Pharmacotherapy Case: Chronic Obstructive Pulmonary Disease (COPD) by Dr. Nehad Ahmed

 

Pharmacotherapy Case: Chronic Obstructive Pulmonary Disease (COPD)

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Patient Information:

• Age: 64
• Gender: Male
• Date of Visit: February 5, 2025

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Chief Complaint:

"I’ve been coughing a lot more lately, and I feel out of breath when I try to walk up a flight of stairs. I’m also wheezing more at night."

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Subjective Data:

• History of Present Illness: A 64-year-old male with a history of chronic obstructive pulmonary disease (COPD), diagnosed 5 years ago, presents with a noticeable increase in symptoms over the past 6 months. The patient reports a progressive cough that has become more productive with thick, yellow sputum. He has also experienced worsening shortness of breath (dyspnea), especially with exertion, and is unable to walk more than one flight of stairs without needing to rest. He also notes increased wheezing at night, which sometimes interferes with his sleep. The patient denies recent upper respiratory infections but has a long history of morning cough and dyspnea upon exertion. He has a history of smoking but quit 2 years ago after smoking for 40 years (1 pack/day).
• Past Medical History:
• Chronic obstructive pulmonary disease (COPD), diagnosed 5 years ago
• Hypertension, diagnosed 10 years ago, well-controlled with medication
• Hyperlipidemia, diagnosed 5 years ago
• Gastroesophageal reflux disease (GERD), diagnosed 3 years ago
• Medications:
• Albuterol inhaler (90 mcg/puff) for rescue use, 1-2 puffs as needed, 3-4 times per week
• Fluticasone/Salmeterol inhaler (Advair) 250/50 mcg, 1 puff twice daily
• Lisinopril 10 mg daily for hypertension
• Atorvastatin 20 mg daily for hyperlipidemia
• Omeprazole 20 mg daily for GERD
• Allergies:
• No known drug allergies
• Family History:
• Father had COPD and passed away at age 70 due to complications of the disease
• Mother had hypertension and type 2 diabetes
• Social History:
• Quit smoking 2 years ago after 40 years of smoking (1 pack/day)
• No alcohol use
• Works as a truck driver, which involves long hours of sitting
• Lives alone, mostly sedentary lifestyle at home, with limited physical activity
• No pets, no recent travel
• Review of Systems:
• Respiratory: Productive cough, wheezing, shortness of breath on exertion, increased morning sputum production
• Cardiovascular: No chest pain, no palpitations, occasional leg swelling at the end of the day
• Gastrointestinal: No nausea, vomiting, or abdominal pain, occasional heartburn
• Neurological: No dizziness, lightheadedness, or headaches

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Objective Data:

• Vital Signs:
• Temperature: 98.7°F (37°C)
• Blood Pressure: 130/80 mmHg (well-controlled hypertension)
• Heart Rate: 88 bpm (regular)
• Respiratory Rate: 20 breaths per minute (normal)
• Oxygen Saturation: 93% on room air
• Physical Examination:
• General Appearance: Patient appears in mild respiratory distress with increased work of breathing.
• HEENT: No nasal congestion, no throat redness, no sinus tenderness
• Chest and Lungs:
• Inspection: Mild use of accessory muscles during breathing
• Palpation: No tenderness
• Percussion: Hyperresonance on both sides (suggestive of air trapping)
• Auscultation: Wheezing noted on expiration, particularly in the lower lung fields. Prolonged expiratory phase. Decreased breath sounds at the bases.
• Cardiovascular: Regular rhythm with no murmurs, no peripheral edema
• Abdomen: Soft, non-tender, no signs of distension or abnormal bowel sounds
• Extremities: No cyanosis, good peripheral pulses
• Peak Flow Measurement:
• Forced Expiratory Volume (FEV1): 45% of the predicted value, indicating moderate obstruction
• FEV1/FVC ratio: 60% (consistent with COPD)
• Pulmonary Function Tests:
• FEV1: 45% of predicted value
• FVC: 70% of predicted value
• Post-bronchodilator FEV1 improvement of 12%, consistent with reversible airflow limitation
• Chest X-ray:
• Hyperinflation of the lungs, flattened diaphragm consistent with COPD. No acute infiltrates or consolidation.
• Arterial Blood Gas (ABG):
• pH: 7.42
• pCO2: 48 mmHg (mildly elevated)
• pO2: 75 mmHg (lower than normal)
• HCO3: 28 mEq/L (compensated)
• O2 saturation: 93% on room air

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Assessment:

The patient has moderate COPD with worsening symptoms over the past several months, including increased cough, sputum production, shortness of breath on exertion, and wheezing. The patient is showing signs of airway obstruction with reduced FEV1, hyperinflation on chest x-ray, and mild hypoxemia (pO2 = 75 mmHg). While the patient has some improvement with bronchodilator use, the symptoms and decline in lung function suggest that better control and management are needed.

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Plan:

1. Optimize Pharmacotherapy:
• Continue current inhaler regimen of Fluticasone/Salmeterol (Advair) 250/50 mcg twice daily for maintenance therapy.
• Add a Long-Acting Muscarinic Antagonist (LAMA):
• Tiotropium (Spiriva) 18 mcg, 1 inhalation daily to further improve bronchodilation and reduce exacerbations.
• Rescue Medication:
• Continue Albuterol inhaler for acute symptoms but educate the patient on proper inhaler technique and not to exceed 2 doses in 4 hours.
• Consider adding oral steroids during exacerbations as needed, depending on the severity.
2. Smoking Cessation:
• Reinforce the importance of smoking cessation to prevent further deterioration of lung function. Offer resources for a smoking cessation program or counseling.
3. Pulmonary Rehabilitation:
• Refer to pulmonary rehabilitation to improve exercise tolerance and teach better breathing techniques, especially considering the patient's sedentary lifestyle.
4. Oxygen Therapy (if needed):
• Consider home oxygen therapy if oxygen saturation consistently falls below 88% during physical activity or sleep.
5. Vaccinations:
• Flu vaccination and pneumococcal vaccination if not done recently to reduce the risk of respiratory infections.
6. Monitoring and Follow-up:
• Reassess in 3 months to evaluate symptom control, medication adherence, and the need for further adjustments. Repeat pulmonary function tests and peak flow monitoring to track disease progression.
• Schedule a follow-up with a pulmonologist for a comprehensive review and additional management options.
7. Lifestyle Modifications:
• Encourage the patient to avoid environmental triggers, such as dust or cold air, and maintain good hydration to help with mucus clearance.
• Promote a gradual increase in physical activity to improve exercise tolerance and reduce breathlessness.

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Discharge Instructions:

• Continue the prescribed medications and follow the instructions for inhaler use.
• Seek medical attention if symptoms worsen or if breathing becomes more labored.
• Practice techniques to prevent exacerbations and track symptoms using a daily symptom diary.

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Assessment Summary:

• Diagnosis: Moderate Chronic Obstructive Pulmonary Disease (COPD) with increasing symptoms of cough, sputum production, and dyspnea.