P-II-15. Respiratory disease, Case 2

Case II — 69-year-old male; main complaints are dyspnea, high fever, chest pain (COPD)

Medical history:

50 pack years smoking, hyperlipidemia, hypertension, acute myocardial infarction, coronaria bypass surgery, chronic obstructive pulmonary disease (COPD), many hospital stays because of acute exacerbation, need for non-invasive respiratory support (acute but reversible global respiratory insufficiency).

Permanent medication:

Aspirin, ACE inhibitor, Betaloc (nonselective β-blocker), inhaled long-acting β2-agonist (LABA) and inhaled long-acting muscarinic antagonist (LAMA).

Complaints:

Fever (39.0 °C), chest pain, dyspnea.

Physical examination:

• Blood pressure: 145/82 mmHg, pulse: 90/min
• Wheezing (rather deep sound) over the lungs; over the left lateral zone of the chest above the diaphragm faint crackles can be heard

Pulmonary function test:

Irreversible obstruction of the large and small airways; FVC 1.35 L (34%), FEV1 0.58 L/s (19%), FEV1/FVC 0.5 (below 0.7 might be COPD), Rairway 405%. Body plethysmography: hyperinflation, dynamic compression of the small airways; total airway resistance 4-fold.

Blood gas, acid-base:

• pO2: 66 mmHg (with 2 L/min O2 inhalation - FiO2 27%)
• pH: 7.40
• pCO2: 43 mmHg

Chemistry:

• CRP: 88 mg/L
• Electrolytes in reference range
• GGT and LDH increased
• Troponin T negative, BNP in reference range

ECG: no new alterations.

Chest X-rays: Diaphragm is elevated on the left, left costodiaphragmatic angle is rounded, configuration of the heart is abnormal (pulm. hypertension?). Sutures of sternotomy (coronaria bypass).

Treatment and blood gas results:

Antibiotics, systemic steroid, inhaled bronchodilator (like in the acute exacerbation of COPD).

	before	after
PaO2	66 mmHg (+2 l/min O2, FiO2 27%)	60 (without O2)
PaO2/FiO2	244	286
pH	7.40	7.43
pCO2	43	47
BE	+1.0 mmol/l	+6.1 mmol/l

Diagnoses upon discharge:

• J4490 Chronic obstructive pulmonary disease, unspecified
• J1890 Pneumonia, unspecified
• I2500 Atherosclerotic cardiovascular disease, so described
• I10H0 Essential (primary) hypertension
• E7850 Hyperlipidemia, unspecified
• J4390 Emphysema, unspecified

After a few days the complaints improved. Supposedly there was a mild acute exacerbation. It is not certain based on the findings.

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Key Quotes & What They Tell Us

Quote / Value	Interpretation
“50 pack years smoking” + known COPD/emphysema	Heavy smoking → the principal cause of chronic obstructive pulmonary disease
FEV1/FVC 0.5, FEV1 0.58 L (19%), “Irreversible obstruction”	Fixed airflow obstruction (ratio < 0.7, very low FEV1) → confirms COPD, not asthma
Body plethysmography: “hyperinflation … total airway resistance 4-fold”	Air trapping and high airway resistance from small-airway disease/emphysema
Fever 39 °C, CRP 88, left basal crackles, X-ray changes	Superimposed infection/pneumonia precipitating an acute exacerbation
pCO2 43→47 mmHg + “global respiratory insufficiency”	Tendency to CO2 retention (type 2 respiratory failure) during exacerbation
Troponin negative, BNP normal, ECG unchanged	Excludes acute cardiac causes of the dyspnoea/chest pain
“Betaloc (nonselective β-blocker)”	Non-selective β-blockade can worsen bronchospasm — a relevant medication caution in COPD

Key Points

• Diagnosis: Chronic obstructive pulmonary disease with an acute exacerbation (and likely pneumonia).
• Spirometry: Irreversible obstruction (FEV1/FVC < 0.7) with very low FEV1 and hyperinflation — distinguishes COPD from asthma.
• Pathophysiology: Smoking-induced small-airway inflammation + emphysema → air trapping, dynamic compression, and impaired gas exchange.
• Respiratory failure: Prone to type 2 (hypercapnic) failure — controlled O2 needed to avoid worsening CO2 retention.
• Comorbidity: Significant cardiovascular disease (prior MI, bypass, hypertension) and a medication caution (non-selective β-blocker).