I once went to a primary hospital, and the local doctor asked me to consult an elderly (close to 80-year-old) male patient, a patient with chronic obstructive pulmonary disease (COPD) with severe lung function decline, the patient was using Budigfu inhalant, and the patient's sputum culture found Aspergillus, and began oral voriconazole therapy. There are two problems in patients: one is that there is no obvious relief of breathing difficulties, and the other is that adverse reactions such as headache and dizziness occur after taking voriconazole. I came to the patient's bedside, after understanding the basic situation, I first asked the patient to do an inhalation action to show me, the result is that the patient will not use this device at all, he opened his mouth to press the drug device, and then did the inhalation action, the result is that the powder is all in his mouth, and does not suck into the lungs. So I taught patients again to use inhalation devices correctly.
Secondly, the patient also has constipation and has not had a bowel movement for five days. The reason why COPD patients have worsening symptoms in winter, one of the factors that we are more likely to ignore is that the winter weather is dry and prone to constipation, while COPD patients cannot increase abdominal pressure during defecation due to diaphragmatic weakness, resulting in difficulty in defecation, and defecation difficulties will increase oxygen consumption, which in turn will aggravate the condition.
Third, does the patient need voriconazole? Looking at the patient's lung CT, there is a significant emphysema and large vesicles and upper lobe bronchiectasis, but there is not much change from the previous lung CT, so the patient's sputum cultured Aspergillus may be colonized, so there is no rush to use voriconazole.
This week, I consulted another case in the hematology department, which was written as a case of bone marrow transplantation, diagnosed with bronchiolitis obliterans, and recently had obvious cough symptoms and requested a consultation. After I visited the patient, I learned that the patient had had episodic post-activity dyspnea before the diagnosis of the blood disease, but once visited the respiratory department, the lung function test passed normally, so the relevant drug treatment was not given. But the problem is that asthma itself is a reversible disease, and lung function can be normal when it is not attacked, and a bronchial provocation test is usually required to find out whether there is airway hyperreactivity. Regrettably, however, most of our hospitals do not currently carry out this test.
The patient had a bone marrow transplant in August 2019 and has not had regular lung function tests since then. Until June 2021, after the patient developed post-activity dyspnea, a lung function test showed severe obstructive ventilation dysfunction, but no bronchodilation test was done or a respiratory doctor was consulted. Diagnosis of bronchiolitis obliterans, given a quadruple therapy (rucortinib + montelukast + hormone + azithromycin), the patient is stable, still has dyspnea after activity.
After understanding the situation, I went to see the lung function pattern, although the existence of BO can not be denied, but it is not a typical BO pattern, and the patient has not been treated with inhaled hormones combined with adrenaline agonists, and patients have always had allergic rhinitis. Therefore, I cannot rule out the possibility of bronchial asthma.
Above, lung function in a typical BO patient is produced
Therefore, there are several problems in the diagnosis and treatment of this patient:
Bo is not diagnosed rashly based solely on clinical symptoms in the case of complete exclusion of asthma;
No inhalation of ICS + L ABA inhalation was given to patients;
Lung function is not regularly reviewed after bone marrow transplantation; because lung function in patients with BO can suggest the development of lesions earlier, that is, patients can develop abnormalities in lung function earlier before symptoms develop;
In the figure above, a heart-lung transplant patient has a BO lung function evolution process, and it can be found that there is usually a significant abnormality of lung function within one year.
After years of clinical trials, I have found that many doctors lack rules in their clinical work, so that they often lose sight of one or the other, and forget about the future, so how do we improve work efficiency? I always recommend using the worklist. I have also said something similar in the public account article (see "Clinical Medicine Needs a List Revolution - The List Revolution After Reading Feeling").
For example, in cases of bone marrow transplantation, patients can be asked to review lung function every three months and include them in the follow-up review form.
For example, when an inpatient with COPD has difficulty breathing, make the following list:
Whether there are factors that precipitate dyspnea, such as smoking, exposure to allergic substances, and aggravation of infections;
Whether there is an error in the use of inhalation devices and irregular medication;
Presence of complications: spontaneous pneumothorax, pulmonary embolism, pulmonary heart disease, etc.;
Whether there is an increase in aerobic consumption of events: such as constipation, difficulty urinating;
whether adequate oxygen therapy (including assisted breathing) is given;
Whether it is accompanied by the presence of other diseases, such as cardiac insufficiency, allergic rhinitis;
whether improper use of drugs increases oxygen consumption: eg, oral adrenergic agonists or excessive doses of theophylline in elderly patients;
Presence or absence of respiratory aspergillosis infection;
Then, take this list and check the relevant factors one by one so that you don't miss some important complications. Spontaneous pneumothorax, for example, is a very easy complication to miss, and I myself, including my colleagues and many of my peers, have experienced similar situations.
Therefore, I hope that everyone can carefully read this list revolution and make a list of their own work, so as to improve clinical work efficiency. Book Purchase Link: