Based on these clinical findings the most likely diagnosis is Chronic Obstructive Pulmonary disease (COPD). The five clinical findings in this case scenario that support the diagnosis of COPD are: in-office spirometry results, dyspnea on exertion, chronic bronchitis, 20-year smoking history, and expiratory wheezes bilaterally. A major risk factor in COPD is tobacco smoke, and this patient has 20-year smoking history as well as family history which increases the patient’s risk. The most common symptom of COPD is dyspnea on exertion and even at rest. The patient was unable to take her walks without getting short of breath. The chief complaint that the patient came in with was having had bronchitis 2-3 times over the last year, which in combination with emphysema make up the disease of COPD. Bilateral expiratory wheezes may be related to the airway being inflamed, infected, or blocked with excess mucus. The patient also had low FEV1 during in-office spirometry testing. A low FEV1 reveals airway obstruction and is also progressive and unresponsive to bronchodilators (McCance, Huether, Brashers, & Rote, 2018, p. 1185 para 2).
COPD pathologic changes occur in the large central airways, small peripheral airways, and the lung parenchyma (McCance, Huether, Brashers, & Rote, 2018, p. 1181 para 7). Chronic irritant exposure during both chronic bronchitis and emphysema form neutrophils, macrophages, and lymphocytes to the lungs causing progressive damage from inflammation, oxidative stress, extracellular matrix proteolysis, and apoptotic and autophagic cell death (McCance, Huether, Brashers, & Rote, 2018, p. 1181 para 7). During chronic bronchitis, inhalation of irritants lead to bronchial inflammation causing edema. The number of mucus glands and goblet cells in the airway epithelium are increased, the smooth muscle hypertrophies with fibrosis, and the airway is narrowed. The ciliary function in the lungs are impaired causing the defense mechanism of the lungs to compromise. The defense mechanism being compromised leads to an increase in pulmonary infections and the damaged airways from infection are complicated with dyspnea and a productive cough. "The thick mucus and hypertrophied smooth muscle narrow the airways and lead to obstruction mostly during expiration, and obstruction leads to ventilation-perfusion mismatching” (McCance, Huether, Brashers, & Rote, 2018, p. 1181 para 1). Emphysema is another condition that makes up chronic obstructive pulmonary disease. Emphysema is the destruction of alveoli through the breakdown of elastin which leads to apoptosis of lung structural cells (McCance, Huether, Brashers, & Rote, 2018, p. 1182 para 1). In an emphysema patient, the number of neutrophils are increased leading to destruction of bronchial and alveolar structures, and macrophages enhance the release of inflammatory mediators. There are two types of emphysema. Centracinar emphysema which is the septal destruction that occurs in the respiratory bronchiolar walls and the alveolar ducts in the center of the pulmonary lobule and occurs mostly in smokers with chronic bronchitis (McCance, Huether, Brashers, & Rote, 2018, p. 1182 para 1). Panacinar emphysema involves alveolar and respiratory bronchiolar walls. The involvement of these two walls result in more damage to the lower lobes of the lung unlike centracinar which occurs more in the upper lobes. Expiration becomes difficult in COPD due to the obstruction of the airways caused by excessive mucus, edema, loss of elastic recoil, and airway collapse (McCance, Huether, Brashers, & Rote, 2018, p. 1184 para 2). Due to the collapse of airway, air becomes trapped in the lungs causing hyperexapansion of the chest or “barrel chest.” Barrel chest causes the patient to have an increase in work of breathing and will eventually develop hypoventilation and hypercapnia. Chronic inflammation of the airways can have systemic effects including weight loss, muscle weakness, and increase to infection. (McCance, Huether, Brashers, & Rote, 2018, p. 1184 para 2).
The management of COPD is based on stopping the disease progression, improving respiratory symptoms, controlling exacerbations, and reducing mortality. Inhaled long-acting anticholinergics or long-acting inhaled beta agonists, and expectorants are given to control symptoms of dyspnea. Patients may be given a short-acting and long-acting bronchodilator for fast action and long-lasting relief and supplemental oxygen to treat low oxygen levels. Some patients with COPD have a productive cough that is more frequent and shortness of breath that increases the patient’s risk for infection. These patients are treated with antibiotics as well as bronchodilators (“Managing Your COPD Medications”, 2017). Inflammation also leads to an increase in mucus production and shortness of breath which can be treated with inhaled or oral corticosteroids (“Managing Your COPD Medications”, 2017). This patient could benefit from inhaled steroids, supplemental oxygen due to low oxygen saturation, mucolytics, and bronchodilators, due to chronic cough and mucus production as well as the shortness of breath. However, this patient had a low FEV1, so the benefits of inhaled corticosteroids would outweigh the risk and the patient should be closely monitored for potential side effects such as the risk of pneumonia (McCance, Huether, Brashers, & Rote, 2018, p. 1185 para 4).
In this case scenario that patient complained of significant weight loss of 20 pounds within five months. In this situation, the patient needs thorough education on nutrition to maintain good health as well as gain weight. The purpose of maintaining good weight in COPD patient’s that are undernourished is to maintain respiratory muscle strength. The diet recommended for these patients are high-energy and protein-enriched diet, and this can be achieved by taking smaller portions throughout the whole day (Schols, et al., 2014). Other foods that are good for COPD patients are foods high in fiber, fresh fruits and vegetables, and foods high in vitamins and minerals. Some examples of foods in these categories are: milk, eggs, cheese, nuts, meat, fish, poultry, bananas, strawberries, carrots, sweet potatoes, and dark leafy greens. Patients who also suffer with this chronic illness also tend to have vitamin D deficiency, which can cause a rapid decline in pulmonary function if not replaced, so is important to also consume foods high in vitamin D as well supplements if needed (Schols, et al., 2014). Nutritional education is available to patients with COPD through the internet as well as an appointment with a dietician to set the goal for the specific need, which in this patient’s case, is weight gain. Potential obstacles may involve financial issues. These patients may not have the financial ability to afford the nutrition that they really need to maintain a good weight to build their muscle mass. A study has shown that patients who are undernourished tend to have longer hospitalizations than those who are over-nourished or well-nourished (Schols, et al., 2014). It is important to maintain a balanced diet to prevent these hospitalizations from occurring.