2022 BPharm: Respiratory System BPH2236: Workshop 2: Case-Based Learning

Case 1: Make sense of these investigation results

 A 55-year old man with a 35 pack-year smoking history presents to hospital with a 3-day history of increasing breathlessness, cough productive of
mucopurulent sputum & general malaise. Investigation results at the time of admission are –
 BP 145/90mmHg || Heart rate (apex) 105 bpm || Breaths per minute 30 || Temp. 37.7oC
 Anterior-posterior CXR: Hyperinflation in both lung fields.
 White cell count 13 x109/L (4 – 11) || Neutrophils 8 x109/L || Eosinophils not raised
 RBCs 6.5 x109/L (4.7 – 6.1) || Haematocrit 60% (45-54) || MCV 85 (80-95 fL)
 SpO2 on air 89% || PaO2 72mmHg || PaCO2 50mmHg || pH 7.34 || [HCO3-] 19mmol/L
 BMI 19kg /m2
 On examination: Bilaterally reduced air entry || Right basal crepitations
 Sputum culture (results received 24h after admission): Mixed growth + Haemophilus influenzae R ampicillin || Blood culture: No growth
The diagnosis is an acute exacerbation of COPD, & right sided pneumonia. Is the diagnosis consistent with the results? Explain.

Case 2: Make sense of these investigation results

Following referral to the chest clinic, a 55-year old man is diagnosed with chronic bronchitis / COPD, based on these findings–
 A 30 pack-year cigarette smoking history. || Chronic cough productive of white sputum.
 Examination: Peripheral cyanosis, breathless; enlarged accessory muscles of breathing; mild bilateral ankle oedema || Speaks in short
sentences. || SpO2 on air 89% || BMI 25 kg/m2
 Chest radiograph shows bronchial wall thickening & cardiac enlargement.
 FVC 60% of predicted. || FEV1/ FVC ~ 0.65
 PEFR 60% of predicted for age, height and gender. || PEFR increased by ~100ml, 30 minutes after salbutamol nebuliser driven by oxygen.
 SpO2 at rest, on air 92% || PaO2 79 (75 – 100mmHg) || PaCO2 38 (35 – 45mmHg) || pH 7.40 (7.35 – 7.45) || [HCO3-] 25 mmol/L (23 – 28
mmol /L)
 Haematocrit 60 (45-54%) || MCV 95 (80-95 fL). In fluid balance.
Interpret these results: Is the diagnosis consistent with the results? Explain.

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 2022 BPharm: Respiratory System BPH2236: Workshop 2: Case-Based Learning

Case 3: Plan a medication review

 A 60-year-old woman was admitted to your ward late last night with breathlessness, bilateral wheeze, unable to speak in full sentences. and signs of
hypoxia. She is a known asthmatic, and her current asthma medication consists of beclomethasone metered dose inhaler (MDI) 50 micrograms (1
puff) twice daily, and MDI Berodual N, two puffs when needed. She was given oxygen, nebulised salbutamol, and a 30mg statim oral dose of
prednisolone (she is able to swallow). Today she is better and able to engage in conversation.
 What are ‘signs of hypoxia’?
 Construct a plan to review her ‘at home’ medication, providing a rationale for all proposed actions. Refer to GINA 2021
……………………………………………………………………………………………………………..
Answer framework
Elicit (take / gather) a full medication, symptom and allergy history.
Evaluate appropriateness (e.g. compare against guidelines) of regular asthma medication according to asthma severity
Evaluate actual use of medication, including adherence & inhaler technique

Case 4: Explain the role of inhaled corticosteroids in the management of asthma

Amanda, a 41-year old accountant was diagnosed with asthma when she was 35 years old. Currently she is prescribed inhaled corticosteroid
(equivalent to 800mcg beclometasone) daily and a reliever inhaler. She presented to Accident & Emergency last week when her asthma worsened.
Today she is at your pharmacy seeking information about her asthma treatment. Amanda mentions that she has been using her reliever inhaler more
frequently (3 to 5 times per week) for about a month.

 What is the role of inhaled corticosteroids in the management of asthma? Refer to GINA 2022
 What information, advice or counselling should you provide regarding increasing use of reliever medication, and why?

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