiative for Chronic Obstructive Lung Disease (GOLD)
COPD may be punctuated by periods of acute worsening of respiratory symptoms, called EXACERBATIONS.
Level of Consciousness: Drowsy- responds to questions then falls asleep
Alertness- speak to the patient in a normal tone of voice
Lethargy- speak in a loud voice, drowsy- responds to questions the fall asleep
Obtundation- shake patient gently, response slowly, somewhat confused
Stupor- apply painful stimulus, arrouses from sleep after painful stimuli
Coma- apply repeated painful stimuli, unarousable with eyes closed
