Thursday, May 2, 2013

What's With My Cough?

I was working in a family practice/urgent care clinic when I went into see a established patient of the clinic.  He was from India, having emigrated to the U.S. some 20+ years ago to acquire a better life for his young and growing family.  He had been working as an industrial engineer all these years and had recently just retired. 
I knocked on the exam door and then went in to introduce myself. 
“Hi, I’m Sharon, I’m working in this clinic for a few months to help out until they hire another permanent provider.  And you are,  A-jit?  Did I pronounce that correctly?”
“Yes, A-jit, with the emphasis on the first syllable.”
“Okay, Ajit, what can I do for you?”
“Well, I’ve noticed over the past 2-3 months that I’ve become short of breath when I’m out walking in the evening with my wife.  I’ve never been short of breath before when we walked, but it seems to be happening more frequently now.”
“Do you have a history of asthma?”
“No, I only have some problems with my blood pressure, which I take a daily medication for.  Nothing else.”
“So no other medications except your blood pressure med?”
“That’s right.”
“Do you have any other medical problems beside your blood pressure?”
“Do you have any other symptoms, like coughing with your shortness of breath?”
“Hmm, I do wake up in the morning with some coughing on occasion, but I think that’s related to my drippy nose, I sometimes have problems with allergies.”
“Okay.  How about any smoking history?”
“Any alcohol intake?”
“I may drink one or two glasses of wine before dinner with my wife when we go out to eat, but that’s it.”
“Uh, it says here on your information sheet that you’re retired.  What did you do for a living?”
“I was an engineer.”
“Ok, what kind of an engineer?”
“An industrial engineer for  Dow Chemical Plant.  Where I worked they manufactured plastics of all kinds.”
“So were you on the manufacturing floor, where they were mixing all of the solvents, in otherwords coming in contact with the organic solvents they used to make the plastics on a daily or weekly basis?”
“Yeah, I was usually on the floor with the industrial technicians on a daily basis, making sure everything was running the way it should.”
“How many years did you work for Dow?”
“A total of 22 years, I just retired a few months ago.”

Working up a new patient who complains of shortness of breath needs to have the two main bodily systems worked up:  heart (cardiac) or lungs (pulmonary).    Cardiac disease can cause shortness of breath if the heart is not pumping correctly, or if the patient has a problem with one of their heart valves not working correctly. 

Pulmonary disease (lungs) can cause shortness of breath due to the lungs not being able to exchange air correctly or there being inflammation in the bronchial (airway passages) tubes which can cause an obstruction to air passing to and from (which is the reason that asthma exists). 

So when we (as the medical provider) have a patient come in and complains of shortness of breath we have to work up both systems.  In the office, we do a EKG (electrocardiogram) to look for problems related to the heart (it gives us a good estimate of heart chamber size as well as it’s rhythm) and also order pulmonary function testing to look for problems related to lung function. 

“Okay, well let me listen to your heart and lungs and quickly listen to your carotid arteries in your neck as well as look at your throat.  Then I’ll have the medical assistant come in and put the pulse ox finger clip on you and walk you around the clinic for 5 minutes.  That will tell me whether your oxygen levels drop while you are exercisng.”
The patient’s physical examination was normal, so I had him walk around the clinic with a pulse oximetry on his finger.  His pulse ox started out at 94%, and after walking for 5 minutes it dropped down to 90%.  So I explained to him that we were going to give him a albuterol nebulizer treatment and see what would happen to his oxygen level.  After his nebulizer his pulse oximetry went up to 97%. 
“I’m feeling better,” he stated. 
“I’m glad.  Before I sent you home, I also need to get a EKG on you to make sure that your shortness of breath is not related to your heart function.”
The patient’s EKG was normal. 
“Alright, Ajit, I’m going to send you home with a prescription for an albuterol inhaler to take every day.  I’m also going to set you up to go over to the hospital so you can get pulmonary function testing (PFT) done.  I should have those results by the time you come back into clinic in 3-4 weeks and then we will know whether you have asthma or COPD (chronic obstructive pulmonary disease).  So I’ll see you back in a few weeks.”
“Thanks for your help.  I go to the front desk and they’ll have my order form for the pulmonary function testing?”
“Yes, I’ll go give it to Laura, who will order them for you.”

Giving a patient an albuterol inhaler by nebulizer helps to open up their bronchial tree (airway passage) so that they are able to exchange oxygen and carbon dioxide easier.  When a patient responds to albulterol this tells me that they have either new onset asthma or COPD.

Pulmonary function testing involves the patient exhaling air into a machine as forcefully as they can.  They also exhale air forcefully after they have received a bronchodilator treatment (generally an albuterol nebulizer).  These two results are then compared to look at the difference and to assess the response to bronchodilation medication.  These results are also compared to what would be expected given the patient's age and height (which is measured as the forced volume capacity).
Risk factors for COPD include:
smoking (80% of all patients)
occupational exposure to organic or inorganic dust particles, particulate matter, gas fumes which over time can causes inflammation of the airways
alpha 1 anti-trypsin enzyme deficiency (a gene disorder)
atopy (allergic reaction to inhaled particles)
tuberculosis survivors

Two weeks later I received the patient’s PFT testing.    This revealed that his lung function was not in the normal range.  He had airflow obstruction with his forced expiratory volume(air volume)  as compared to his forced vital capacity (FEV1/FVC) was < 70% which was diagnostic of COPD (chronic obstructive pulmonary disease). 
Ten days later the patient was back in the clinic for his follow-up appointment.  His pulse oximetry was normal, after walking around the clinic for five minutes, his pulse oximetry didn’t drop at all.  He had been using his albuterol inhaler three times a day with a good response at home. 
“My coughing is gone, I’m able to walk with my wife every night without any problems.  I feel like I’m back to normal,” stated Ajit. 
“I’m glad to hear that.  Stay on your inhaler then.  Your pulmonary function testing came back and showed that you have COPD, which I believe is related to all of your occupational exposure to dust, organic particle matter and the like while you were working for more than 20 years at Dow Chemical.  So, we’ll need to see you every six months for follow-up and if you have any more problems with your breathing make sure to come back in and be seen, okay?”
“Sure thing.”

There are many medications which can treat COPD they include:
bronchodilators (airway passageways) such as albuterol inhalers, anticholinergic inhalers
steroids via inhalers to deal with the inflammation response
roflumilast (a new drug family that can be used in patients with severe COPD)

Patients are also advised to stop smoking (if this is the case), receive all needed vaccines (especially the annual flu vaccine), and antibiotics when they come down with upper respiratory infections.   Patients with severe COPD are also given oxygen supplementation.

Patients are treated in a step wise fashion with albuterol being the first medication we use, adding on steroid inhalers, long acting bronchodilators, etc. as the patient may need them. 


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