Case Presentation on COPD with RV failure

1. CASE PRESENTATION ON
COPD with RV FAILURE
FLEMIN THOMAS, PharmD

2. COPD with RV FAILURE
COPD is a disease characterized by the presence of
airflow obstruction due to chronic bronchitis or
emphysema ;the air flow obstruction is generally
progressive may be accompanied by airway
hyper activity .
Complications of COPD ;
Acute bronchitis ,pneumonia ,pulmonary
thromboembolism and concominant left
ventricular failure may worsen otherwise stable
COPD.

3. Pathophysiology
Predisposing factors :
Aging
Alpha 1 anti-trypsin deficiency
(hereditary)
allergies
Precipitating factors:
Smoker/cigarette smoking
Second hand smoker
Exposure to air pollution
IV drug use –methadone/cocaine
HIV infecton
Recurrent respiratory infection
Chronic irritation to the airflows of the lungs
Infiltration of lymphocytes ,
Macrophages,polymorphonuclear
leukocytes in the mucosal areas
The elastin and fiber network
of the alveoli are broken
Vasodilation, congestion
and oedema of the bronchial mucosa
As a compensatory mechanism,
The alveoli enlarge but the walls
Are damaged

4. ‘.
Thickening due to excessive
Mucus plug formation and
rigidity of bronchi
Narrowing of air passages
Chronic bronchitis
Consistent destruction of the alveoli
And alveolar walls
Enlargement of acini
Reduction in the alveolar
Diffusing space and some
Tissue changes
Pulmonary emphysema
CHRONIC OBSTRUCTIVE PULMONARY DISEASE

5. In severe COPD,
oxygen concentration in the blood falls
pulmonary hypertension
High blood pressure in the pulmonary arteries puts excess
strain on the right ventricle
Over time right ventricle may become stretched and dilated,
and fail to pump blood effectively.
Right-sided heart failure causes fluid to accumulate in the
body, such as in the legs and abdomen.

6. Signs and symptoms
• Excessive cough
• Sputum production
• Shortness of breath
• Symptoms have often been present for 10 years
or more 10 years
• Dyspnea is noted initially only on heavy exertion.
• These exacerbation precipitated by infection
(more often viral than bacterial)

7. Patient details
Patient name : SDD
Age :65
Sex : male
I.P. no : 15-1157 Dept: medicine Unit: F

8. Reason for admission
c/o cough with expectoration since 2-3 months
Breathlessness since 2 months
fever with chills since 5-4 days

9. Past medical history
No H/O similar complaints in past
No H/O DM/HTN/asthma
History of present illness :patient was alright 3
months back then he developed H/O cough
insidious in onset and progressive in nature
.cough expectoration bile stained sputum
scanty in amount purulent in consistency
,aggravated more in night , h/o breathlessness
while be walking for long distance &relived on
rest .

10. Family history
• Appetite –normal
• Sleep- disturbed
• Habbits - tobacco consumption

11. General physical examination
Pallor is present
Pulse rate :90 bpm
BP: 120/80 mmhg
febrile
Systemic examination
CVS :S1S2 + no murmurs
RS: B/L basal creps ,intrascapular rhonchi ,
increased right air entry
CNS : NAD
P/A: soft ,epigastric tenderness+ ,no organomegaly

12. Others:
• CBC with ESR
• CXR
• ECG
• Urine test
• LFT
• Sr. urea
• Sr.creatinine

13. Provisional diagnosis
• COPD with RV failure

14. Laboratory data
Haemoglobin – 18.3 g/dl
WBC -9500 cells/uL
Polymorphs- 70%
Basophils-0%
Eosinophils -3%
Lymphocytes -27%
Monocytes -0%

15. RBC -6.69 milloin/uL
PLT – 2,39,000 cells/mmᶟ
ESR -40 mm
Sr.creatinine -1.1 mg/dl
Sr.urea-23 mg/dl
ALT(SGPT):17U/L
AST(SGOT):14U/L
ALP(alkaline phosphatase):39U/L

16. BILIRUBIN
Total bilirubin :1.8mg%
Direct bilirubin :0.4mg%
Indirect bilirubin:0.2mg%
Total protein :4.9mg%
Albumin : 2.0mg%
Globulin : 2.9 mg%
AFB sputum test - negative

17. ECG
T wave inversion in the right precordial region.

18. Treatment chartBrand name Generic name dose R freque
ncy
1 2 3 4 5 6 7
Inj.levoflox Levofloxacin 500mg iv 1-0-0 y y y y y y Y
Inj.pantop pantoprazole 40mg iv 1-0-0 y y y y Y y y
Inj.febrinil paracetamol 100ml Iv 1-0-1 y y y y y y y
Tab.dytor torsemide 10mg iv 1-0-1 y y Y
Cap.AB phylline acebrophylline 100mg p/
o
1-0-1 y y y y y Y Y
Syp.brozedex Terbutaline sulphate
+bromohexine+guaiphen
esin
2tsp p/
o
1-0-1 y y y y y y Y
Neb.doulin Salbutamol+ipratropium
bromide
50/20
mcg
1-1-1-1 y y y y Y y y
Neb.budecort budesenoide 200mc
g
1-1-1 y y y Y y y Y
Tab.ecosprin AV Aspirin+ atorvastatin 150/2
0mg
p/
o
0-1-0 y Y
tab,.avas atorvastatin 40mg p/
o
0-1-0 n n y y y Y
Syp.viminta 2tsp p/ 1-0-1 y y y Y

19. Follow up
• Day 1
BP- 110/70mmHG
Pulse-90bpm
NFC
febrile
RS: B/L basal creps , AE in right side
CVS: s1s2+
P/A: soft ,epigastric tenderness+

20. • Day2
BP:110/80 mmHG
Pulse:82bpm
NFC,afebrile
RS: B/L basal creps+
CVS: s1s2+
P/A: NAD

21. • Day3
BP- 120/70 mmHG
Pulse:82 bpm
NFC, afebrile,
RS:B/L basal creps +
CVS: s1s2 heard with out murmur
P/A: NAD
Adv, AFB sputum
test

22. • Day 4
BP-120/80mmHG
Pulse: 90bpm
NFC, afebrile,nausea +
RS: left basal creps+
CVS: s1s2 + no murmurs
P/A: NAD

23. • Day 5
BP:120/70mmHG
Pulse:90bpm
NFC, afebrile,nausea+
RS: B/L creps+
CVS: s1s2 + ,no murmurs
P/A : nad

24. • Day 6
BP- 120/70mmHG
Pulse: 80bpm
NFC, afebrile,nausea+
RS: B/L creps +
CVS:s1s2+ no murmurs
P/A: NAD

25. • DAY 7
BP: 120 /70mmHG
Pulse: 72bpm
NFC,afebrile
Nausea present
RS:B/L creps +
Cvs :s1s2 + no murmurs
P/A : NAD

26. Discharge medication
Brand name Generic
name
dose route Freq. Duration
Tab.pantop Pantoprazol
e
40mg p/o 1-0-0 7 days
Cap.abflo acebrophylli
ne
100mg p/o 1-0-1 7 days
Syp.brozede
x
2tsp p/o 1-0-1 7 days
t.avas atorvastatin 40mg p/o 0-0-1 7 days
Syp.viminta 2tsp p/o 1-0-1 7 days
Tab.emset ondasetron sos

27. Pharmaceutical care plan
.
Subjective evidences
•Cough with
expectoration
•Breathlessness
•Fever with chills
Objective evidences
• Pallor present
• RS: B/L basal creps
present
• Intrascapular rhonchi
present
• ESR-40mm at the end of
first hour
• Haemoglobin-18.3g/dl
• Polymorphs- 70%
• RBC -6.69 milloin/uL
• ECG-T wave inversion in the right
precordial region.

28. ASSESSMENT
BASED ON SUBJECTIVE AND
OBJECTIVE EVIDENCES PATIENT WAS
DIAGNOSED TO HAVE COPD WITH
RIGHT VENTRICULAR FAILURE

29. Monitoring parameters
• ECG
• Cardiac biomarkers
• 2D echocardiogram
• Spirometry
• Erythrocyte sedimentation rate(ESR)

30. Pharmacist intervention
Significant interactions found in prescribed
drugs:
• atorvastatin + budesonide
atorvastatin will increase the level or effect of
budesonide by P-glycoprotein (MDR1) efflux
transporter.
Pharmacist suggetion:
discontinue the budesenoid and start with
fluticasone 200 mcg inhalation and continue
the therapy.

31. PLANNING
Goals to be achived
• To reduce the breathlessness.
• To reduce cough with expectoration.
• Reduce the fever with chills.

32. Standard recommendation
• SMOKING CESSATION
• IMMUNIZATIONS
• PULMONARY REHABILITATION
Pulmonary rehabilitation has been shown to
improve exercise tolerance, reduce dyspnea, and
improve health-related quality of life in patients
• INHALED MEDICATIONS
a short-acting anticholinergic (e.g., ipratropium)
short-acting beta2 agonist (e.g., albuterol,
levalbuterol, pirbuterol) is recommended on an
as-needed basis for mild intermittent symptoms

33. long-acting beta2 agonists (e.g., arformoterol ,
formoterol , indacaterol , salmeterol) .
Inhaled corticosteroids:
• Budesonide (budecort, 90 to 180 mcg per puff)
180 to 360 mcg twice per day
• Ipratropium/albuterol -One or two puffs every six
hours as needed.
for acute or chronic right vetricular failure-
Pre load optimization can be done by mild progressive
diuresis

34. Goals achieved
• Cough reduced
• Fever spikes reduced
• Breathlessness reduced

35. Patient counselling
About disease:
COPD with RV failure is the comorbid condition that
affects the lungs and heart respectively , so you
may have the symptoms like breathlessness,chest
pain,etc
About drugs:
Consumption of drugs in right time
Tab.pantop(pantoprazole): take the drug once a day
half an hour before meals in the morning .this
helps to relieve your gastric acidity
Cap.abphylline: this is drug for used to avoid
breathlessness

36. Syp.brozedex: it is a mucolytic agent which has
to take 2tsp twice a day
Tab.emset : this drug is for vomiting and nausea
. Take it only when necessary.
About life style modification:
Avoid high salt contained food
Limit fluid intake to 6-8 cups/day
Reduce the daily intake of saturated fat and
cholesterol.