RESPIRATORY CASE: COPD

PATIENT: a 68 y/old 68-year-old man with progressive SOB and chest pain on exertion

COMORBIDITIES: History of hypertension, coronary artery disease (CAD) - PCI 2008, COPD, benign prostatic
hyperplasia, hypothyroidism

History of presenting illness: Patient experiencing progressive SOB for the past 2 months. Today patient was
mowing lawn and experienced dyspnea, and wheezing with little relief from salbutamol. No change in cough
or sputum.

Chest pain on exertion (6/10), no radiation or syncope/dizziness experienced. 1 dose of nitroglycerin used
without effect. Chest pain now 2/10

No fever, or other infectious symptoms.

ECG normal.

Medical Conditions: hypertension x 15 years, NSTEMI 7 years ago - PCI w/ drug eluting stent x2,
hypothyroidism x 7 years, BPH x 2 years, COPD x 5 years

SOCIAL HISTORY: Retired, lives at home with wife. Quit smoking 6 months ago

BP 145/82 HR 101 RR 28

P02 91% on 2L nasal prongs (NP)

Plan: admit to medicine

maintain O2 saturation 88-92%

ECG, trops x3

CXR - r/o pneumonia

CT PE protocol - r/o pulmonary embolism

PROGRESS Notes:

ECG normal, troponins negative, CT PE negative; CXR shows osteopenia but no signs of consolidation or
pneumonia

DIAGNOSIS: progression of COPD

FEV1 79% predicted (1 year ago), awaiting PFTs in hospital

PULMONARY FUNCTION TESTS

FEV1/FVC = 0.60 (60%) - An FEV1/FVC of <70% is commonly used to denote airflow obstruction (Moore,
2012).

FEV1 (pre-bronchodilator) = 1.65L (55% of predicted)

FEV1 (post-bronchodilator) = 1.75L (<200 mL improvement)

MEDICATION ORDERS

acetylsalicylic acid 81 mg po daily – Anticoagulant

ramipril 10 mg po daily – ACE
tamsulosin SR 0.4 mg po daily - BPH
atorvastatin 80 mg po qHS – Cholesterol
bisoprolol 7.5 mg po daily – beta blockers
levothyroxine 0.025 mg po daily - hypothyroidism
Spiriva (tiotropium) 18 mcg inhaled daily - LAMA (Anticholinergics)
salbutamol 4 puffs inhaled q1h PRN - SABA
ipratropium 4 puffs inhaled q1h PRN
nitroglycerin 0.4 mcg SL q5min PRN MAX 3 doses
enoxaparin 40 mg SC daily – No medically valid indication
PRESCRIBED MEDICATIONS:

Levothyroxine 0.025 mg in the morning for 7 years – hypothyroidism

ramipril 10 mg in the evening for 10 years - ACE

bisoprolol 7.5 mg in the morning for 7 years – Beta Blockers

atorvastatin 80 mg before bed for 7 years – anti-Cholesterol

tamsulosin SR 0.4 mg before bed for 2 years - BPH

Spiriva 1 capsule inhaled in the morning for 4 years - long-acting bronchodilator (LABA)

salbutamol 2 puffs inhaled every 4 hours as needed - short-acting β₂ adrenergic (SABA)

nitroglycerin pump spray as needed – vasodilator

Please answer the following:

1. Identify the Drug Therapy Problems (DTPs)

2. Identify the proper management.

SOLUTION:

IDENTIFIED DTPs

1. acetylsalicylic acid 81 mg po daily – Anticoagulant - NO medically valid indication, CT PE is negative

2. ramipril 10 mg po daily – ACE - Excessive Dose, for the patient known to be hypertensive for 15 years but
now having a controlled BP – PO – 2.5 – 5 mg OD is recommended (Medicine Blue Book, 5th ED)

-Ineffective Drug, ACE inhibitors should probably not be used as first-line

antihypertensive therapy in patients with COPD. When it is desirable to block
the renin–angiotensin system, administration of an angiotensin II antagonist
may be a better alternative because ACE inhibitor treatment may cause
harm. ( https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3724277/)

3. atorvastatin 80 mg po qHS – for hyperlipidemia - No medically valid indication, No Laboratory results

showing increase/high cholesterol, No Triglycerides or lipid profile – Incomplete lab results

4. ipratropium 4 puffs inhaled q1h PRN - Excessive Dose, - Recommended Dose for Inhaler: 2 actuations (34
mcg) q6hr, then additional actuations PRN; (no more frequent than every 4 hours) not to exceed 12
actuations/day (408 mcg/day). https://www.pdr.net/drug-summary/Ipratropium-Bromide-ipratropium-
bromide-3270

5. Spiriva (tiotropium) 18 mcg inhaled daily - LAMA (Anticholinergics)

ipratropium 4 puffs inhaled q1h PRN - Short-Acting Muscarinic Antagonists (SAMA)

- Contra-indicated drug/ Use caution/Monitor. Using ipratropium together with tiotropium may
increase side effects such as drowsiness, blurred vision, dry mouth, heat intolerance, flushing,
decreased sweating, difficulty urinating, abdominal cramping, constipation, rapid heartbeat,
confusion, memory problems, and glaucoma. (Cochrane Database of Systematic Reviews 2015, Issue
9. Art. No.: CD009552. DOI: 10.1002/14651858.CD009552.pub3)

MANAGEMENT: COPD with comorbidities

Note: GOLD’s (2018) ABCD assessment tool

When the patient was diagnosed, his predicted FEV1 of 55% categorized him as GOLD grade 2-
MODERATE, but there was no mention about his (mMRC) scale and CAT. The mMRC scale only
measures breathlessness, but the CAT can also assess the impact COPD has on his life, meaning
consecutive CAT scores can be compared, providing valuable information for follow-up and
management (Zhao, et al, 2014).

After assessing the level of disease burden, Patient X, SOB - 68y/o should then be provided with
education for self-management and lifestyle interventions.
 Lifestyle interventions
Smoking cessation – although the patient quit smoking 6 months ago, it should be emphasized to
him that he should no longer go back to smoking and educate him regarding the benefits of smoking
cessation such as -
• Slowing the progression of COPD;
• Improving lung function;
• Improving survival rates;
• Reducing the risk of lung cancer;
• Reducing the risk of coronary heart disease risk (Qureshi et al, 2014).

Pharmacological interventions
Chest pain is common in people living with COPD. Changes in lung structure and function can
contribute to pain. Muscles in the chest can also be strained and cause pain. Medications to treat
COPD are an important part of preventing and managing pain.
✓ For the chest pain on exertion, the prescribed doses of nitroglycerin 0.4 mcg SL q5min PRN MAX 3
doses are to be carried.
✓ Levothyroxine 0.025 mg in the morning for 7 years – for hypothyroidism
The treatment goals for hypothyroidism are to reverse clinical progression and correct metabolic
derangements, as evidenced by normal blood levels of thyroid-stimulating hormone (TSH) and free
thyroxine (T4).
The patient’s recent TSH - 1.2 mU/L is within normal, although it is on the lower range. No data for
T4 was seen in the lab report.
- The use of lower dosage is justifiable for elderly patients and those with cardiac disease. The
treatment is for life. (Medicine Blue Book, 5th ED)
✓ For hypertension, Systemic hypertension and chronic obstructive pulmonary disease (COPD)
frequently coexist in the same patient, especially in the elderly. Change Ramipril 10mg to
Amlodipine given as a single daily oral dose of 10mg is a safe and effective pulmonary
vasodilator in COPD patients. (https://pubmed.ncbi.nlm.nih.gov/12395224/)
✓ For BPH, tamsulosin SR 0.4 mg po daily can be continued as it has no contraindication with other
medicines taken by the patient. Take this medication regularly to get the most benefit from it. To
help you remember, take it at the same time each day.
✓ For COPD, the patient was diagnosed with progression of COPD and has been prescribed inhaled
salbutamol as required; this is a SABA that mediates the increase of cyclic adenosine
monophosphate in airway smooth-muscle cells, leading to muscle relaxation and bronchodilation.
SABAs facilitate lung emptying by dilatating the small airways, reversing dynamic hyperinflation of
the lungs (Thomas et al, 2013). He also uses a long-acting muscarinic antagonist, Spiriva
(tiotropium) (LAMA) inhaler, which works by blocking the bronchoconstrictor effects of
acetylcholine on M3 muscarinic receptors in airway smooth muscle; release of acetylcholine by
the parasympathetic nerves in the airways results in increased airway tone with reduced diameter.
But in spite of that, there is still exacerbation of COPD, I would advise to change the medications
currently prescribed to the following:

o For continuous symptoms: maintain on inhaled B2 agonist and anticholinergics-

Ipratropium Br & Salbutamol (Combivent MDI) 1- 2 puffs TID. If response is unsatisfactory
add oral theophylline (Bronchodilator and pulmonary vasodilator) or long acting B2-
agonist/ICS (such as Salmeterol/Fluticasone MDI).
o Consider mucokinetic agent
o Pulmonary rehabilitation
(Medicine Blue Book, 5th ED)

Vaccinations
Encourage the patient, Mr. X to keep up to date with his seasonal influenza and pneumococcus
vaccinations. This is in line with the low-cost, highest-benefit strategy identified by the British Thoracic
Society and Primary Care Respiratory Society UK’s (2012) study, which was conducted to inform
interventions for patients with COPD and their relative quality-adjusted life years. Influenza
vaccinations have been shown to decrease the risk of lower respiratory tract infections and concurrent
COPD exacerbations (Walters et al, 2017; Department of Health, 2011; Poole et al, 2006).
Self-management
Mr. X will be given a self-management plan that include:
• Information on how to monitor his symptoms;
• A rescue pack of antibiotics, steroids and salbutamol;

Self-management plans and rescue packs have been shown to reduce symptoms of an exacerbation
(Baxter et al, 2016), allowing patients to be cared for in the community rather than in a hospital setting
and increasing patient satisfaction (Fletcher and Dahl, 2013).
Improving Mr X’s adherence to a TID- daily inhalers and supporting him to self-manage and make the
necessary lifestyle changes, will improve his symptoms and result in fewer exacerbations.