Chronic Obstructive Pulmonary Disease (COPD)
R.W is a 64-year-old Caucasian postal clerk. He has a 35-pack year smoking history. He presented to the clinic with progressive dyspnea while doing simple tasks. He is having difficulty doing manual work but has no symptoms when working behind his desk. He also reports having a cough, fatigue, and weight loss. He has been treated for three respiratory infections a year for three years; he feels like he is about to have another infection. On physical examination, he has finger clubbing; he uses accessory muscles of respiration; wheezing in the lungs and the lungs are hyperresonant on percussion. Pulmonary function studies show an FEV1 of 58%. The most likely diagnosis in this patient is Chronic Obstructive Pulmonary Disease (COPD). This is supported by the fact that the patient has dyspnea as well as reduced pulmonary functions. His risk factor is smoking. COPD is characterized by persistent respiratory symptoms and airflow limitation caused by airway abnormalities resulting from exposure to harmful gases or particles. (Vestbo et al., 2012).Besides smoking, other toxic substances that can cause COPD include dust and the use of biomass fuel. The risk of getting COPD is increased in individuals with antitrypsin deficiency.
According to the COPD Foundation system, the patient in question has COPD stage 2. This is because the FEV1 is less than 60%. This staging system is simple and uses spirometric measurements. According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD), the patient is in the GOLD 2 category, moderate in terms of severity. This is also based on the FEV1 of 58%. The BODE index can also be used to assess the severity and prognosticate patients with COPD. However, it would not apply to this patient because we don’t have all the parameters for the calculation. The index looks at the Body-mass index, airflow Obstruction, Dyspnea, and Exercise. (Faganello et al., 2010).
COPD is a common condition with high mortality. The symptoms can be disabling, especially when severe. Management of the disease aims to relieve the symptoms, prevent disease progression, improve exercise tolerance, and reduce overall mortality. Other goals of management include the prevention and treatment of exacerbations as well as the complications of the disease. Possible complications of COPD include respiratory failure, cor pulmonale, pneumothorax, skeletal muscle dysfunction, and mental health disorders such as depression and anxiety. Management of COPD requires close interaction with the healthcare providers so that any problem that arises is treated in good time.
The patient belongs to group D in the GOLD ABCD classification. He has had more than three infections a year in the last three years, and he feels like he is developing one now. The initial management of this group of patients is with a long-acting muscarinic antagonist (LAMA). This class of drug will reduce breathlessness and prevent exacerbations in most patients. This class of drugs blocks the muscarinic receptors leading to smooth muscle relaxation and bronchoconstriction. Examples of LAMA include glycopyrrolate, tiotropium and aclidinium. Tiotropium is the most commonly used and is available as an inhaler for once daily use. It decreases hyperinflation and improves lung functions. For patients with severe dyspnea, combining LAMA with long-acting beta-agonist is reasonable. A combination of both drugs increases the degree of bronchodilation and, therefore, improves the symptoms of dyspnea. Using an inhaler with both drugs is recommended due to the potential for good adherence, which may result in better outcomes of the disease than using separate inhalers. Examples of LABA include salmeterol, formoterol, bambuterol, and clenbuterol. This class of drugs acts on the beta receptors in the airway, causing dilation. The treatment of pneumonia should be done promptly and the treatment tailored towards the suspected organism. Supplemental oxygen forms a cornerstone in the management of acute exacerbations.
Patients with COPD need to be monitored regularly for compliance. Symptoms can be assessed using standardized tools such as the COPD Assessment Test (CAT) or the modified Medical Research Council (mMRC) dyspnea scale. The BODE index can also be used to assess the response to therapy. The number of exacerbations should also be noted to help determine the disease’s progression and in the adjustment of medications. More exacerbations may point towards the worsening of the condition. Blood eosinophil levels and the response to inhalational corticosteroids can also help guide therapy with glucocorticoids. Eosinophil levels less than 100 cells/microL predict a low likelihood of response to treatment. Low eosinophil levels are associated with increased risk for pneumonia in patients receiving inhaled corticosteroids. (Parvord et al., 2016). The inhaler technique should also be reviewed during each visit to ensure that the patient is using it properly. The need for supplemental oxygen can also be used in the assessment of the progress of patients with COPD. Increased demand for oxygen may suggest the worsening of the disease.
The patient should continuously be educated about the therapy to improve the outcome of the disease. The patient should understand that the medications, in addition to specific lifestyle changes, help with the improvement of life functions and reduce breathlessness symptoms. The drug also helps in preventing acute flares and complications of COPD. The drug classes used in the treatment of COPD either open the airway or reduce the airway’s inflammatory activity. Corticosteroids help with the reduction of inflammation. COPD drugs such as tiotropium and salmeterol can come as metered-dose inhalers, dry powder inhalers, and soft mist inhalers. For a tiotropium inhaler, the patient needs to prepare the inhaler before use. The inhaled is then sprayed to the ground before use. Once the mist is seen, the inhaler is sprayed three more times. If the inhaler has not been used in three days, it is sprayed once onto the ground. If it has not been used in 21 days, the preparation begins again. The patient should follow the directions for cleaning after use. He or she should also watch out for adverse effects of tiotropium, such as blurred vision, dizziness, and dry mouth. (Savaria et al., 2017).
Tiotropium is associated with acute urinary retention, especially in men with benign prostatic hyperplasia. A study in patients with COPD showed that inhaled anticholinergics such as tiotropium could result in urinary retention that necessitates intervention. (Stephenson et al., 2011). Apart from the risk of acute urinary retention, tiotropium is generally well tolerated. Dizziness, dry mouth and blurry vision are other side effects of the drug. A combination of LABA and inhaled corticosteroids (ICS) such as salmeterol-fluticasone can be used in patients who develop adverse effects with tiotropium. This combination therapy improves lung function, controls milder exacerbations, and is associated with fewer instances of pneumonia. (Wedzicha et al., 2016).
The management of COPD goes beyond pharmacotherapy. Several lifestyle adjustments need to be effected to improve the outcome of patients. The patient needs to be vaccinated against common respiratory infections that may result in acute exacerbations. The vaccines include pneumococcal, influenza, and pertussis. These vaccinations have been shown to reduce the rate of hospitalization in patients with COPD. (Ignatova & Antonov, 2017). Patients with COPD should stop smoking. Smoking increases the rate of decline in lung functions in patients with COPD. Smoking cessation reduces the risk of pulmonary infections, which are likely to exacerbate COPD. Besides reducing the mortality from COPD, smoking cessation also reduces the risk of other non-communicable conditions such as cardiovascular diseases, osteoporosis, peptic ulcers, lung cancer, and other malignancies. Several interventions are available to help patients quit smoking. Initiating discussions about smoking during hospital visits is important to help the patients quit smoking. There are behavioral as well as pharmacologic strategies that can help with quitting smoking. Patients who are reluctant to quit smoking should be encouraged and educated on the dangers of smoking. Nicotine replacement therapy and bupropion are examples of pharmacologic interventions that can be employed in smoking cessation programs. (Cummings & Carpenter, 2017)
Patients with COPD should avoid exposure to noxious stimuli such as gases, fumes, and vapors that can worsen the pulmonary decline. This involves proper ventilation of homes and workspaces, using clean fuels instead of biomass and reducing pollution in factories. Airborne exposure in the workplace should be strictly monitored. (Zhou et al., 2014). Physical activity plays a pivotal role in the management of COPD. Exercise decreases the rate of decline in lung functions, particularly in smokers. Active smokers who exercise regularly are less likely to develop COPD than their physically inactive counterparts. (Vaes et al., 2014). Physical activity also improves the symptoms of COPD and the overall quality of life of patients. Nutrition is also vital in the prevention and management of COPD. COPD is associated with cachexia and muscle wasting, which is a consequence of imbalanced demand and supply of nutrients. Undernutrition in COPD patients can also be explained by factors such as aging, pulmonary cachexia syndrome, and systemic inflammation. Adequate nutrition helps patients build muscle and improve exercise tolerance. (Collins et al., 2013).
Metoprolol is a beta 1 selective antagonist that is used to treat high blood pressure and chest pains due to myocardial ischemia and heart failure. Metoprolol is cardioselective and therefore can be used in patients who are on beta agonists such as albuterol, salmeterol and formoterol. However, such patients will need to be closely monitored to ensure that the COPD is adequately controlled. Other alternatives for the management of headaches should, however, be considered in this patient. (Ajimura et al., 2018).
References
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