Week 2 Discussion Advance

Apply information from the Aquifer Case Study to answer the following discussion questions:

Discuss the Mr. Barley’s history that would be pertinent to his respiratory problem. Include chief complaint, HPI, Social, Family and Past medical history that would be important to know.
Describe the physical exam and diagnostic tools to be used for Mr. Barley. Are there any additional you would have liked to be included that were not?
What plan of care will Mr. Barley be given at this visit, include drug therapy and treatments; what is the patient education and follow-up?
Do 2 pages.

Provide references.

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South University College of Nursing and Public Health Graduate Online

Nursing Program

Aquifer Family Medicine

Family Medicine 28: 58- year-old man with shortness of breath

Author:Author: Alexander Chessman, MD

INTRODUCTION CLINICAL REASONING

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Dr. Wilson discusses the next patient with you.Dr. Wilson discusses the next patient with you.

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While working with your family medicine preceptor you are scheduled to see Mr. John Barley, a 58-year-old man who has sought medical attention only rarely in the past 10 years. He comes to the office today because of progressively worsening cough and shortness of breath during the previous month.

Before you and your preceptor Dr. Wilson enter the room to meet Mr. Barley, you think about the definition of dyspnea:

Dyspnea DeHnition Dyspnea is defined as an uncomfortable awareness of breathing.

Any problem in the mechanical system of breathing can trigger dyspnea, including (but not limited to):

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blockage in the nose fluid in the alveoli irritation of the diaphragm

Question Dr. Wilson asks you, “What are some of the conditions that lead to dyspnea?”

The suggested answer is shown below.

Pneumonia, CHF, Flu, COPD, Asthma.

Letter Count: 34/1000

SUBMITSUBMIT

Answer Comment

Causes of Dyspnea It often helps to organize your list of differential diagnoses by system, so that you make sure that it is complete. Also, an organized list can make it easier to rule in or out the diagnostic possibilities.

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One way to organize the causes of dyspnea in adults is by categories: cardiac, hematologic, pulmonary, or psychogenic:

Cardiac:Cardiac:

Congestive heart failure (CHF), coronary artery disease (CAD), dysrhythmia, pericarditis, acute myocardial infarction

Hematologic:Hematologic:

Anemia

Pulmonary:Pulmonary:

Obstructive lung disease: Chronic Obstructive Pulmonary Disease (COPD), asthma, bronchitis

Diseases of lung parenchyma & pleura: pneumonia, pleural effusion, cancer involving the lungs, pneumothorax, pulmonary edema, restrictive lung disease, interstitial lung disease

Pulmonary vascular disease: pulmonary embolism, pulmonary hypertension

Obstruction of the airway: gastroesophageal reflux disease with aspiration, foreign body aspiration

Environmental irritants and allergens: dust or chemical

Psychogenic:Psychogenic:

Panic attacks, hyperventilation

Other:Other:

Deconditioning Neuromuscular conditions (myasthenia, Gullain-Barre, ALS) Metabolic (carbon monoxide, anion and non-anion gap

acidosis)

Congestive heart failure (CHF), coronary artery disease (CAD), dysrhythmia, pericarditis, acute myocardial infarction, anemia, chronic obstructive pulmonary disease (COPD), asthma,

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pneumonia, pneumothorax, pulmonary embolism, pleural effusion, cancer involving the lungs, pulmonary edema, gastroesophageal reflux disease with aspiration, restrictive lung disease, panic attacks, hyperventilation. Exposure to dust or chemical that causes irritation, an allergic reaction, or poisoning. Deconditioning, because of lack of exercise.

“A couple of things are worth noting here,” Dr. Wilson concludes. “The severity of dyspnea does not necessarily correlate with the gravity of the underlying disease. And we could have chosen “cough” instead of “dyspnea” as the most important symptom to generate a differential diagnosis.”

PATIENT HISTORY 1 HISTORY

Mr. Barley tells you about his current health issues.Mr. Barley tells you about his current health issues.

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Dr. Wilson greets Mr. Barley, introduces you, and then excuses himself to go see another patient. He states he will be back for you to present Mr. Barley’s case to him.

You sit down across from Mr. Barley and say, “Hi, Mr. Barley. Thanks for letting me work with you.” Mr. Barley says, “Sure, anyone working with Dr. Wilson is OK by me.”

You begin eliciting the history:

“I understand you have a cough and shortness of breath. Can you tell me more about it?”

“OK. Have you noticed anything else that seems to be related to the cough? Things like weight loss, chest pain, and fever?”

“Have you had any nausea, vomiting, or diarrhea?”

“Do you have shortness of breath when you are active and when you are at rest?”

“Have you had in the past, or currently have, exposures to things that can cause cough, like chemicals, and smoking?”

“Do you have any trouble lying Xat when you sleep?”

You learn that he has not traveled recently, which could have exposed him to an unusual form of pneumonia. He also has not been exposed to tuberculosis. From other questions, you learn that Mr. Barley has no leg swelling or paroxysmal nocturnal dyspnea (PND). You know that he has had no orthopnea.

As a farmer, he is active during the day. Deconditioning is not likely.

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Wondering if his shortness of breath is due to a panic disorder, you ask him a series of questions and note that his symptoms are not associated with paresthesia, choking, nausea, chest pain, derealization feeling, trembling or shaking, dizziness, palpitations, sweating, chills, or flushes.

Orthopnea DeHnition Dyspnea which occurs when lying flat, forcing the person to have to sleep propped up in bed or sitting in a chair. It is commonly measured according to the number of pillows needed to prop the patient up to enable breathing (Example: “three pillow orthopnea”).

Paroxysmal nocturnal dyspnea (PND) – DeHnition, Etiology, Symptoms DefinitionDefinition

Sudden, severe shortness of breath at night that awakens a person from sleep, often with coughing and wheezing.

EtiologyEtiology

It is most closely associated with congestive heart failure.

SymptomsSymptoms

PND commonly occurs several hours after a person with heart failure has fallen asleep. PND is often relieved by sitting upright, but not as quickly as simple orthopnea. Also unlike orthopnea, it does not develop immediately upon lying down.

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PATIENT HISTORY 2 HISTORY Now that you have a good understanding of the history of the present illness, you continue the interview by turning to past medical, social, and family histories.

You say, “I think I have a clear idea about what brought you in today. Let me ask you now about your health in general.”

“Any serious illnesses in the past?”

“I’d like to ask about your personal life. Tell me about your home life.”

“Tell me about your immediate family health history.”

You say, “So I understand that you have had a cough with white phlegm for the past two winters and that you have been experiencing shortness of breath with exertion. You may have been exposed to some chemical irritants at your farm, but you have been careful about this. You also smoke cigarettes.”

SUMMARY STATEMENT CLINICAL REASONING After thanking Mr. Barley, you leave the room while he changes into a gown. Seeing you in the hall, Dr. Wilson says, “I can join you now. Can you fill me in on what you have learned so far?”

Question Based on what you know about the patient so far, write a one- to three- sentence summary statement to communicate your understanding of the patient to other providers.

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Guidelines for summary statements.

Your response is recorded in your student case report.

Letter Count: 0/1000

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Answer Comment Mr. Barley is a 58-year-old male smoker who presents with a two- week history of productive cough and dyspnea on exertion. He has had similar symptoms during the past two winters. He denies fever, chest pain, epigastric pain, symptoms of CHF, recent travel, or TB or chemical exposures.

The ideal summary statement concisely highlights the most pertinent features without omitting any significant points. The summary statement above includes:

1. Epidemiology and risk factors: 58-year-old smoker

2. Key clinical findings about the present illness using qualifying adjectives and transformative language:

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productive cough dyspnea on exertion similar symptoms past two winters no fever, chest pain, epigastric pain, symptoms of CHF, recent

travel, Tb or chemical exposures.

DIFFERENTIAL DIAGNOSIS CLINICAL REASONING

You discuss the differential with Dr. Wilson.You discuss the differential with Dr. Wilson.

!

“Let’s go in and do the physical together,” says Dr. Wilson, “But, first, what are you thinking so far, in terms of a differential?”

After pausing to think, you reply to Dr. Wilson, “He could have bronchitis.”

“Good thought.” Dr. Wilson added, “What in the history supports bronchitis?”

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The best options are indicated below. Your selections are indicated by the shaded boxes.

You reply that the cough and shortness of breath of two to three weeks duration could support acute bronchitis.

Dr. Wilson tells you, “While the duration of illness provides a clinical distinction between acute and chronic bronchitis, the actual mechanisms and pathophysiology also probably differ between the two. Chronic bronchitis causes long-term inflammation that can lead to irreversible structural changes. He might qualify for this diagnosis because he describes cough with phlegm production during the past two winters. But let’s assume for the moment that he doesn’t have chronic bronchitis.”

He then prompts you, “What else are you thinking for the differential diagnosis?”

Acute vs Chronic Bronchitis Clinical distinction between acute bronchitis & chronic bronchitis: duration of illness.

Acute BronchitisAcute Bronchitis Chronic BronchitisChronic Bronchitis

Productive cough lasting 1-3 weeks

Productive cough for at least three months for the past two years

Question Based on your findings so far, select the top four diagnoses on your differential diagnosis.

A. Acute bronchitis

B. Angina

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C. Asthma

D. Bronchiectasis

E. Chronic obstructive pulmonary disease (COPD)

F. Congestive heart failure (CHF)

G. Lung cancer

H. Panic disorder

I. Pneumonia

J. Pulmonary embolism (PE)

K. Pulmonary tuberculosis

SUBMITSUBMIT

Answer Comment The correct answers are A, C, E, G.The correct answers are A, C, E, G.

Di]erential of Shortness of Breath in Middle-Aged Man Who Smokes Most Likely DiagnosesMost Likely Diagnoses

AcuteAcute bronchitisbronchitis

Acute bronchitisAcute bronchitis can cause cough in the absence of fever.

AsthmaAsthma

The onset of asthmaasthma is typically earlier, usually in childhood, so it is less likely here. Asthma occurs more frequently in smokers, but the association is not as strong as it is with COPD.

A worsening winter cough could indicate COPD COPD because breathing cold dry air causes

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COPDCOPD

constriction of the airways and obstructs air flow. In addition, shortness of breath mostly with activity, a history of heavy smoking, and the absence of orthopnea or paroxysmal nocturnal dyspnea (PND) all argue for a diagnosis of COPD. Although dyspnea is a relatively nonspecific finding, dyspnea with exertion is a cardinal symptom of COPD. COPD develops slowly over years, so most people are at least 40 years old when symptoms begin and cigarette smoking is the most commonly encountered risk factor for the development of COPD. The risk is dose-related.

LungLung cancercancer

Lung cancerLung cancer can cause cough. Cigarette smoking is the single most important risk factor for developing lung cancer.

The following diagnoses are less likely:The following diagnoses are less likely:

Dyspnea is one of the cardinal manifestations of congestive heart failure (CHF), but is a nonspecific finding. One study found that dyspnea on exertion has a specificity of only 17% for CHF. Paroxysmal nocturnal dyspnea (PND) is more closely associated with CHF.. Orthopnea, too, is often a symptom of CHF and/or pulmonary edema but can also occur with pulmonary pathology (such as asthma and chronic bronchitis) as well as with sleep apnea or panic disorder. When patients with CHF are recumbent for an extended period, such as at night, peripheral edema is reabsorbed. This increases total blood volume and blood pressure and can lead to pulmonary hypertension in people with underlying left ventricular dysfunction. Pulmonary hypertension leads to pulmonary edema which causes both orthopnea and PND. The absence of these symptoms makes CHF unlikely.

Shortness of breath with activity can suggest angina, especially in the setting of a long history of smoking, but the symptom of cough in the absence of other symptoms (chest pressure,

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nausea, and diaphoresis) makes this an unlikely primary diagnosis.

Pulmonary embolism presents with shortness of breath, but the symptoms are generally acute, and larger emboli typically cause sharp chest pain that worsens with inspiration.

Patients with bronchiectasis usually have a history of recurrent or persistent pneumonia.

Pneumonia occurs more frequently in smokers, and cough and shortness of breath (with or without activity) fit with the diagnosis of pneumonia. Typically, however, the patient would have a fever, and the sputum would appear purulent.

Pulmonary tuberculosis should be on the differential, but is relatively rare and typically presents with chronic cough, fever/night sweats, weight loss, and hemoptysis in patients with risk factors such as exposures to high-risk groups or travel.

Panic disorder is an unlikely cause of shortness of breath without other associated symptoms.

References Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. http://goldcopd.org/wp- content/uploads/2016/12/wms-GOLD-2017-Pocket-Guide.pdf. Accessed April 19, 2018.

King M, Kingery J, Casey B. Diagnosis and evaluation of heart failure. Am Fam Physician. 2012 Jun 15;85(12):1161-1168.

RESEARCHING PHYSICAL EXAM FINDINGS

TEACHING

Dr. Wilson says, “Why don’t you review the physical examination findings consistent with COPD while I return a phone call to a patient?”

While Dr. Wilson is gone, you go online to learn more about what physical findings you should look for in a patient with COPD.

http://goldcopd.org/wp-content/uploads/2016/12/wms-GOLD-2017-Pocket-Guide.pdf
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When you are finished, you rejoin Dr. Wilson and approach the exam room where Mr. Barley is waiting.

Classic Findings on Physical Exam for COPD COPDCOPD

Increased anteroposterior (AP) diameter of the chest Decreased diaphragmatic excursion Wheezing (often end-expiratory) Prolonged expiratory phase

PHYSICAL EXAM PHYSICAL EXAM

How to measure laryngeal heightHow to measure laryngeal height

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After knocking on the door to make sure Mr. Barley is ready you and Dr. Wilson enter the room.

You say to Mr. Barley, “I’m going to do the physical exam, and then Dr. Wilson will repeat it.” He nods assent.

Your exam reveals:

Vital signs:Vital signs:

Temperature:Temperature: 98.9 Fahrenheit Heart rate:Heart rate: 94 beats/minute Respiratory rate:Respiratory rate: 22 breaths/minute Blood pressure:Blood pressure: 128/78 mmHg

General:General: Appears mildly short of breath

Head, eyes, ears, nose and throat (HEENT):Head, eyes, ears, nose and throat (HEENT): Normocephalic / atraumatic, conjunctivae and sclerae are normal, PERRL, oropharynx is normal.

Neck:Neck: Supple without masses, lymphadenopathy, or thyromegaly. Laryngeal height measures 2 cm from sternal notch to the top of the thyroid cartilage upon full expiration.

Lungs:Lungs: Increased AP diameter. Percussion is normal. Inspiratory crackles at the bases, and end-expiratory wheezing diffusely.

Heart:Heart: Regular rate and rhythm. 2/6 systolic murmur loudest at the right upper sternal border (RUSB) with radiation to the left lower sternal border (LLSB).

Abdomen:Abdomen: Bowel sounds normal, no hepatomegaly, no tenderness.

Extremities:Extremities: 1+ pitting pretibial edema.

Question Which of the following physical examination findings support the diagnosis of COPD? Select all that apply.

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The best options are indicated below. Your selections are indicated by the shaded boxes.

A. Increased AP diameter

B. 2/6 systolic murmur loudest at the right upper sternal

border (RUSB)

C. 1+ pretibial pitting edema

D. Laryngeal height 2 cm above the sternal notch, upon

full expiration

E. End-expiratory wheezing

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Answer Comment The correct answers are A, D, E.The correct answers are A, D, E.

Findings Predictive of COPD A combination of specific findings in a patient’s history and physical may be predictive of COPD.

Increased AP diameter and end-expiratory wheezing are generally considered to be classic signs of COPD.

Less commonly considered to indicate COPD is a decreased height of the larynx. Measurement of laryngeal maximum height, at full expiration (distance from the suprasternal notch to the top of the thyroid cartilage) is used in the diagnosis of obstructive airway disease.

One study examined the value of specific signs and symptoms in diagnosing COPD. Four items predicted the presence of COPD:

Smoking more than 40 pack-years

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Self-reported history of chronic obstructive airway disease Maximum laryngeal height of 4 cm or less, and Age at least 45 years

Patients having all four findings had a likelihood ratio (LR) of 220, effectively ruling in COPD. Patients without any of the four findings had a LR of 0.13. See more about the use of likelihood ratios in clinical practice.

Link to a good article on the characteristics and diagnosis of COPD.

A systolic murmur loudest at the RUSB (B) could indicate aortic stenosis or sclerosis, but does not support COPD.

Pretibial pitting edema (C) could result from congestive heart failure (CHF). (While it is true that right-sided heart failure could result from COPD, COPD does not directly cause edema.)

References Dewar M, Curry RW, Chronic Obstructive Pulmonary Disease: Diagnostic considerations. Am Fam Physician. 2006;73:669-676,677-678. http://www.aafp.org/afp/20060215/669.html. Accessed April 29, 2017.

Straus SE, McAlister FA, Sackett DL, Deeks JJ, for the CARE COAD1 Group. The accuracy of patient history, wheezing, and laryngeal measurements in diagnosing obstructive airway disease. JAMA. 2000;283:1853-1857.

DIAGNOSTIC TESTING 1 CARE DISCUSSION First confirming your findings with his own exam, Mr. Wilson then agrees that Mr. Barley has three signs of COPD:

Increased AP diameter Laryngeal height 2 cm above the sternal notch Expiratory wheezing

Diagnostics and Likelihood Ratios, Explained


http://www.aafp.org/afp/20060215/669.html
http://www.aafp.org/afp/20060215/669.html
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The best option is indicated below. Your selections are indicated by the shaded boxes.

Dr. Wilson asks, “What test can we do to confirm that COPD is the correct diagnosis?”

Question Which of the following is the best next step in diagnosis? Choose the single best answer.

A. Serum creatinine

B. Pulmonary angiogram

C. Stress echocardiogram

D. Pulmonary function testing

E. Chest CT

F. Chest radiography

SUBMITSUBMIT

Answer Comment The correct answer is D.The correct answer is D.

Pulmonary Function Test to Diagnose COPD Pulmonary function testing (PFT)Pulmonary function testing (PFT) is the gold standard for diagnosing COPD. In pulmonary function testing, either a FEV1/FVC ratio less than the 5th percentile, or less than 70%, confirms a diagnosis of COPD.

Note: Chest radiographs are not generally part of the initial diagnosis of COPD. Radiographic findings of COPD are generally only seen in more advanced disease. In advanced COPD,

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suggestive findings include: hyperinflation (flattened diaphragm on lateral chest film and increased volume of retrosternal air space), hyperlucency of the lungs, and rapid tapering of the vascular markings.

Also of note: we are talking here about diagnosing COPD in a symptomatic patient. The USPSTF does not recommend screening for COPD using spirometry in asymptomatic patients.

Serum creatinine (A) is helpful for diagnosing renal insufficiency.

A pulmonary angiogram (B), although a risky and expensive procedure, serves as the gold standard for diagnosing pulmonary embolism, not COPD.

A stress echocardiogram (C) can confirm cardiac ischemia.

A chest CT (E) could diagnose cancer. Chest CT often serves as a reasonable gold standard for diagnosing pulmonary embolism, because pulmonary angiography is so risky.

References Final Recommendation Statement: Chronic Obstructive Pulmonary Disease: Screening. U.S. Preventive Services Task Force. September 2016. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFi nal/chronic-obstructive-pulmonary-disease-screening . Accessed October 31, 2016.

DIAGNOSTIC TESTING 2 CARE DISCUSSION

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Here are examples of chest-x-rays with abnormal findings (not fromHere are examples of chest-x-rays with abnormal findings (not from Mr. Barley). This x-ray of pneumonia shows a wedge-shaped area ofMr. Barley). This x-ray of pneumonia shows a wedge-shaped area of

consolidation.consolidation.

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“However,” you ask, “if we got a chest x-ray, wouldn’t it also support the diagnosis?”

When Chest X-ray is Appropriate in Setting of Dyspnea The current literature doesn’t support the use of chest x-ray to rule in or out COPD, but some studies suggest that a chest x-ray might be helpful for finding other causes of dyspnea.

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One guideline based on expert opinion recommends getting a chest x-ray at first presentation to exclude causes or problems other than COPD.

Another study examined chest x-ray results in a screening program and found that 14% of all the radiographs detected potentially treatable causes of dyspnea other than lung cancer and COPD, including:

pneumonia bronchiectasis pulmonary fibrosis pleural effusion left ventricular failure, and possible active tuberculosis

In addition, the chest radiograph found lung cancer in a significant number of patients.

In summary, it makes sense to get a chest x-ray when a patient presents with shortness of breath, not to rule in or out COPD, but to look for other diagnoses.

Example of lung cancer seen on chest radiograph (seen in upper left lung field).

References Wallace G, Winter J, Winter J, Taylor A, Taylor T, Cameron R. Chest x-rays in COPD screening: Are they worthwhile? Respir Med. 2009;103:1862-1865.

DIAGNOSTIC TESTING 3 TEACHING

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Dr. Wilson explains the pulmonary function tests.Dr. Wilson explains the pulmonary function tests.

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While Mr. Barley gets dressed, Dr. Wilson takes the opportunity to teach you about pulmonary function tests. He shows you a graph, and explains how spirometry is helpful in diagnosing COPD:

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Spirometry for Diagnosis/Monitoring COPD Spirometry is the most commonly used office-based device for lung function testing. A spirometer is a hand-held device that can easily be used in the clinician’s office by a patient with the assistance of a technician.

How it works:How it works:

1. The patient is asked first to exhale completely, then to inhale deeply. 2. Next, the patient is told to exhale rapidly into the device until all the air is exhausted from his lungs.

These two steps measure the inspiratory and expiratory flow of air. A number of calculations can then be derived from these measurements. An individual’s spirometry results are based on comparison to predicted values of a standardized, healthy population.

Definitions:Definitions:

Forced Vital Capacity (FVC)Forced Vital Capacity (FVC) = total amount of air the patient can expel from the lungs after a full inspiration

Forced Expiratory Volume – 1 second (FEV1)Forced Expiratory Volume – 1 second (FEV1) = amount of air the patient can expel after a full breath in one second

Diagnosing COPD:Diagnosing COPD:

COPD causes the air in the lungs to be exhaled at a slower rate and in a smaller amount compared to a normal, healthy person (obstructiveobstructive defectdefect). The amount of air in the lungs will not be readily exhaled due to either a physical obstruction (such as with mucus production) or airway narrowing caused by chronic inflammation.

Post-bronchodilator FEV1-to-FVC ratio (FEV1/FVC) less than 70% (or less than the fifth percentile) with compatible symptoms and history, is diagnostic of COPD.

Further, the FEV1 impairment defines the level of COPD severity:

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Measured post-bronchodilator FEV1 ImpairmentMeasured post-bronchodilator FEV1 Impairment (Compared to Predicted)(Compared to Predicted)

SeveritySeverity

>> 80% Mild – GOLD 1

50-79% Moderate – GOLD 2

30-49% Severe – GOLD 3

< 30% Very severe – GOLD 4

NARROWING THE DIFFERENTIAL DIAGNOSIS 1

TEACHING

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!

Before taking another phone call, Dr. Wilson hands you some information on COPD. You read:

Chronic Obstructive Pulmonary Disease (COPD) – DeHnition, Epidemiology, Diagnosis DefinitionDefinition

COPD encompasses both chronic bronchitis and emphysema and is characterized by airflow limitation that is progressive and not fully reversible with bronchodilators.

EpidemiologyEpidemiology

While it is currently estimated by the World Health Organization to be the 12th most common cause of morbidity and the fourth most common cause of death worldwide, COPD is set to become the fifth most common

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cause of morbidity and third most common cause of death by 2020. Almost 15.7 million Americans are diagnosed with COPD, yet an additional 12 million Americans may have COPD and remain undiagnosed.

DiagnosisDiagnosis

A clinical diagnosis of COPD should be considered in any middle-aged or older adult who has:

dyspnea chronic cough or sputum production, or a history of tobacco use

The diagnosis should be confirmed by spirometry.

COPD vs Asthma Since a major clinical distinction between these two diagnoses is that COPD is not reversible via bronchodilator therapy, and asthma isCOPD is not reversible via bronchodilator therapy, and asthma is, spirometry data is collected twice: pre- and post-bronchodilator therapy.

Other major differences between COPD and asthma are outlined below:

COPDCOPD AsthmaAsthma

Onset in mid-life Onset early in life

Symptoms slowly progress Symptoms vary day to day

Symptoms during exertion Symptoms more common at night or early morning

Long history of smoking Not dependent on smoking

Not related to rhinitis, allergy, Often related to rhinitis, allergy, or

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The best option is indicated below. Your selections are indicated by the shaded boxes.

or eczema eczema

Largely irreversible Air-flow limitation is largely reversible

PathophysiologyPathophysiology

Differences between the mechanisms underlying COPD and asthma include:

Cigarette smoke is more of a causal agent in COPD, Mast cells, T helper cells, and eosinophils play more of a role in what

appears to be an allergic bronchoconstrictive response in asthma, and Macrophages, T killer cells, and neutrophils play a role in an

inflammatory and destructive process in COPD.

As noted on the previous card, a post-bronchodilator FEV1/FVC ratio < 70% confirms the presence of airflow limitation that is not fully reversible (hence a diagnosis of COPD).

Significant reversibility is defined as an increase in FEV1 ≥ 12% after bronchodilator.

Question Which of the following is generally considered to be helpful in distinguishing between COPD and asthma? Choose the single best answer.

A. FEV1/FVC is greater than 60% in asthma, but less than

60% in COPD.

B. FVC is increased in COPD, but unchanged in asthma.

C. Air-flow obstruction in asthma is reversible, but in

COPD it is not.

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D. Macrophages and T killer cells play a role in asthma,

but not in COPD.

SUBMITSUBMIT

Answer Comment The correct answer is C.The correct answer is C.

Distinguishing COPD from Asthma Air-flow obstruction in asthma is reversible, but in COPDAir-flow obstruction in asthma is reversible, but in COPD it is notit is not.

The major distinction between asthma and COPD is the reversible nature of asthma’s obstruction to air flow.

By definition, FEV1/FVC is decreased in COPD, but can be decreased or normal in asthma if the FEV1 and FVC are both decreased proportionally.

FVC is normal to decreased in COPD, but always decreased in asthma.

Macrophages and T killer cells play a role in COPD.

Note that, though this distinction of reversibility versus non- reversibility of obstruction is a general rule, this characteristic is not completely reliable. You need to consider all aspects of the presentation, including:

age smoking history relationship to environmental allergies, and time course of symptoms

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References Barnes PJ. Asthma and COPD: basic mechanisms and clinical management. (graphic) Philadelphia, PA: Elsevier. 2002; Chapter 1, page 3.

Halbert RJ, Isonaka S, George D, Iqbal A. Interpreting COPD prevalence estimates: what is the true burden of disease? Chest. 2003 May;123(5):1684-92.

Mannino DM, Gagnon RC, Petty TL, Lydick E. Obstructive lung disease and low lung function in adults in the United States: data from the National Health and Nutrition Examination Survey 1988-1994. Arch Intern Med. 2000;160:1683-1689.

Wheaton AG, Cunningham, TJ, Ford ES, Croft JB. Employment and activity limitations among adults with chronic obstructive pulmonary disease—United States, 2013. MMWR. 2015:64 (11):290-295.

NARROWING THE DIFFERENTIAL DIAGNOSIS 2

TEACHING

“So let’s compare asthma to COPD,” suggests Dr. Wilson. “Why does it matter? Why worry about any differences between asthma and COPD?” You and Dr. Wilson discuss the differences in prognosis and treatment modalities for COPD vs asthma.

“Cigarette use makes either of the conditions worse, of course,” adds Dr. Wilson, “We will have to address that issue with him no matter what.”

Dr. Wilson finishes up the discussion of asthma by referring you to the 2017 Global Initiative for Chronic Obstructive Lung Disease (GOLD) guideline, which clarifies that it is not always possible to differentiate between asthma and COPD, and it makes sense to treat patients who have features of both as if they had asthma.

Asthma vs COPD Prognosis & Treatment

AsthmaAsthma COPDCOPD

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PrognosisPrognosis Reversible Not reversible

TreatmentTreatment modalitiesmodalities

Medications Patient education Removal of triggers (e.g., dust, pollen) Immunotherapy

Medications

References Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management and prevention of chronic obstructive lung disease: 2017 report. http://goldcopd.org/gold-2017-global-strategy-diagnosis-management-prevention-copd/. Accessed April 19, 2018.

U.S. Preventive Services Task Force. Chronic Obstructive Pulmonary Disease: Screening. April 2016. Agency for Healthcare Research and Quality, Rockville, MD. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/chronic- obstructive-pulmonary-disease-screening. Accessed April 19, 2018.

STAGES OF SEVERITY TEACHING Dr. Wilson notes, “The first step – often combined with confirming the diagnosis of COPD – is to determine the stage of severity. Different organizations use slightly different categories. Here are the GOLD criteria. All you have to remember is the FEV1 to FVC ratio is less than 0.7 for all stages of COPD, and then the cutoffs for FEV1 are 80, 50, and 30% of predicted.”

GOLD Spirometric Criteria for COPD Severity

GOLDGOLD GradeGrade

SeveritySeverity SpirometrySpirometry ResultsResults

Clinical PresentationClinical Presentation

FEV1/FVC At this stage, the patient is

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GOLD 2017 Global Strategy for the Diagnosis, Management and Prevention of COPD


https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/chronic-obstructive-pulmonary-disease-screening
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1 Mild < 0.7 FEV1 ≥ 80% predicted

probably unaware that lung function is starting to decline.

2 Moderate

FEV1/FVC < 0.7 50% ≤ FEV1 < 80% predicted

Symptoms during this stage progress, with shortness of breath developing upon exertion.

3 Severe

FEV1/FVC < 0.7 30% ≤ FEV1 < 50% predicted

Shortness of breath becomes worse at this stage, and COPD exacerbations are common.

4 Very Severe

FEV1/FVC < 0.7 FEV1 < 30% predicted

Quality of life at this stage is gravely impaired. COPD exacerbations can be life threatening.

References Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management and prevention of chronic obstructive lung disease: 2017 report. http://goldcopd.org/gold-2017-global-strategy-diagnosis-management-prevention-copd/. Accessed April 19, 2018.

TREATMENT CARE DISCUSSION Dr. Wilson asks you to think about how to best treat Mr. Barley.

GOLD 2017 Global Strategy for the Diagnosis, Management and Prevention of COPD


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The best options are indicated below. Your selections are indicated by the shaded boxes.

Question “Which of the following are the best next steps in management?” Select all that apply.

A. Check alpha-1 antitrypsin levels.

B. Prescribe an albuterol metered-dose inhaler on an as-

needed basis.

C. Start prednisone at a low dose.

D. Help the patient to quit or decrease smoking.

E. Admit the patient to the hospital for intensive training

and support.

SUBMITSUBMIT

Answer Comment The correct answers are B, D.The correct answers are B, D.

Therapy for Mild Symptomatic COPD Prescribe an albuterol metered-dose inhaler on an as needed basis.

Albuterol is a member of a class of medications called bronchodilators that improve lung function by altering airway smooth muscle tone and reducing dynamic hyperinflation. Bronchodilators include:

inhaled short-acting and long-acting beta-2-agonists inhaled long-acting anticholinergics, and

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oral methylxanthines

They are essential for symptom management in COPD. According to the Global Initiative for Chronic Obstructive Lung disease:

All symptomatic patients with COPD should be prescribed a short-acting bronchodilator (e.g., albuterol) on an as-needed basis.

If symptoms are still inadequately controlled, a daily dose of long-acting bronchodilator should be added.

The choice between beta-2-agonist, anticholinergic, theophylline, or combination therapy depends on availability and individual response in terms of symptom relief and side effects.

Combining bronchodilators of different pharmacological classes may improve efficacy and decrease the risk of side effects compared to increasing the dose of a single bronchodilator.

Risks of overuse of beta-agonists include:

tachycardia exaggerated somatic tremor, and hypokalemia (especially with concurrent use of thiazide

diuretics)

Smoking cessation is single-most important treatment strategy for COPD. Although it sounds logical to have the patient decrease smoking, complete abstinence has been shown overall to have better quit rates than cutting down. Some structured smoking cessation programs, however, have had success with cutting down. Assess your patient’s readiness to quit smoking, recommend that he stop smoking, and give him information on available smoking-cessation programs.

Other unwarranted management for straightforward,Other unwarranted management for straightforward, uncomplicated symptomatic COPD:uncomplicated symptomatic COPD:

Although COPD is usually caused by damage inflicted from long- term cigarette smoke or air pollution, it is occasionally caused by an alpha-1 antitrypsin deficiency. A good clue that this may be

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present is when a patient younger than 45 years old is diagnosed with COPD, as they are not old enough to have developed the long-term effects from smoking. In such a case, especially if the patient is of Caucasian descent and has a strong family history of the disease, you may want to check alpha-1 antitrypsin levels — but you do not have to check this level in all adults who have COPD.

Systemic glucocorticoids, such as prednisone, may be useful during an acute COPD exacerbation. And systemic glucocorticoids may improve lung function for about 20 percent of patients with stable COPD. However, the risks of chronic systemic steroid use outweighs the benefits — as prednisone, even at a low dose, can cause serious side effects, such as osteoporosis, suppression of the hypothalamus-pituitary-adrenal axis, diabetes, cataracts, and necrosis of the femoral head. Perhaps the most relevant side effect of long-term treatment with systemic glucocorticoids is steroid myopathy — contributing to muscle weakness, decreased functionality, and respiratory failure in advanced COPD.

Hospitalization is indicated only for a patient who needs observation and more intensive treatment than can be provided at home. Supplemental oxygen and continuous nebulizer therapy can be given in the hospital. In addition, the patient can be monitored closely for respiratory failure and the need for intubation and artificial ventilation.

References Global Initiative for Chronic Obstructive Lung Disease, Executive Summary: Global Strategy for the Diagnosis, Management, and Prevention of COPD, 2017, http://www.goldcopd.org

Global Initiative for Chronic Obstructive Lung Disease. Pocket guide to COPD diagnosis, management and prevention: A guide for health professionals – 2017 Report. http://goldcopd.org/wp-content/uploads/2016/12/wms-GOLD-2017-Pocket-Guide.pdf. Accessed April 19, 2018.

Global Initiative for Chronic Obstructive Lung Disease


http://goldcopd.org/wp-content/uploads/2016/12/wms-GOLD-2017-Pocket-Guide.pdf
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Walters JAE, Walters EH, Wood-Baker R. Oral corticosteroids for stable chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews. 2005(3)

SMOKING CESSATION CARE DISCUSSION Dr. Wilson says, “Let’s talk a bit about the research regarding how smoking affects lung function in patients with COPD.” He shows you an article by PD Scanlon, et al., in 2000 reporting their findings on the effects of smoking cessation on lung function in mild-to-moderate chronic obstructive pulmonary disease. Below is the abstract:

Abstract:Abstract:

Previous studies of lung function in relation to smoking cessation have not adequately quantified the long-term benefit of smoking cessation, nor established the predictive value of characteristics such as airway hyperresponsiveness. In a prospective randomized clinical trial at 10 North American medical centers, we studied 3,926 smokers with mild-to-moderate airway obstruction (3,818 with analyzable results; mean age at entry, 48.5 yr; 36% women) randomized to one of two smoking cessation groups or to a nonintervention group. We measured lung function annually for 5 yr. Participants who stopped smoking experienced an improvement in FEV1 in the year after quitting (an average of 47 ml or 2%). The subsequent rate of decline in FEV1 among sustained quitters was half the rate among continuing smokers, 31 ± 48 versus 62 ± 55 ml (mean ± SD), comparable to that of never- smokers. Predictors of change in lung function included responsiveness to beta-agonist, baseline FEV1, methacholine reactivity, age, sex, race, and baseline smoking rate. Respiratory symptoms were not predictive of changes in lung function. Smokers with airflow obstruction benefit from quitting despite previous heavy smoking, advanced age, poor baseline lung function, or airway hyperresponsiveness.

Scanlon PD, Connett JE, Waller LA, Altose MD, Bailey WC, Buist AS, Tashkin DP. Smoking cessation and lung function in mild-to-moderate chronic obstructive pulmonary disease: The Lung Health Study. AM J Respit Crit Care Med. 2000;161:381-390.

http://ajrccm.atsjournals.org/content/161/2/381.full
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The best option is indicated below. Your selections are indicated by the shaded boxes.

BeneHts of Quitting Smoking Figure from study

Lung function decreased at twice the rate in patients who continued smoking versus those who quit.

Quitting smoking provided benefit whenever the person quit. Continuing smoking or relapsing worsened lung function.

Scanlon PD, Connett JE, Waller LA, Altose MD, Bailey WC, Buist AS, Tashkin DP. Smoking cessation and lung function in mild-to-moderate chronic obstructive pulmonary disease: The Lung Health Study. AM J Respit Crit Care Med. 2000;161:381-390.

Question After reading the graph, which of the following conclusions do you think is correct? Choose the single best answer.

A. The rate of decline was the same in quitters as in

smokers.

B. Quitting smoking did not improve lung function.

C. All benefits of smoking cessation were lost if the

patient restarted tobacco use.

D. The major benefit occurred in the first year after

smoking cessation.

SUBMITSUBMIT

Answer Comment

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The correct answer is D.The correct answer is D.

BeneHts of Smoking Cessation The major benefit occurred in the first year after smokingThe major benefit occurred in the first year after smoking cessation.cessation.

This study provides important evidence to support telling your patient:

“Your lungs will work better within that first year of quitting smoking.”

“When you quit smoking, your lungs will not ‘age’ as quickly as if you continued smoking.”

“Even if you quit and then start smoking again, there may be benefit to you.”

The FEV1 did decline after an initial improvement with smoking cessation, but the rate appears to be less than the decline rate for those patients who continued to smoke (A,B).

Even if the patient began to smoke, there was benefit to having stopped versus not having stopped, according to this graph (C).

References Scanlon PD, Connett JE, Waller LA, Altose MD, Bailey WC, Buist AS, Tashkin DP. Smoking cessation and lung function in mild-to-moderate chronic obstructive pulmonary disease: The Lung Health Study. AM J Respit Crit Care Med. 2000;161:381-390.

Simmons MS, Connett JE, Nides MA, et al. Smoking reduction and the rate of decline in FEV(1): results from the Lung Health Study. Eur Respir J. 2005;25:1011-7.

DIAGNOSTIC TESTING 4 TESTING

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Dr. Wilson explains his diagnosis to Mr. Barley.Dr. Wilson explains his diagnosis to Mr. Barley.

!

Dr. Wilson asks you to consider how you might encourage Mr. Barley to quit smoking and offers you a clinician’s guide to the five As of counseling smokers to quit.

You and Dr. Wilson then join Mr. Barley in the room. “Mr. Barley,” begins Dr. Wilson, “from your physical exam and the symptoms you describe, it appears that you have chronic obstructive pulmonary disease, usually referred to as COPD. For us to be sure, however, we would like to test your breathing function. During this test, you’ll be asked to blow into a large tube connected to a spirometer. This machine measures how much air your lungs can hold and how fast you can blow the air out of your lungs.”

Dr. Wilson concludes, “OK, Mr. Barley. After your spirometry, we’ll talk about next steps.”

References

” DEEP DIVEDEEP DIVE

http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/clinicians-providers/guidelines-recommendations/tobacco/clinicians/references/quickref/tobaqrg.pdf
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Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Quick Reference Guide for Clinicians. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. April 2009. http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/clinicians-providers/guidelines- recommendations/tobacco/clinicians/references/quickref/tobaqrg.pdf. Accessed April 29, 2017.

Larzelere MM1, Williams DE. Promoting smoking cessation. Am Fam Physician. 2012 Mar 15;85(6):591-8.

Parkes G, Greenhalgh T, Griffin M, Dent R. Effect on smoking quit rate of telling patients their lung age: the Step2quit randomised controlled trial. BMJ 2008 Mar 15;336(7644):598-600.

United States Public Health Service (USPHS) clinical practice guideline on treating tobacco use and dependence. DHHS. 2008 May.

INTERPRETATION OF TEST RESULTS CARE DISCUSSION

Pulmonary Function Test (PFT)Pulmonary Function Test (PFT)

!

Mr. Barley soon returns from the lab with his pulmonary function test (PFT) report. His results are shown in the image above.

DIAGNOSES

FINDINGS

NOTES

BOOKMARKS

MENUMENU

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Question Summarize the findings from the PFT.

The suggested answer is shown below.

Letter Count: 0/1000

SUBMITSUBMIT

Answer Comment The post-bronchodilator FEV1/FVC ratio is 69%, which is less than 70%, indicating obstructive airway disease. Since significant reversibility is defined as an increase in FEV1 ≥ 12% after bronchodilator treatment, the absence of significant change of FEV1 following bronchodilator treatment on this PFT argues against asthma. The FVC is above normal or predicted, so there is no restriction to airflow. The diagnosis is likely COPD. With the FEV1 around 100%, definitely above 80% predicted, the severity is mild. So this patient has mild COPD.

While the interpretation above is generally correct, there are many nuances to interpreting these results. For more information, see references this article in American Family Physician for a good

http://www.aafp.org/afp/2004/0301/p1107.html
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overview.

Additionally, this five-minute video provides a detailed summary of spirometry findings in obstructive lung diseases:

SpirometrySpirometry

References Johnson JD, Theurer WM. A stepwise approach to the interpretation of pulmonary function tests. Am Fam Physician. 2014 Mar 1;89(5):359-366.

DISCUSSING SMOKING CESSATION CARE DISCUSSION You and Dr. Wilson enter the exam room after the two of you agree that you will be the one to inform Mr. Barley of the test results.

You begin, “Mr. Barley, the lung-function report shows that your lung function is decreased, and you do have mild COPD. This means that there’s a blockage within the tubes and air sacs that make up your lungs, which makes it harder to exhale, or blow out the air, after you breathe it in. When you can’t properly exhale or breathe out, air gets trapped in your lungs and makes it difficult for you to breathe in normally. COPD is usually caused by long-term smoking and could be prevented by not smoking or quitting smoking. However, once symptoms begin, the damage to your lungs can’t be reversed. While there is no cure, there are ways to help you breathe better. For one, we are going to prescribe a medication for you that you will inhale, so it will go directly to your airways and minimize side effects.”

Next, you and Dr. Wilson also talk with Mr. Barley about quitting smoking, using the counseling guidance outlined in the handout. You offer Mr. Barley

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There is no single best answer.

the phone number of your medical center’s smoking cessation program, and Dr. Wilson asks in a friendly way if he can call Mr. Barley in three weeks to ask about his efforts to stop smoking, to which Mr. Barley agrees.

Question What would be an effective way to begin this conversation with Mr. Barley? Choose the single best answer.

A. You know that you are killing yourself by smoking,

right?

B. Have you ever thought about quitting smoking?

C. I would like to switch gears and talk about what you

can do to keep the COPD from getting worse.

D. I think that the most important step you can take

today is to quit smoking.

E. In addition to medication, there’s something more

important that you can do. Quit smoking.

SUBMITSUBMIT

Answer Comment

How to Advise Smoking Cessation There isn’t one best way to introduce the discussion about smoking cessation. The 5 A’s of counseling were created by expert opinion, and there is no research to back up the recommendation that the ADVISE step precedes the ASSESS step. In general, connecting the smoking to the patient’s reason for being there, and delivering a clear and direct message about the need to quit smoking are felt to be most important.

TEACHING POINTTEACHING POINT

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A Cochrane Database review found that brief advice offered by a physician improved the smoking cessation rate modestly. “…Assuming an unassisted quit rate of 2 to 3%, a brief advice intervention can increase quitting by a further 1 to 3%…”

“You know that you are killing yourself by smoking, right?” (A)

Probably not the best choice, because the statement is confrontational, and the question is leading rather than more open- ended asking the patient. However, the approach is good in that the advice is given clearly and strongly.

“Have you ever thought about quitting smoking?” (B)

Choice B is a good choice if you are making an ASSESSment of the patient’s willingness to make a quit attempt. Usually the step of ASSESSment comes after the ADVICE to quit is given.

“I would like to switch gears, and talk about what you can do to keep the COPD from getting worse.” (C)

This is probably the best choice, because the statement is personalized, and offers a great transition to the ADVISE step of smoking cessation counseling: “The best thing you could do to prevent the COPD from getting worse would be to stop smoking.” This amended statement is clear, strong and personalized, key features of the ADVISE step.

“I think that the most important step you can take today is to quit smoking.” (D)

Choice D is clear and strong advice (the ADVISE step), but not personalized.

“In addition to medication, there’s something more important that you can do: quit smoking.” (E)

This statement contains a double message. Although the statement

http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD000165.pub4/abstract
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emphasizes that quitting smoking is most important, by preceding it with: “In addition to medication….” the message becomes watered down and dilutes the advice to stop smoking.

References Stead LF1, Buitrago D, Preciado N, Sanchez G, Hartmann-Boyce J, Lancaster T. Physician advice for smoking cessation. Cochrane Database Syst Rev. May 2013;(5):CD000165.

US Preventive Services Task Force. Final Recommendation Statement: Tobacco Smoking Cessation in Adults, Including Pregnant Women: Behavioral and Pharmacotherapy Interventions. September 2015. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/tobacco -use-in-adults-and-pregnant-women-counseling-and-interventions1. Accessed April 26, 2018.

THERAPEUTIC CONSIDERATIONS THERAPEUTICS

Nurse Ragucci demonstrates the use of the inhaler with a spacer.Nurse Ragucci demonstrates the use of the inhaler with a spacer.

!

https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/tobacco-use-in-adults-and-pregnant-women-counseling-and-interventions1
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Since Mr. Barley cannot commit to a quit date for smoking right then, Dr. Wilson assures him that he will be there when Mr. Barley is ready.

Nurse Ragucci joins you, bringing an inhaler and spacer with her. She first shows Mr. Barley a video showing how to use a metered dose inhaler and spacer. Then, after handing Mr. Barley the devices, she asks him to demonstrate the technique back to her while describing what he is doing to make sure that he understands (the “teach back” method).

Mr. Barley asks about using a nebulizer machine like he has seen used when a friend was in the hospital. Dr. Wilson tells him that research shows that a metered-dose inhaler with a spacer achieves equal or better results than a nebulizer machine.

What would the treatment be if Mr. Barley’s COPD were more advanced?

Comprehensive Assessment of COPD Severity In its 2017 report, the GOLD organization recommends assessing a patient’s severity of symptoms in addition to their degree of obstruction (based on the FEV1). Several objective measures of COPD symptomatology have been developed, including the COPD Assessment Test (CAT) and the Modified British Medical Research Council (mMRC) Questionnaire. Physicians then should categorize patients into one of four severity groups, A through D, depending on the combination of their testing and symptoms scores. The following table explains this in more detail:

GOLD Symptom Groups Based on Symptom Scores and Number ofGOLD Symptom Groups Based on Symptom Scores and Number of Exacerbations:Exacerbations:

CAT score < 10 orCAT score < 10 or mMRC 0-1mMRC 0-1

CAT score >= 10, orCAT score >= 10, or mMRC >= 2mMRC >= 2

0 to 1 prior0 to 1 prior exacerbationsexacerbations

Group A Group B

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http://www.mayoclinic.com/health/asthma/MM00608
http://www.catestonline.org/english/indexEN.htm
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>= 2 prior>= 2 prior exacerbationsexacerbations

Group C Group D

Therapy for Moderate & Severe COPD Therapy for GOLD group BTherapy for GOLD group B

In addition to a short acting beta agonist (SABA) for symptoms, patients in group B should be given a long acting beta agonist (LABA) or long acting anti-muscarinic antagonist (LAMA). Eventually, if symptoms worsen, they may be given both a LABA and LAMA.

Therapy for GOLD group CTherapy for GOLD group C

In addition to a SABA, LABA, and LAMA, patients in group C should be given an inhaled corticosteroid (ICS).

Therapy for GOLD group DTherapy for GOLD group D

In symptomatic COPD patients whose FEV1 is < 50% of predicted and severity of dyspnea and exacerbations is high, it is recommended that inhaled corticosteroids (ICS) be added to LABA bronchodilator treatment and/or LAMA. The addition of a glucocorticoid may increase the risk of pneumonia. Roflumilast, a Phosphodiesterase-4 inhibitor, can be substituted or added to the LAMA/LABA/ICS combinations. A SABA, ipratropium, or their combination can be used as needed. The cost of many of these inhalers can be a barrier to use. Oxygen therapy is indicated if room air oxygen saturations < 88%.

IMMUNIZATIONS CARE DISCUSSION

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The best options are indicated below. Your selections are indicated by the shaded boxes.

Mr. Barley practices using the inhaler.Mr. Barley practices using the inhaler.

!

Dr. Wilson turns to you and says, “So far, we have introduced pharmacologic therapy to improve Mr. Barley’s current quality of life. Our next goal is to prevent a COPD exacerbation. Since infection is a common cause of COPD exacerbations, we should offer Mr. Barley immunizations that might avert certain infections.”

Question “Which of the following immunizations would you recommend for Mr. Barley?” Select all that apply.

A. Influenza

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B. Varicella

C. Pneumococcus

D. Parainfluenza

E. Meningococcus

F. TdaP

G. Zoster

SUBMITSUBMIT

Answer Comment The correct answers are A, C, F.The correct answers are A, C, F.

Vaccine Adverse Events Rare, serious side effects associated with vaccines should be reported to the United States Department of Health and Human Services using the Vaccine Adverse Events Reporting System (VAERS) at www.vaers.org. VAERS produces a table of reportable events including: anaphylaxis, encephalopathy, serious or unusual events, and events described on the manufacturer’s package insert as contraindications to additional doses of vaccine.

CDC Adult Immunization Schedule The CDC’s complete schedule of immunizations for adults.

Adult Vaccine Administration Procedure

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TEACHING POINTTEACHING POINT

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https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf
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Adult Vaccine Administration Procedure Administration procedure is specified on the manufacture’s package insert. Most adult vaccines are given either: intramuscularly with a 1 to 1.5 inch needle to achieve at least 5 mm of deltoid muscle penetration; or subcutaneously with a 23- 25 gauge needle with a needle length of 5/8 to ¾ inch.

Recommended Immunizations for Patients with COPD InfluenzaInfluenza and pneumococcal vaccinespneumococcal vaccines are recommended for adults with COPD. If the patient is due for a tetanus booster, then he should receive TdaPTdaP, which contains Tetanus toxoid, diphtheria, and acellular pertussis.

The previous recommendation was to administer all tetanus boosters with Td, without the pertussis antigen. But this recommendation was changed because of increasing incidence of whooping cough and the development of an acellular pertussis component for the vaccine, reducing the side effects of the vaccine. Currently, this is a one-time booster with Td recommended every 10 years following the initial TdaP.

InfluenzaInfluenza vaccinesvaccines

PneumococcalPneumococcal vaccines (PCV13vaccines (PCV13 and PPSV23)and PPSV23)

RecommendedRecommended scheduleschedule

Annually for all persons > 6 months (influenza strains are adjusted each year for appropriate effectiveness). Vaccination is especially important

For adults aged 19 through 64 years with chronic medical conditions (this includes those with lung disease such as COPD or asthma) PPSV23 is

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for those who are at high risk of developing flu- related complications (this includes people with lung disease).

recommended. PCV13 followed by PPSV23 one year later is recommended for all adults 65 years old and older.

EffectivenessEffectiveness

Reduces serious illness and death in patients with COPD by about 50%.

Reduces the incidence of community- acquired pneumonia in patients < 65 years old with COPD and an FEV1 < 40% predicted.

AdministrationAdministration

Inactivated preparations are injected intramuscularly or intrademally. For the 2016-2017 flu season, the intranasal vaccine is no longer recommended.

Injected intramuscularly as a 0.5 mL dose at a separate site from the influenza vaccine

Previous concerns administering in patients with a history of allergy to eggs; evidence

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Side effectsSide effects

shows, however, that reactions are rare and the vaccine can be administered under the supervision of a health care provider who is competent in managing an allergic reaction. Fewer than 5 percent of patients experience side effects, which include low grade fever and mild systemic symptoms for 8-24 hours post- immunization.

Approximately one-third of patients demonstrate mild side effects (e.g., pain, erythema, and swelling at injection site) Fever, myalgias, and more severe local reactions are rare.

CONCLUDING THE VISIT MANAGEMENT

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Dr. Wilson explains COPD management to Mr. Barley.Dr. Wilson explains COPD management to Mr. Barley.

!

After reviewing Mr. Barley’s immunization history, Dr. Wilson writes an order for influenza and pneumoccocal vaccines. He then reviews with Mr. Barley instructions for managing his COPD, discussing COPD exacerbation management and when to seek emergency help.

He adds, “It will be important for you to return for regular checkups -just like we need to monitor folks with heart disease with regular visits to check their blood pressure, I would like to perform the pulmonary function tests you did today every six months to a year so we can determine how well you are responding to treatment and if your disease is progressing. And we will also want to keep track of your nutrition using what we call the body mass index (BMI), as good nutrition is especially important in COPD. Do you have any questions?”

Mr. Barley says, “Does this mean I’m not going to be able to breathe normally again?”

Dr. Wilson replies, “There’s no cure for COPD. And it’s impossible to undo

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damage to your lungs. But your treatments can control symptoms, reduce the risk of complications and improve your ability to lead an active life. Difficulty breathing can keep you from doing activities that you enjoy. And it can be very difficult to deal with a disease that is progressive and incurable. Please talk to me if you feel sad or helpless or think that you may be experiencing depression.”

“In the future, if you are interested and you’re having more trouble with COPD, I can send you to a pulmonary rehabilitation program to help with your breathing. These are programs that typically combine education, exercise training, nutrition advice and counseling. You would work with physical therapists, respiratory therapists, exercise specialists and dietitians. Again, I don’t think you need this help right now. But I want you to know there’s a whole team of folks ready to help you as you need help.”

COPD Exacerbations, When to Seek Emergency Medical Care Individuals with COPD are more likely to get frequent colds, bronchitis, the flu, or even pneumonia. When this happens, the symptoms of COPD may noticeably worsen. This is called a COPD exacerbation. An individual may find:

Difficulty catching his or her breath Chest tightness Fever Increased coughing or A change in the cough (more productive, more mucus expelled)

If the exacerbation is due to a lung infection, it can be treated with antibiotics. But there are other causes for symptoms getting worse, such as heart disease related to worsening lung disease. Patients should be instructed to seek medical care right away so the cause of the exacerbation can be determined and treatment provided.

When to Seek Emergency HelpWhen to Seek Emergency Help

A patient should seek emergency medical care if the usual medications are

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not working and he or she finds:

It is unusually hard to walk or talk (such as difficulty completing a sentence)

The heart is beating very fast or irregularly Lips or fingernails are gray or blue, or Breathing is fast and hard, even when medication is being used

References National Heart Lung Blood Institute. http://www.nhlbi.nih.gov/. Accessed April 29, 2017.

EXACERBATIONS TEACHING After Mr. Barley has gone, you ask Dr. Wilson, “Should all smokers be screened for COPD?”

Dr. Wilson tells you that the USPSTF and the American College of Physicians do not recommend screeningdo not recommend screening spirometry in asymptomaticasymptomatic adult patients. He states that some experts recommend spirometry in smokers over 45 years of age, but this recommendation may be based on the testing increasing smoking cessation rates.

Dr. Wilson then tells you about the role of antibiotics in treating patients with COPD.

Interested in the treatment of exacerbated COPD, you consult a reference and read about its causes and management:

COPD Exacerbation: DeHnition, Etiology, Treatment, Hospitalization & Followup Definition:Definition:

An exacerbation of COPD is defined as an event in the natural course of the disease characterized by a change in the patient’s baseline dyspnea,

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http://www.nhlbi.nih.gov/
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cough, and/or sputum that is beyond normal day-to-day variations and is acute in onset. An exacerbation may warrant a change in regular medication in a patient with underlying COPD.

Etiology:Etiology:

The most common causes of an exacerbation are infection of the tracheobronchial tree and air pollution, but the cause of about a third of severe exacerbations cannot be identified.

Treatment:Treatment:

Inhaled bronchodilators (particularly inhaled beta 2-agonists with or without anticholinergics) and oral glucocorticosteroids are effective treatments for exacerbations of COPD.

Antibiotics should be given to:

Patients with exacerbations of COPD with the following three cardinal symptoms: increased dyspnea, increased sputum volume, and increased sputum purulence

Patients with exacerbations of COPD with two of the cardinal symptoms, if increased purulence of sputum is one of the two symptoms

Patients with a severe exacerbation of COPD that requires mechanical ventilation (invasive or noninvasive).

Hospitalization:Hospitalization:

For those patients more severely ill who might require hospitalization, noninvasive mechanical ventilation in exacerbations improves respiratory acidosis; increases pH; decreases the need for endotracheal intubation; and reduces PaCO , respiratory rate, severity of breathlessness, the length of hospital stay, and mortality.

2

Follow-up:Follow-up:

Medications and education to help prevent future exacerbations should be considered as part of follow-up, because exacerbations affect the quality of life and prognosis of patients with COPD.

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The best options are indicated below. Your selections are indicated by the shaded boxes.

Question Which of the following are indicators that an antibiotic would be helpful for a patient with a diagnosis of an acute exacerbation of COPD? Select all that apply.

A. Increased dyspnea

B. Low-grade fever

C. Increased phlegm production

D. Change in sputum color

E. O saturation of 92% with walking 100 feet

F. Pleuritic chest pain

2

SUBMITSUBMIT

Answer Comment The correct answers are A, C, D.The correct answers are A, C, D.

Anthonisen et al. studied patients presenting with an acute exacerbation of chronic bronchitis (AECB). They examined how the symptoms of increased dyspnea (A), increased sputumincreased dyspnea (A), increased sputum (phlegm) production (C)(phlegm) production (C), and a change in color of sputum (D)change in color of sputum (D) predicted response to an antibiotic. This classic study found that in the group who presented with an exacerbation characterized by the presence of all three symptoms, 44% improved in the antibiotic group versus 31% in the placebo group. Also, only 10% of patients in the antibiotic group experienced deterioration of condition compared to 22% in the placebo group.

Low-grade fever (B), decreased O saturation of 92% with walking2

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100 feet (E), and pleuritic chest pain (F) are not indications for antibiotic treatment without making a diagnosis in addition to an acute exacerbation of chronic bronchitis. A fever might indicate pneumonia, which should be confirmed by chest x-ray, though a low-grade fever could represent a viral infection. And decreased oxygen saturation might also indicate pneumonia. Antibiotics would be prescribed for a pneumonia, but- these findings in the context of AECB do not support use of an antibiotic. Pleuritic chest pain, especially in concert with acute hypoxemia, could indicate a pulmonary embolism.

References: Anthonisen NR, Manfreda J, Warren CPW, Hershfield ES, Harding GKM, Nelson NA. Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease. Ann Intern Med. 1987;106:196-204.

Papi A, Rabe KF, Rigau D, et al. Management of COPD exacerbations: a European Respiratory Society/American Thoracic Society guideline. Eur Respir J. 2017; 49: 160079 https://doi.org/10.1183/13993003.00791-2016. Accessed April 26, 2018.

Qaseem A, Wilt TJ, Weinberger SE, Hanania NA, et al. Diagnosis and Management of Stable Chronic Obstructive Pulmonary Disease: A Clinical Practice Guideline Update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med 2011;155(3):179-191. http://www.annals.org/content/155/3/179.abstract. Accessed April 29, 2017.

Sutherland ER, Cherniack RM. Management of Chronic Obstructive Pulmonary Disease. N Engl J Med. 2004;350:2689-2697.

COMPLICATIONS TEACHING

https://doi.org/10.1183/13993003.00791-2016
http://www.annals.org/content/155/3/179.abstract
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!

Dr. Wilson also points out that one of the major complications of COPD is heart failure.

COPD and Heart Failure The proposed mechanism for COPD leading to heart failure is that chronic hypoxia (1) causes pulmonary vasoconstriction (2), which increases blood pressure in the pulmonary vessels. This elevation in blood pressure causes permanent damage to the vessel walls and leads to irreversible hypertension (3). The right heart eventually fails (4) because the pump cannot sustain flow effectively against this pressure. Right heart failure leads to an increase in preload, with peripheral edema and increased jugular venous distention.

TEACHING POINTTEACHING POINT

” DEEP DIVEDEEP DIVE

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FOLLOW-UP CARE DISCUSSION Six months later, on your longitudinal rotation with Dr. Wilson, after seeing a different patient with COPD, you ask about Mr. Barley:

“In late spring, he developed an acute exacerbation of chronic bronchitis. I prescribed an antibiotic for him, because he had severe shortness of breath and cough, with increased phlegm and a color change to the sputum. After that, he finally agreed to sign up for the smoking-cessation classes and nicotine patches. And he actually quit! He slipped back into smoking for a couple of weeks, but now he’s back to smoke-free again. I’ll probably get another PFT at his next annual physical. The evidence isn’t 100% clear, but common advice is to get PFTs at least annually for a patient who has COPD. If his PFT shows that his FEV1/FVC is < 70% or FEV1 is less than 60% of predicted, I would consider adding tiotroprium and/or a long-acting beta agonist combined with steroid to treat moderate COPD. These have been shown to decrease exacerbations and emergency room visits and may decrease the decline in lung function. I’ll be sure to let you know what they show.”

References Global Initiative for Chronic Obstructive Lung Disease. Pocket guide to COPD diagnosis, management and prevention: A guide for health professionals – 2017 Report. http://goldcopd.org/wp-content/uploads/2016/12/wms-GOLD-2017-Pocket-Guide.pdf. Accessed April 26, 2018.

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http://goldcopd.org/wp-content/uploads/2016/12/wms-GOLD-2017-Pocket-Guide.pdf
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You may now continue to the optional self-assessment questions for you to assess what you have learned in this case.

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shortness of breath.

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