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The patient is a 56-year-old male who was admitted in early December 2011 with a diagnosis of chronic obstructive pulmonary disease (COPD) exacerbation. The patient has a 76 pack-year smoking history (2 packs per day for 38 years). He has a marked barrel-shaped chest and mild paradoxical breathing pattern that worsens with physical activity. His chest radiograph demonstrates markedly enlarged lungs, increased lucency, and numerous bullae (greater in the upper lobes bilaterally), and marked flattening of the diaphragm. The patient has been admitted twice over the past 6 months for similar COPD exacerbations that produced marked dyspnea and fatigue, fever, decreased functional and exercise tolerance, excessive coughing (which made it even more difficult to breathe), and marked anxiety. The patient reports more frequent exacerbations in the winter (especially when family members are ill) and tries to remain indoors throughout most of the season. Six months prior to the current admission, the patient was intubated and received mechanical ventilation for 1 week. However, on the most recent admission 3 months ago, he underwent a trial of bilevel positive airway pressure (BiPAP) noninvasive mechanical ventilation, which prevented the need for him to be intubated and mechanically ventilated. The emergency department admission note for the current hospitalization indicated that the patient demonstrated less of a paradoxical breathing pattern than the last admission and that the patient was posturing himself to facilitate his breathing (sitting with trunk flexion and both forearms resting on his thighs). The patient's pulmonary function test (PFT) results have been stable over the past year (Table 14-1), but his arterial blood gas (ABG) values have been progressively worsening (Table 14-3). The ABG values during this hospitalization reveal a substantially higher level of carbon dioxide and lower level of oxygen. The medical team is contemplating intubation and mechanical ventilation versus a BiPAP trial because of his ABG values, marked dyspnea and fatigue, difficulty breathing, and paradoxical breathing pattern. On the second day after admission, the physical therapist is consulted to examine and treat the patient and to assist the medical team in determining the best treatment plan for the patient (invasive versus noninvasive ventilation).

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What examination signs may be associated with this diagnosis?

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Based on the patient's diagnosis, what do you anticipate may be the contributing factors to his condition?

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What are the most appropriate physical therapy outcome measures for patients hospitalized with an acute exacerbation of COPD?

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What is his rehabilitation prognosis?

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What are the most appropriate physical therapy interventions?

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What precautions should be taken during physical therapy examination and/or interventions?

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Table Graphic Jump Location
Table 14-1 Pulmonary Function Tests for Case Study Patient and Comparison to Predicted Norms

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