The PRAXIS Nexus The PRAXIS Nexus

Our First PRAXIS Case Study

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 Doctor thinking about case

At the COPD Foundation's recent 2017 Readmissions Institute for Connecticut healthcare providers, participants broke into groups to discuss distinct pulmonary case studies. The following is one of those case studies along with the recommendations of the group who focused on the case. Do you agree with their assessment and approach?

Situation

A 72-year-old man is admitted to the hospital with respiratory symptoms. He had been feeling well but developed a URI about 10 days ago. This was followed by chest congestion, wheezing, shortness of breath and a cough productive of green sputum.

Background

This patient has a medical history of asthma, depression, an MI, HTN, GERD, cataract, erectile dysfunction and a 40-pack-year smoking history for which he quit smoking in 2012. His respiratory history includes childhood asthma, which he outgrew in his teens, occasional bouts of sinusitis, started smoking in his 20s, began having recurrent wheezing, exertional dyspnea and twice yearly bouts of bronchitis beginning at age 45. He has had three admissions to the hospital for respiratory illnesses in the past five years, most recently one admission six months ago. 

Family history: his father had asthma beginning in his 50s and died of respiratory disease in his 60s. This patient has never had spirometry. He currently lives alone, is retired, active in church, loves to travel, has difficulty reading English, has Medicare insurance and has low social support. His medications upon admissions are Venlafaxine for anxiety, Hydrochlorothiazide for hypertension, Atelolol for HTN post-MI, Tadalafil, a vasodilator, Albuterol MDI and Advair 250/50 "when he needs it."

Assessment

On physical exam on admission, he has normal vital signs, SpO2 of 94% on room air and 98% on oxygen. Upon auscultation he has bilateral medium pitched expiratory wheezes. His cardiac workup is negative including evidence of CHF. His lab work does not reflect any signs of infection. 

Recommendations and discussion from Group A:

  • Gather the interdisciplinary team: hospitalist, pulmonologist, psychiatrist or psychologist, RN, RT, PT, social work, nutrition, care management, pharmacy and interpreter services (if the patient cannot read English well, provide him discharge instructions in his native language).
  • Obtain a sputum culture.
  • DFA/PCR
  • Obtain imaging: CXR, CT scan
  • Possibly alpha-1 antitrypsin deficiency testing or his history and family history of worsening of symptoms in his 40s and 50s.
  • Treat initially with empiric antibiotics, steroids (both oral/IV and inhaled), beta-agonists.
  • Social work consult -- assess social support, reach out to family, friends, other social services
  • Bedside education by RT on inhaler use with interpreter services.
  • Pharmacy medication education with interpreter services

Questions from the discussion group:

  • Does this patient's presentation warrant hospitalization? O2 use?
  • Conflicting views during discussion: should we obtain spirometry and FeNO testing during a suspected exacerbation? Should we wait?
  • Without spirometry and FeNO it is difficult to differentiate between asthma, COPD and asthma-COPD overlap syndrome. But does this differentiation matter at this point in terms of his management?

Assuming for the purposes of the discussion that this patient responds at a reasonable rate and is ready for discharge on day 5:

  • Arrange for an apothecare service or Med to Bed to supply patient with medications upon discharge.
  • Arrange for follow up with PMD or pulmonologist within five days of discharge.
  • Purse Alpha-1 testing.
  • Within 48 hours of discharge, APRN or RN makes a discharge phone call to check in.
  • PTs within six weeks, including spirometry, lung volumes, diffusion, FeNO, pre- and post-bronchodilator and 6-minute walk.
  • Social work follow up to connect to resources in the community (e.g., Agency on Aging).
  • Psych follow up for anxiety.
  • Pulmonary rehabilitation if he qualifies.
  • Once diagnosis is confirmed, establish an asthma or COPD action plan: make sure the action plan is clear, mostly likely needed in his native language, with instructions for how to escalate rescue medications and when to contact the doctor vs. go to the hospital.
 COPD case study

How would we measure our success with this patient?

  • A diagnosis
  • Improved patient understanding of disease and treatment plan
  • Patient controlling his symptoms from home/outpatient care
  • Improved dyspnea
  • Reduction in exacerbations
  • Reduction in readmissions

What are your thoughts on this patient's presentation? Do you see any other red flags in his history? Do you agree with this group's assessment and treatment plan? We want to hear from you in the comments!

The COPD Foundation would like to thank Dr. Dick ZuWallack and Marjorie Cullinan for their work on this case study as well as all participants who contributed to this robust discussion.

2 Comments



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  • Awesome Study.
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  • One thing I would add as far as measuring success is an actual definition of "controlling his symptoms." I would recommend the use of an objective assessment tool (such as the St. George's, the CAT, or the CCQ, with a preference for the CAT for GOLD classification) and trending over time to more clearly assess symptom burden and functional management. I would also keep roflumilast on the table, since it seems unclear whether he's a true frequent exacerbator or not; this should become clear when his medication regimen is optimized. Either way, he probably needs to add a LAMA to his treatment, and (should his formulary permit it) switch to a LAMA/LABA combination rather than the LABA/ICS to minimize the risk of pneumonia.
    Reply

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