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

 Pharmacotherapy Case: Chronic Obstructive Pulmonary Disease (COPD)

Patient Name: James Carter
Age: 68 years
Gender: Male

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Subjective Data

• Chief Complaint: "I’ve had a nagging cough and trouble breathing for years, but it’s gotten worse over the last 6 months. I can’t even walk to the mailbox without gasping."

• History of Present Illness:

  • Progressive dyspnea on exertion (e.g., climbing stairs, walking short distances).

  • Chronic productive cough with thick, white sputum daily for >10 years.

  • Reports 2 exacerbations in the past year requiring oral steroids and antibiotics.

  • Uses albuterol inhaler 4–5×/day with minimal relief.

• Smoking History: 50-pack-year history (smoked 1 pack/day for 50 years), quit 2 years ago.

• Social History: Retired construction worker; lives with spouse in a single-story home.

• Medications: Albuterol MDI (PRN), occasional OTC cough syrup.

• Adherence: Uses albuterol frequently but inconsistently; no prior maintenance therapy.

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Objective Data

• Vital Signs:

  • BP: 136/88 mmHg | HR: 102 bpm | RR: 24 breaths/min | SpO2: 91% (RA).

• Physical Exam:

  • Lungs: Decreased breath sounds bilaterally, end-expiratory wheezing. Barrel chest noted.

  • Prolonged expiratory phase; no cyanosis or clubbing.

• Spirometry (Post-Bronchodilator):

  • FEV1/FVC: 0.58 (<0.7 confirms airflow obstruction).

  • FEV1: 48% predicted (GOLD Stage 2).

• ABG (Room Air): pH 7.38 | PaCO2 52 mmHg | PaO2 68 mmHg (indicative of chronic respiratory acidosis with mild hypoxemia).

• Chest X-Ray: Hyperinflation, flattened diaphragms, no acute infiltrates.

• CAT (COPD Assessment Test) Score: 22 (high symptom burden).

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Assessment

• Diagnosis: COPD, GOLD Group E (High Exacerbation Risk, GOLD Stage 2).

  • Supporting Evidence:

    • Chronic dyspnea, cough, sputum production.

    • FEV1/FVC <0.7, FEV1 48% predicted.

    • ≥2 exacerbations/year.

    • High CAT score.

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Pharmacotherapy Plan

1. Maintenance Therapy:

   • Tiotropium (LAMA) 18 mcg inhalation once daily.
     Rationale: Reduces exacerbations and improves lung function.

   • Indacaterol/Glycopyrronium (LABA/LAMA) 110/50 mcg inhalation once daily.
     Rationale: Dual bronchodilation for symptom relief and exacerbation prevention.

2. Rescue Therapy:

   • Albuterol MDI 90 mcg: 1–2 puffs every 4–6 hours PRN.

3. Exacerbation Prophylaxis:

   • Inhaled Fluticasone (ICS) 250 mcg twice daily.
     Rationale: Added due to history of exacerbations (GOLD Group E).

4. Non-Pharmacologic Interventions:

   • Smoking Cessation Support: Continued counseling.

   • Pulmonary Rehabilitation: Referral for exercise training and education.

   • Vaccinations: Pneumococcal and annual influenza vaccines administered.

   • Oxygen Therapy: Evaluate for long-term O2 if SpO2 ≤88% at rest.

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Follow-Up/Monitoring

• Reassessment in 4 Weeks:

  • Symptom control (CAT score), dyspnea severity, and rescue inhaler use.

  • Repeat spirometry in 6 months to monitor progression.

• Monitor for Adverse Effects:

  • ICS: Oral thrush (advise rinsing mouth post-inhalation).

  • LAMA/LABA: Dry mouth, tachycardia.

• Exacerbation Plan: Prescribe prednisone 40 mg × 5 days and azithromycin 500 mg × 3 days for future exacerbations.

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Education

• Emphasize adherence to maintenance inhalers, even when asymptomatic.

• Teach energy conservation techniques and pursed-lip breathing.

• Encourage prompt treatment of exacerbations (e.g., increased sputum volume or purulence).

• Review inhaler technique with valved holding chamber.

Outcome Goals:

• Reduce exacerbations to ≤1/year.

• Improve CAT score to <15.

• Maintain SpO2 ≥92% at rest.