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Clinical Practice Keywords COPD/Spirometry/Lifestyle

interventions/Self-management
Case study
Respiratory This article has been
double-blind peer reviewed

In this article...
● A
 case study of a patient with chronic obstructive pulmonary disease
● Pathophysiology and diagnosis, including spirometry
● How the condition is managed through interventions and self-management

Diagnosis and management of

COPD: a case study
Key points
Authors Debbie Price is lead practice nurse, Llandrindod Wells Medical Practice; Nikki
Chronic obstructive Williams is associate professor of respiratory and sleep physiology, Swansea University.
pulmonary disease
is a progressive Abstract This article uses a case study to discuss the symptoms, causes and
respiratory management of chronic obstructive pulmonary disease, describing the patient’s
condition, projected associated pathophysiology. Diagnosis involves spirometry testing to measure the
to become the third volume of air that can be exhaled; it is often performed after administering a short-
leading cause of acting beta-agonist. Management of chronic obstructive pulmonary disease involves
death globally lifestyle interventions – vaccinations, smoking cessation and pulmonary rehabilitation
– pharmacological interventions and self-management.
Diagnosis involves
taking a patient Citation Price D, Williams N (2020) Diagnosis and management of COPD: a case
history and study. Nursing Times [online]; 116: 6, 36-38.
performing

T
spirometry testing
he term chronic obstructive pul-
Spirometry monary disease (COPD) is used to
identifies airflow describe a number of conditions,
obstruction by including chronic bronchitis and
measuring the emphysema. Although common, prevent-
volume of air that able and treatable, COPD was projected to
can be exhaled become the third leading cause of death
globally by 2020 (Lozano et al, 2012). In the
Chronic obstructive UK in 2012, approximately 30,000 people
pulmonary disease died of COPD – 5.3% of the total number of
is managed with deaths (Bit.ly/BLFCOPDdeaths2012). By 2016,
lifestyle and information published by the World Health
pharmacological Organization (Bit.ly/WHOtop10deathcauses)
interventions, as well indicated that Lozano et al (2012)’s projec-
as self-management tion had already come true.
People with COPD experience persis-
tent respiratory symptoms and airflow
limitation that can be due to airway or
alveolar abnormalities, caused by signifi-
cant exposure to noxious particles or
gases, commonly from tobacco smoking.
The projected level of disease burden poses
a major public-health challenge and pri-
mary care nurses can be pivotal in the early
identification, assessment and manage-
ment of COPD (Hooper et al, 2012).
Grace Parker (the patient’s name has
ALAMY
clinic for routine reviews. A widowed,
60-year-old, retired post office clerk, her
main complaint is breathlessness after
moderate exertion. She scored 3 on the
modified Medical Research Council
(mMRC) scale (Fletcher et al, 1959), indi-
cating she is unable to walk more than
100 yards without stopping due to breath-
lessness. Ms Parker also has a cough that
produces yellow sputum (particularly in
the mornings) and an intermittent wheeze.
Her symptoms have worsened over the last
six months. She feels anxious leaving
the house alone because of her breathless-
ness and reduced exercise tolerance, and
scored 26 on the COPD Assessment Test
(CAT, catestonline.org), indicating a high
level of impact.
Ms Parker smokes 10 cigarettes a day
and has a pack-year score of 29. She has not
experienced any haemoptysis (coughing
up blood) or chest pain, and her weight is
stable; a body mass index of 40kg/m2
means she is classified as obese. She has
had three exacerbations of COPD in the
previous 12 months, each managed in the
community with antibiotics, steroids and

been changed) attends a nurse-led COPD salbutamol.

Nursing Times [online] June 2020 / Vol 116 Issue 6 36 www.nursingtimes.net


Clinical Practice
Case study
Diagnosis
Ms Parker was diagnosed with COPD five
years ago. Using Epstein et al’s (2008)
guidelines, a nurse took a history from her,
which provided 80% of the information
needed for a COPD diagnosis; it was then
confirmed following spirometry testing as
per National Institute for Health and Care
Excellence (2018) guidance.
The nurse used the Calgary-Cambridge
consultation model, as it combines the
pathological description of COPD with the
patient’s subjective experience of the ill-
ness (Silverman et al, 2013). Effective com-
munication skills are essential in building
a trusting therapeutic relationship, as the
quality of the relationship between
Ms Parker and the nurse will have a direct
impact on the effectiveness of clinical out-
comes (Fawcett and Rhynas, 2012).
In a national clinical audit report,
Baxter et al (2016) identified inaccurate his-
tory taking and inadequately performed
spirometry as important factors in the
inaccurate diagnosis of COPD on general
practice COPD registers; only 52.1% of
patients included in the report had
received quality-assured spirometry.
Pathophysiology of COPD
Knowing the pathophysiology of COPD
allowed the nurse to recognise and under-
stand the physical symptoms and provide
effective care (Mitchell, 2015). Continued
exposure to tobacco smoke is the likely
cause of the damage to Ms Parker’s small
airways, causing her cough and increased
sputum production. She could also have
chronic inflammation, resulting in airway
smooth-muscle contraction, sluggish cil-
iary movement, hypertrophy and hyper-
plasia of mucus-secreting goblet cells, as
well as release of inflammatory mediators
(Mitchell, 2015).
Ms Parker may also have emphysema,
which leads to damaged parenchyma
(alveoli and structures involved in gas
exchange) and loss of alveolar attachments
(elastic connective fibres). This causes
gas trapping, dynamic hyperinflation,
decreased expiratory flow rates and airway
collapse, particularly during expiration
(Kaufman, 2013). Ms Parker also displayed
pursed-lip breathing; this is a technique
used to lengthen the expiratory time and
improve gaseous exchange, and is a sign of
dynamic hyperinflation (Douglas et al, 2013).
In a healthy lung, the destruction and
repair of alveolar tissue depends on pro-
teases and antiproteases, mainly released
by neutrophils and macrophages. Inhaling
cigarette smoke disrupts the usually
Nursing Times [online] June 2020 / Vol 116 Issue 6
delicately balanced activity of these
enzymes, resulting in the parenchymal
damage and small airways (with a lumen
of <2mm in diameter) airways disease that
is characteristic of emphysema. The
severity of parenchymal damage or small
airways disease varies, with no pattern
related to disease progression (Global Ini-
tiative for Chronic Obstructive Lung Dis-
ease, 2018).
Ms Parker also had a wheeze, heard
through a stethoscope as a continuous
whistling sound, which arises from turbu-
lent airflow through constricted airway
smooth muscle, a process noted by
Mitchell (2015). The wheeze, her 29 pack-
year score, exertional breathlessness,
cough, sputum production and tiredness,
and the findings from her physical exami-
nation, were consistent with a diagnosis of
COPD (GOLD, 2018; NICE, 2018).
“COPD is a major public-
health challenge; nurses
can be pivotal in early
identification, assessment
and management”
Spirometry
Spirometry is a tool used to identify airflow
obstruction but does not identify the cause.
Commonly measured parameters are:
l F orced expiratory volume – the volume
of air that can be exhaled – in one
second (FEV1), starting from a maximal
inspiration (in litres);
l F orced vital capacity (FVC) – the total
volume of air that can be forcibly
exhaled – at timed intervals, starting
from a maximal inspiration (in litres).
Calculating the FEV1 as a percentage of
the FVC gives the forced expiratory ratio
(FEV1/FVC). This provides an index of air-
flow obstruction; the lower the ratio, the
greater the degree of obstruction. In the
absence of respiratory disease, FEV1
should be ≥70% of FVC. An FEV1/FVC of
<70% is commonly used to denote airflow
obstruction (Moore, 2012).
As they are time dependent, FEV1 and
FEV1/FVC are reduced in diseases that
cause airways to narrow and expiration to
slow. FVC, however, is not time dependent:
with enough expiratory time, a person can
usually exhale to their full FVC. Lung func-
tion parameters vary depending on age,
height, gender and ethnicity, so the degree
of FEV1 and FVC impairment is calculated
by comparing a person’s recorded values
with predicted values. A recorded value of
>80% of the predicted value has been
37
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considered ‘normal’ for spirometry param-
eters but the lower limit of normal – equal
to the fifth percentile of a healthy, non-
smoking population – based on more
robust statistical models is increasingly
being used (Cooper et al, 2017).
A reversibility test involves performing
spirometry before and after administering
a short-acting beta-agonist (SABA) such as
salbutamol; the test is used to distinguish
between reversible and fixed airflow
obstruction. For symptomatic asthma, air-
flow obstruction due to airway smooth-
muscle contraction is reversible: adminis-
tering a SABA results in smooth-muscle
relaxation and improved airflow (Lumb,
2016). However, COPD is associated with
fixed airflow obstruction, resulting from
neutrophil-driven inflammatory changes,
excess mucus secretion and disrupted
alveolar attachments, as opposed to airway
smooth-muscle contraction.
Administering a SABA for COPD does
not usually produce bronchodilation to
the extent seen in someone with asthma: a
person with asthma may demonstrate sig-
nificant improvement in FEV1 (of >400ml)
after having a SABA, but this may not
change in someone with COPD (NICE,
2018). However, a negative response does
not rule out therapeutic benefit from long-
term SABA use (Marín et al, 2014).
NICE (2018) and GOLD (2018) guidelines
advocate performing spirometry after
administering a bronchodilator to diag-
nose COPD. Both suggest a FEV1/FVC of
<70% in a person with respiratory symp-
toms supports a diagnosis of COPD, and
both grade the severity of the condition
using the predicted FEV1. Ms Parker’s
spirometry results showed an FEV1/FVC of
56% and a predicted FEV1 of 57%, with no
significant improvement in these values
with a reversibility test.
GOLD (2018) guidance is widely accepted
and used internationally. However, it was
developed by medical practitioners with a
medicalised approach, so there is potential
for a bias towards pharmacological man-
agement of COPD. NICE (2018) guidance
may be more useful for practice nurses, as
it was developed by a multidisciplinary
team using evidence from systematic
reviews or meta-analyses of randomised
controlled trials, providing a holistic
approach. NICE guidance may be outdated
on publication, but regular reviews are per-
formed and published online.
NHS England (2016) holds a national
register of all health professionals certified
in spirometry. It was set up to raise spirom-
etry standards across the country.
www.nursingtimes.net

Clinical Practice
Case study
Fig 1. ABCD assessment tool
Spirometrically Assessment of Assessment of
confirmed airflow symptoms and risk of
diagnosis limitation exacerbations
Moderate/severe
exacerbation history C D
GOLD FEV (% of ≥2
grade predicted) or
Post- GOLD 1 ≥80 ≥1 leading to
B
bronchodilator hospital A
FEV1/FVC <70%
GOLD 2 50-79 administration
GOLD 3 30-49
0 or 1
GOLD 4 <30 mMRC 0-1 mMRC ≥2
not leading to
hospital CAT <10 CAT ≥10
administration
Symptoms
Source: Global Initiative for Chronic Obstructive Lung Disease (2018)
Assessment and management l I mproves lung function;
The goals of assessing and managing l I mproves survival rates;
Ms Parker’s COPD are to: l R  educes the risk of lung cancer;
l R  eview and determine the level of l R  educes the risk of coronary heart
airflow obstruction; disease risk (Qureshi et al, 2014).
l A  ssess the disease’s impact on her life; Ms Parker accepted a referral to an All
l R  isk assess future disease progression Wales Smoking Cessation Service adviser
and exacerbations; based at her GP surgery. The adviser used
l R  ecommend pharmacological and the internationally accepted ‘five As’
therapeutic management. approach:
GOLD’s (2018) ABCD assessment tool l A  sk – record the number of cigarettes
(Fig 1) grades COPD severity using spirom- the individual smokes per day or week,
etry results, number of exacerbations, CAT and the year they started smoking;
score and mMRC score, and can be used to l A  dvise – urge them to quit. Advice
support evidence-based pharmacological should be clear and personalised;
management of COPD. l A  ssess – determine their willingness and
When Ms Parker was diagnosed, her confidence to attempt to quit. Note the
predicted FEV1 of 57% categorised her as state of change;
GOLD grade 2, and her mMRC score, CAT l A  ssist – help them to quit. Provide
score and exacerbation history placed her behavioural support and recommend
in group D. The mMRC scale only meas- or prescribe pharmacological aids. If
ures breathlessness, but the CAT also they are not ready to quit, promote
assesses the impact COPD has on her life, motivation for a future attempt;
meaning consecutive CAT scores can be l A  rrange – book a follow-up
compared, providing valuable informa- appointment within one week or, if
tion for follow-up and management (Zhao, appropriate, refer them to a specialist
et al, 2014). cessation service for intensive support.
After assessing the level of disease Document the intervention.
burden, Ms Parker was then provided with NICE (2013) guidance recommends that
education for self-management and life- this be used at every opportunity. Stead et
style interventions. al (2016) suggested that a combination of
counselling and pharmacotherapy have
Lifestyle interventions proven to be the most effective strategy.
Smoking cessation
Cessation of smoking alongside support Pulmonary rehabilitation
and pharmacotherapy is the second-most Ms Parker’s positive response to smoking
cost-effective intervention for COPD, cessation provided an ideal opportunity to
when compared with most other pharma- offer her pulmonary rehabilitation (PR) – as
cological interventions (BTS and PCRS UK, indicated by Johnson et al (2014), changing
2012). Smoking cessation: one behaviour significantly increases a per-
l S lows the progression of COPD; son’s chance of changing another.
Nursing Times [online] June 2020 / Vol 116 Issue 6 38
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PR – a supervised programme including
exercise training, health education and
breathing techniques – is an evidence-
based, comprehensive, multidisciplinary
intervention that:
l I mproves exercise tolerance;
l R educes dyspnoea;
l P romotes weight loss (Bolton et al, 2013).
These improvements often lead to an
improved quality of life (Sciriha et al,
2015).
Most relevant for Ms Parker, PR has
been shown to reduce anxiety and depres-
sion, which are linked to an increased risk
of exacerbations and poorer health status
(Miller and Davenport, 2015). People most
at risk of future exacerbations are those
who already experience them (Agusti et al,
2010), as in Ms Parker’s case. Patients who
have frequent exacerbations have a lower
quality of life, quicker progression of dis-
ease, reduced mobility and more-rapid
decline in lung function than those who do
not (Donaldson et al, 2002).
Pharmacological interventions
Ms Parker has been prescribed inhaled sal-
butamol 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). Ms Parker also
uses a long-acting muscarinic antagonist
(LAMA) inhaler, which works by blocking
the bronchoconstrictor effects of acetyl-
choline on M3 muscarinic receptors in
airway smooth muscle; release of acetyl-
choline by the parasympathetic nerves in
the airways results in increased airway
tone with reduced diameter.
At a routine review, Ms Parker admitted
to only using the SABA and LAMA
inhalers, despite also being prescribed a
combined inhaled corticosteroid and long-
acting beta2-agonist (ICS/LABA) inhaler.
She was unaware that ICS/LABA inhalers
are preferred over SABA inhalers, as they:
l L ast for 12 hours;
l I mprove the symptoms of
breathlessness;
l I ncrease exercise tolerance;
l C an reduce the frequency of
exacerbations (Agusti et al, 2010).
However, moderate-quality evidence
shows that ICS/LABA combinations, par-
ticularly fluticasone, cause an increased
risk of pneumonia (Suissa et al, 2013; Nan-
nini et al, 2007). Inhaler choice should,
therefore, be individualised, based on
www.nursingtimes.net

Clinical Practice
Case study
symptoms, delivery technique, patient
education and compliance.
It is essential to teach and assess inhaler
technique at every review (NICE, 2011).
Ms Parker uses both a metered-dose
inhaler and a dry-powder inhaler; an in-
check device is used to assess her inspira-
tory effort, as different inhaler types
require different inhalation speeds. Braido
et al (2016) estimated that 50% of patients
have poor inhaler technique, which may
be due to health professionals lacking the
confidence and capability to teach and
assess their use.
Patients may also not have the dex-
terity, capacity to learn or vision required
to use the inhaler. Online resources are
available from, for example, RightBreathe
(rightbreathe.com), British Lung Founda-
tion (blf.org.uk). Ms Parker’s adherence
could be improved through once-daily
inhalers, as indicated by results from a
study by Lipson et al (2017). Any change in
her inhaler would be monitored as per
local policy.
Vaccinations
Ms Parker keeps up to date with her sea-
sonal influenza and pneumococcus vacci-
nations. 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 interven-
tions for patients with COPD and their rel-
ative quality-adjusted life years. Influenza
vaccinations have been shown to decrease
the risk of lower respiratory tract infec-
tions and concurrent COPD exacerbations
(Walters et al, 2017; Department of Health,
2011; Poole et al, 2006).
Self-management
Ms Parker was given a self-management
plan that included:
l I nformation on how to monitor her
symptoms;
l A rescue pack of antibiotics, steroids
and salbutamol;
l A traffic-light system demonstrating
when, and how, to commence
treatment or seek medical help.
Self-management plans and rescue
packs have been shown to reduce symp-
toms of an exacerbation (Baxter et al, 2016),
allowing patients to be cared for in the
community rather than in a hospital set-
ting and increasing patient satisfaction
(Fletcher and Dahl, 2013).
Improving Ms Parker’s adherence to
once-daily inhalers and supporting her to
self-manage and make the necessary
Nursing Times [online] June 2020 / Vol 116 Issue 6
lifestyle changes, should improve her symp-
toms and result in fewer exacerbations.
The earlier a diagnosis of COPD is
made, the greater the chances of reducing
lung damage through interventions such
as smoking cessation, lifestyle modifica-
tions and treatment, if required (Price et
al, 2011). NT
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For more on this topic online
l COPD 1: pathophysiology,
diagnosis and prognosis
Bit.ly/NTCOPD1
l COPD 2: management and
nursing care
Bit.ly/NTCOPD2
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