70-Year-Old Man with 50-Year Smoking History Diagnosed with Emphysema After Chronic Cough and Shortness of Breath Worsen

Understanding Emphysema in Long-Term Smokers: A Real-Life Case Study

Smoking remains one of the leading causes of chronic respiratory diseases worldwide. This case highlights a 70-year-old male patient who developed severe emphysema after five decades of heavy tobacco use. Presenting with long-standing cough, excessive phlegm production, and worsening breathlessness—especially during physical activity—he was admitted to hospital following an acute exacerbation accompanied by fever. His medical journey offers valuable insights into the progression, treatment, and long-term management of chronic obstructive pulmonary disease (COPD), particularly emphysema.

Patient Profile & Clinical Background

Gender: MaleAge: 70 years oldDiagnosis: Emphysema (a form of COPD)Hospital: The Second Affiliated Hospital of Harbin Medical UniversityDate of Admission: November 2019Treatment Approach: Pharmacological therapy including antibiotics, bronchodilators, corticosteroids, and antihypertensive medicationDuration of Treatment: 10-day inpatient care followed by ongoing outpatient follow-upsOutcome: Significant symptom improvement, stabilized vital signs, and enhanced lung function indicators

Initial Evaluation: Recognizing the Signs of Advanced Lung Damage

The patient's family reported a history of persistent cough and sputum production for over 20 years, with increasing shortness of breath during exertion for more than a decade. Symptoms had worsened significantly within the past week, including high fever (up to 38.0°C) and production of thick, yellowish mucus—classic signs of infection-triggered COPD flare-up.

He first experienced recurrent coughing with white phlegm two decades ago, typically during cold seasons or after catching a cold, lasting more than three months each year—a hallmark of chronic bronchitis. Ten years prior, he began noticing difficulty breathing while walking or climbing stairs, and was formally diagnosed with COPD. Despite this, his treatment remained inconsistent; he intermittently used bronchodilator inhalers and took theophylline tablets without medical supervision.

Upon admission, clinical examination revealed:

• Vital signs: Temperature 37.0°C, heart rate 110 bpm, respiratory rate 17 breaths/min, blood pressure 200/109 mmHg
• Physical findings: Barrel-shaped chest, decreased vocal fremitus, coarse breath sounds, and crackles/wheezes heard bilaterally in both lungs
• Cardiovascular status: Normal heart size on percussion, no murmurs detected
• Abdominal exam: Soft, non-tender, no hepatosplenomegaly

Medical Intervention: Managing Acute Exacerbation

Blood gas analysis upon admission showed:

• pH: 7.43 (normal)
• PaCO₂: 50 mmHg (elevated, indicating mild hypercapnia)
• PaO₂: 65 mmHg (low, suggesting hypoxemia)

Given the presence of fever and purulent sputum, a bacterial infection was suspected as the trigger for the acute worsening of his COPD. Therefore, aggressive antimicrobial therapy was started using oral moxifloxacin hydrochloride, a broad-spectrum antibiotic effective against common respiratory pathogens.

To address airway inflammation and bronchoconstriction:

• Ambroxol hydrochloride was prescribed to reduce mucus viscosity and promote expectoration.
• Doxofylline tablets were administered for their bronchodilating and anti-inflammatory effects.
• Short-term intravenous corticosteroid therapy with methylprednisolone sodium succinate was given for three days to rapidly improve airflow and reduce airway swelling.
• After stabilization, the patient transitioned to inhaled budesonide suspension via nebulizer for continued anti-inflammatory action.

His elevated blood pressure was managed with nifedipine controlled-release tablets. A cardiology consultation was requested to optimize cardiovascular care, and an echocardiogram was performed to assess for potential complications such as pulmonary hypertension or right-sided heart strain.

Ongoing Management Plan: Transitioning to Long-Term Control

As symptoms improved—fever resolved, sputum cleared, and dyspnea markedly reduced—the focus shifted toward preventing future exacerbations. Using standardized assessment tools like the mMRC Dyspnea Scale and CAT (COPD Assessment Test), clinicians tailored a discharge plan centered around maintenance therapy.

The patient was switched to a dual bronchodilator inhaler containing umeclidinium and vilanterol—a combination that does not include steroids, minimizing side effects while effectively opening airways. He received hands-on training on proper inhaler technique to ensure optimal drug delivery.

A structured follow-up schedule was established, recommending clinic visits every six months or sooner if symptoms recur. Patients like him benefit greatly from consistent monitoring and timely intervention.

Key Lifestyle and Preventive Recommendations

1. Commit to Consistent Medication Use

2. Protect Heart Health Alongside Lung Function

3. Strengthen Immunity and Improve Physical Resilience

• Get annual flu vaccines and recommended pneumococcal vaccinations
• Practice good hand hygiene
• Maintain indoor air quality with HEPA filters and proper ventilation
• Engage in regular, moderate physical activity such as brisk walking, tai chi, or cycling
• Incorporate pulmonary rehabilitation techniques like pursed-lip breathing and diaphragmatic breathing to enhance oxygen exchange and reduce breathlessness

4. Eliminate All Forms of Tobacco Exposure

Clinical Insights: When Is Home Oxygen Therapy Needed?

While this patient currently maintains adequate oxygen levels (PaO₂ = 65 mmHg), home oxygen therapy may become necessary if his condition deteriorates. According to clinical guidelines, long-term oxygen therapy (LTOT) is indicated when:

• Arterial PaO₂ ≤ 55 mmHg or SpO₂ ≤ 88%, or
• PaO₂ between 55–60 mmHg with evidence of end-organ damage such as pulmonary hypertension, congestive heart failure, or polycythemia

For now, the emphasis remains on pulmonary rehabilitation, adherence to inhaler therapy, and proactive prevention strategies to preserve remaining lung function and delay disease advancement.