COPDCaseStudy NumberThree (1)

7/24/2019 COPDCaseStudy NumberThree (1)

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Case Study Number Three

JS is a 74 year old man who presents to your family medicine office with his wife complaining of shortnessof breath and fever. They ust moved to the area and had been planning to come to your office ne!t wee" toestablish care as new patients.

#ue to the onset of symptoms$ JS called and was given a wal"%in slot today. &is wife did bring records

from his last physician's office.

Which of the following is not a risk factor for COPD?

(. Smo"ing history). *ccupational e!posureC. +mmuni,ation history#. &istory of severe lung infections as a child-. amily history of lung disease

/ast 0edical1Surgical &istory2 &eart failure following myocardial infarction at age 3 years

2 C*/# 5on 6 home o!ygen82 &ypertension2 (ppendectomy

amily &istory2 ather died of myocardial infarction at age 9: years 5diabetes$ hypertension$ smo"er82 0other alive 5atrial fibrillation$ heart failure82 &ealthy siblings

Social &istory2 0arried$ ; children2 ;< pac" year smo"ing history 5=uit after 0+82 >or"ed on a farm

2 No alcohol or illicit drug use 0edications 1 (llergies2 isinopril 6< mg twice daily2 0etoprolol 9< mg twice daily2 Spironolactone 69 mg daily2 urosemide 4< mg daily2 Salmeterol1fluticasone 9


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JS /ast ?ecord ?eview 5brought by wife82 -chocardiogram with - of 69@2 Spirometry with -AB ;9@ predicted that does not change significantly after inhaled bronchodilator

Are these findings consistent with diagnosis of COPD?

If yes, what Stage of COPD using the GOLD criteria?

?ecords ?eviewnable to determine when last pneumoccal vaccine was given

2 /atient and wife don't recall Da pneumonia shotE2 #oes "now he got his Dflu shotE last month at a grocery store

In a atient with COPD, assess!ent of sy!to!s should include the following?

(. Severity of breathlessness). Sputum productionC. >hee,ing

#. >eight loss1anore!ia-. (ll of the above

JS current symptoms include the followingF2 nable to spea" in full sentences for the past several hours per wife2 Cough productive but un"nown color of sputum2 (udible whee,ing since last night per wife2 0ild chest tightness2 #yspnea

&is wife has noted no change in his alertness or mental status >hen you in=uire$ the wife states that JS usually has a cough$ worse in the morning$ productive of gray

sputum$ gets short of breath if he wal"s more then B< feet$ and has episodes of whee,ing if he gets sic" 5e.g.with an upper respiratory infection8.

&e usually is able to help around the house with light wor" and fi!ing things.

/hysical e!amination2 Aital SignsF )/ B6174G / 3$ regG ?? ;6G &t 9ft 3 inG >t B66 lbsG T B


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So will you treat $S as an outatient or inatient?

+ndications for hospitali,ation2 ?is" of death from an e!acerbation increases withF

#evelopment of respiratory acidosis

/resence of significant comorbidities$ Need for ventilatory support

ou determine that JS needs to be hospitali,ed and while waiting for -0S transport to your local medical centeryou instruct your nurse to place him on o!ygen by nasal cannula. In addition to o%ygen, you want to ro&idewhich of the following agents &ia ne'uli(er?

(. (rformoterol). (lbuterolC. ormoterol#. )udesonide

pon arrival at the -?$ respiratory therapy as"s to change albuterol to levalbuterol. Which of the followingare reasons to choose le&al'uterol o&er al'uterol?(. +mproved bronchodilation). ess hypo"alemiaC. ess tachycardia#. None of the above

Corticosteroids should 'e deli&ered 'y what route in !ild to !oderate e%acer'ations of COPD?

(. +nhaled via dry powdered inhaler). Nebuli,edC. *ral#. +ntravenous

Which of the following are indications for anti'iotics in atients with acute e%acer'ations of COPD?

(. #yspnea). +ncreased volume of sputumC. Change in sputum purulence#. (ll of the above

&istory of -!acerbations2 pon =uestioning his wife$ you find out that he has had 9 e!acerbations in the past year$ three of

which were treated with antibiotics and oral steroids (mo!icillin !6 courses$ do!ycycline !B course 0ost recent course 3 wee"s ago No hospitali,ations within the last 3 months

2 )ased on this information$ and his chest !%ray findings$ you initiate treatment for communityac=uired pneumonia.


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Which anti'iotic regi!en is !ost aroriate for this hositali(ation?

(. Sulfametho!a,ole1trimethoprim every B6 hours). (mo!icillin1clavulanate every B6 hoursC. Ceftria!one plus a,ithromycin every 64 hours#. /iperacillin1ta,obactam every hours$ levoflo!acin every 64 hours and vancomycin every B6

hours

&ospital Course2 #uring hospitali,ation$ he receives the following treatmentF

Nebuli,ed albuterol1ipratropium every 4 hours as needed /rednisone 3< mg daily by mouth B gm +A ceftria!one plus 9


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Which of the following rinciles of !edication !anage!ent should 'e considered when e&aluating his

discharge !edications?

(. Cost of medications). Therapeutic duplicationC. Compliance with comple! regimen

#. (ll of the above

#ischarge 0edications Streamline regimen

2 No need for levalbuterol2 Continue salmeterol1fluticasone 9


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Answers)*otes

Which of the following is not a risk factor for COPD?

(nswerF C

+mmuni,ation history is not one of the ris" factors for whether or not a person develops C*/# although it canbe an important factor in wellness and prevention

Smo"ing &istory is the most significant ris" factor for C*/# is long%term cigarette smo"ing. Symptoms ofC*/# usually appear about B< years after initiation of smo"ing.

/ipe smo"ers$ cigar smo"ers and people e!posed to large amounts of secondhand smo"e also are at ris". -nvironmental pollution such as smog$ dust$ wood smo"e$ particulates in occupational dust and others

can cause damage to lung tissue similar to smo"ing.*ccupational e!posure with e!posure to several occupational irritants$ usually in the form of dusts$ be ris"factors for C*/#.

ung infections as a childamily history mainly is a result of alpha%B%antitrypsin deficiency

0ostly Northern -uropean heritage ?are cause 56@ of C*/# population8

Cosio$ 6


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In a atient with COPD, assess!ent of sy!to!s should include the following?

(nswerF -

(ssessment of symptomsF

Severity of breathlessness$ cough$ sputum production$ whee,ing$ chest tightness$ weight loss1anore!ia Change in alertness or mental status$ fatigue$ confusion$ an!iety$ di,,iness$ pallor or cyanosis C*/# should be considered in any patient with a chronic cough$ dyspnea or sputum production

/art of diagnosing C*/# is to distinguish it from other causes. The patient's history$ in this case symptoms$ wilhelp in considering if C*/# is the etiology.

/ulmonary symptoms are the hallmar" of the disease but systemic symptoms will often occur due to hypo!ia.

Which of the following is the least likely cause of atient"s sy!to!s?

(nswer )

or a patient with chronic pulmonary symptoms$ a differential includes the followingF/ulmonaryF

(sthma )ronchogenic carcinoma )rochiectasis Tuberculosis +nterstitial lung disease /leural effusion /ulmonary edema ?ecurrent aspiration /ulmonary embolus /neumonia

Non%pulmonary &eart ailure

)ut based on this patient's history and physical e!amination$ the most li"ely differential diagnoses includeC*/# e!acerbation$ pneumonia$ heart failure. No symptoms or history are present that would put recurrentaspiration above the listed conditions. Severe persistent asthma can have many overlapping clinical features andfindings similar to C*/# and should be considered in any patient with a chronic obstructive lung condition thathas acutely worsened.


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#he additional studies you are considering include which of the following?

(nswer (

/ulse o!imetry is a simple office procedure and would help to determine inpatient versus outpatient treatment aslevels L@ suggest the need for supplemental *6. (rterial blood gas can also be used to obtain an accurateo!ygenation status and to get pC*6levels which a pulse o! does not provide but they are not routinely availablein the office setting. 5Strength of ?ecommendationF C8

Spirometry is a re=uirement to ma"e the diagnosis of C*/# but not practical or necessary for acute episodes.(lpha%B antitrypsin levels are not indicated in the acute management of C*/# and would be used only in theinitial wor"up 5Strength of ?ecommendationF C8.

So will you treat $S as an outatient or inatient?

actors that increase ris" of severe C*/# e!acerbations (ltered mental status (t least three e!acerbations in the previous B6 months )ody mass inde! of 6< "g per m6 or less 0ar"ed increase in symptoms or change in vital signs 0edical comorbidities 5especially cardiac ischemia$ heart failure$ pneumonia$ diabetes mellitus$ or renal

or hepatic failure8 /oor physical activity levels /oor social support Severe baseline C*/# 5-AB1AC ratio less than


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In addition to o%ygen, you want to ro&ide which of the following agents &ia ne'uli(er?

(nswerF )

(lbuterol is the mainstay of treatment for acute e!acerbations of C*/#. +t can be used alone or in combination

with ipratropium. (rformoterol and formoterol are both nebuli,ed bronchodilators$ but are long%acting beta%agonists and should only be used for chronic maintenance therapy for C*/#. Similarly$ budesonide is availablefor nebuli,ation but has no role in the acute management of C*/#.

Which of the following are reasons to choose le&al'uterol o&er al'uterol?

(nswerF #

There are no "nown advantages to using levalbuterol over albuterol. +t is not more effective 5i.e. it does notimprove bronchodilation$ -AB$ etc.8 and does not lead to statistically different tachycardia or change inpotassium. evalbuterol is also significantly more e!pensive than albuterol.

Corticosteroids should 'e deli&ered 'y what route in !ild to !oderate e%acer'ations of COPD?

(nswerF C

Systemic corticosteroids have been shown to increase time to subse=uent e!acerbation$ decrease rate oftreatment failure$ shorten length of hospitali,ation$ and improve hypo!emia when used in acute e!acerbations ofC*/#. &owever$ there is no role for inhaled steroids either via dry powdered inhaler or nebuli,ed route. *ralsteroids are as effective as intravenous steroids in patients with functional intestinal tracts who are not vomitingand able to ta"e medications by mouth.

&igh dose regimens 5B69 mg methylprednisolone every 3 hours8 has not been shown to be more effective thanlow%dose regimens 5i.e.$ 4< 2 3< mg prednisone daily8 but does lead to more side effects$ particularlyhyperglycemia.

Which of the following are indications for anti'iotics in atients with acute e%acer'ations of COPD?

(nswerF #

/atients should be as"ed about change in symptoms$ change in sputum color or volume. +f these are present$antibiotics have been shown to be beneficial in the treatment of acute C*/# e!acerbations.


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Which anti'iotic regi!en is !ost aroriate for this hositali(ation?

(nswerF C

The patient has community ac=uired pneumonia$ not hospital ac=uired pneumonia 5ie. no hospitali,ations in the

past 3 months8. &e has had multiple e!acerbations of C*/# and antibiotic use within the past ; months.Therefore$ treatment should follow guidelines for community ac=uired pneumonia and would includeceftria!one plus a,ithromycin every 64 hours. (,ithromycin can be given orally 2 its high bioavailabilitydeems +A therapy unnecessary in patients who are not vomiting and able to ta"e oral therapy. (nother optionwould be levoflo!acin$ orally in patients able to ta"e by mouth 5high oral bioavailability also8. *ptions ( and )are not appropriate for community ac=uired pneumonia. *ption ( should not be used for acute e!acerbations ofC*/# in this patient due to his recent antibiotic e!posure. *ption # is the treatment regimen for health%careassociated pneumonia.

Which corticosteroid regi!en would 'e reco!!ended in this situation?

(nswerF )

The 9 day regimen for a steroid burst is appropriate for patients with asthma$ but not C*/#. 0ost patients needB4 days of treatment. or the patients with fre=uent steroid use or a history of relapse upon abruptdiscontinuation of steroids$ a taper is necessary.

Which of the following rinciles of !edication !anage!ent should 'e considered when e&aluating his

discharge !edications?

(nswerF #

The cost of the medication regimen on admission approaches B


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Oaseem ($ Snow A$ She"elle /$ et al. #iagnosis and management of stable chronic obstructive pulmonarydiseaseF a clinical practice guideline from the (merican College of /hysicians. (nn +ntern 0ed 6

COPDCaseStudy NumberThree (1)

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