Question

Gretchen, a 65-year-old woman, comes into the clinic for follow-up care related to her chronic bronchitis. She has had bronchitis for several years and had an acute episode of respiratory distress 2 months ago. Treatment for the acute respiratory symptoms included the corticosteroid prednisone. She was initially given a high dose of prednisone but was able to tolerate a reduced dose of 10 mg per day since that time. A review of Gretchen’s medical history reveals that she smokes 1 pack of cigarettes a day, a habit she has had for 50 years. She indicates that she is healthy and does not see the need for any other medications. She states that her diet is good, although she has difficulty digesting dairy products and therefore avoids them. She recently experienced low back pain but otherwise has no complaints. Physical examination shows that Gretchen’s body mass index (BMI) is 17; her weight reduced by 5 pounds since her last visit6 weeks before. Her height is 0.5 inches less than the previous visit. Her posture appears to be stooped, and she has difficulty standing up straight. A dual- energy x-ray absorptiometry (DEXA) scan indicates a T score of –2.5 compared with her score of –2.0 12 months before. A radiograph indicates the presence of a vertebral fracture at L3.

1. What is the pathophysiology associated with Gretchen’s clinical presentation?

2. What are the risk factors associated with condition?

3. What clinical manifestations does Gretchen demonstrate?

4. How can Gretchen be diagnosed?

5. What is the treatment for Gretchen?

Answer 1

1.From the above clinical picture it is assumed that Gretchen is suffering from COPD(Chronic Obstructive Pulmonary Disease).it is characterized by airflow limitation that is not fully reversible. Chronic airflow limitation results from a combination of small airway disease and parenchymal destruction due to inflammatory process.These inflammatory process are often caused by exposure to noxious particles or gases.COPD is characterized by chronic inflammation throughout the lung ,with increased neutrophils,macrophages and CD8+Tlymphocytes.An imbalance between proteinase-antiproteinase activity and oxidative stress also contributes to the pathogenesis of the disease .Oxidative stress and proteinase -antiproteinase imbalance can be related to a combination of factors ,including the inflammation itself,environmental exposures and genetics.

2 The number of people affected with continues to increase because of exposure to tobacco smoke abd aging of the population.Previously a higher prevalence of disease occured in men but with changing patterns of exposure to tobacco ,women are now as frequently affected as men.Exposure to indoor pollution from heating and cooking fuels substantially increased the chances of COPD in women.

3 Gretchen had a history of bronchitis and an episode of acute respiratory distress 2 months ago, with unintended weight loss.

4.With the routine chest x-ray it is usefel in the diagnosis of COPD .It is also helpful in excluding other diseases.Chest CT scanning will be more useful in the evaluation of COPD.Non invasive measures are also used to diagnose the severity of the disease such as Spirometry.The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines for diagnosis are based on the ratio of the forced expiratory volume of air in one second to the total volume exhaled.The older version of the GOLD criteria was based solely on the severity of airflow obstruction.If abnormal airflow is present in a subject who meets criteria for asthma,both asthma and COPD may be diagnosed.

5.Smoking cessation is the most important intervention,and it is  one of the best intervention to decline in lung function characteristic of this disease.Bronchodilators treat airway obstruction in patients with COPD .This will improve emptying of the lungs and tends to reduce dynamic hyperinflation,which can improve airflow.Although regular use of inhaled corticosteroids do not prevent loss of lung function in patients with COPD,inhaled corticosteroids are recommended for patients with severe disease.

• Alpha1-antitrypsin replacement -this is recommended for patients with emphysema related to deficiency of alpha1antitrypsin
• vaccines-Pneumoccocal and influenza vacccination ,both alone and in combination have been shown to reduce hozpitalizations and mortality rate.
• Antioxidant agents-N-acetylcysteine may reduce the frequency of exacerbrations
• Mucolytic therapy-the benefits seems to be small and widespread use cannot be recommended
• Giving antibiotics for COPD exacerbrations is associated with beneficial effects on lung function
• Systemic glucocorticoids shorten the duration of the exacerbration and lead to faster improvements in lung function.A recent study suggest that nebulized budesonidemay be an alternative to oral glucocorticoids in nonacidotic exacerbrations.