Cases Flashcards
63 y/o Plumber acute care walk in visit for “chest infection”.
Granddaughter had URI 10 days ago and now he has productive cough with green sputum. Fatigue and ShOB made him come as it is interfering with work.
What do you want to know?
Exacerbation hx: 2-3 times a year for past decade
Rx: SABA helps with day to day six
Impact of COPD: reduced the tempo of work due to symptoms of breathlessness
Exacerbations last longer
Impacts his job, self employed
Failed attempts to stop smoking including with medication
Gets his flu shots yearly
Has HTN and on ADE-I
What is the definition of acute exacerbation?
“An acute event characterised by a worsening of the patient’s respiratory symptoms that is beyond normal day-to-day variation and leads to change in medications.”
Symptoms: increase dyspnea, increased sputum volume, increased sputum purulence
How would you manage his acute treatment for today?
He has an acute URI, probably viral. Most common cause of exacerbation.
Mgmt tools: Antibiotics, oral steroids, increase use of SABD, short term use of systemic corticosteroids (CS) can shorten recovery time,improve FEV1 and arterial hypoxemia, reduce risk of early relapse,treatment failure, and length of hospitalization.
What is the preferred SABD for acute mgmt?
SABA with or without SAAC
How would you manage his routine treatment?
Combined assessment of symptoms GOLD classification of airflow limitation Exacerbation rate mMRC dyspnea score or CAT He needs formal assessment at baseline
What is is mMRC score?
Walks slower than most on level surface or stops after 15 minutes to catch his breath
FEV1: 52%: GOLD classification of airflow: 2
Exacerbations per year: 2
Combined COPD Score: Category D
What therapy is recommended for Category D patients?
ICS + LABA and/or LAAC Assess inhaler technique (See GOLD app) Smoking cessation Pulmonary rehabilitation Physical activity Flu shot, pneumococcal vaccination (23 valent) Self-mgmt plan with written instructions
True or false: He should have a prescription for an emergency course of steroids and antibiotic for start of acute exacerbation.
True if he has good professional support and a written mgmt plan.
There is support for case management and regular direct access to a health care professional.
This can reduce hospitalizations and acute severe exacerbations.
Alert health care team may identify and avoid exacerbations.
74 yo man living alone in remote community. Telephone consultation
Very severe COPD with FEV1 of 24% 2 years ago.
Supportive family
Stopped smoking last year after hospital stay (50 miles from his home): stressful
4 exacerbations at home managed with steroids and antibiotics per self mgmt plan provided by his care team
Regular plan: LABA/ICS and LAAC
Multiple co-morbidities; including decline in memory, function but lives alone; does not want to leave his home of 55 years
Preventive immunizations
Oxygen therapy: needs O2Sat data: long term oxygen improves survival in setting of chronic hypoxia
Options: PDE4 inhibitors (rofumilast) or theophylline, long term macrolides or oral N-acetylcysteine are considerations
Review of co-morbidities
Pulmonary rehab within 1st 4 weeks (QOL, activity, walking distance): may need home based program
62 yo female with severe COPD hospitalized for exacerbation
FEV1 35% at outpatient visit
Retired due to dyspnea, stopped smoking 5 years ago
Meds: LABA/ics and LAAC; theophylline and carbocysteine: not convinced it helps
Courses of oral steroids at least 6 times a year help for dyspnea
Has an action plan and emergency med supply
No co-morbidities
What next?
Detailed medical evaluation
Actual disease mgmt: compliance, proper technique
“How do you take your medication?”
Lifestyle: smoking cessation, physical activity, exercise
Smoke free home?
? Optimum regimen
Reduce admissions/ED vs acute exacerbations
52 yo female heavy smoker. Possible asthma. Having to take “time off” due to flare.
H/o childhood asthma and allergic rhinitis as a teen. Spirometry: COPD flow loop but some reversibility with postBD of 60% FEV1 (20%) Interferes with job, URI triggers long recovery
3 episodes this winter. Sedentary job. Job jeopardy. Uses SABA mostly during flare. Stopped her ICS.
Diagnostic review: Serial peak flows over 2 weeks CXR to r/o cancer Asthma/COPD overlap ICA/LABA, not LABA alone due to asthma component Trial of LAAC if she refuses ICS Rescue meds for exacerbation?
