The PRAXIS Nexus The PRAXIS Nexus

A COPD Case Study: Jim B.

Posted on September 21, 2017   |   
14 Comments   |   
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COPD case study

We're interested in your thoughts on our latest COPD case study: Jim B., a 68-year-old man here for his Phase II Pulmonary Rehabilitation intake interview.

A bit more about Jim:

Medical history: COPD, FEV1 six weeks ago was 38% of normal predicted, recent CXR shows flattened diaphragm with increased AP diameter, appendectomy age 34, broken nose and broken right arm as a child.

Labs: Lytes plus and CBC all within normal limits.

Physical exam: Breath sounds markedly diminished bilaterally with crackles right lower lobe and wheeze left upper lobe. Visible use of accessory muscles. O2 Saturation 93% room air, 95% O2 on 2lpm. Respiratory rate 24 and shallow, HR 94, BP 150/88, 1+ pitting pedal edema.

Current Medications: Prednisone 10mg q day / DuoNeb q 4 hrs. / Ibuprofen 400mg BID / Tums prn (estimates he takes two per day).

Respiratory history: 80-pack-year cigarette history, quit last year. He has developed a dry, hacking, non-productive cough over the last six months. Had asthma as a child and was exposed to second-hand smoke and cooking fumes while working at family-owned restaurant as a child. Lately, he has noticed slight chest tightness and increased cough when visiting his wife’s art studio.

Family history: Father had emphysema, died at age 69, mother died of breast cancer at 62. Grandfather died at age 57, grandmother died in her 40s of suicide. Six adult children, alive and well.

Previous respiratory admissions: Inpatient admission for six days last winter for acute exacerbation of COPD with bacterial pneumonia requiring 24-hour intubation and mechanical ventilation.

Psych: Jim presents to his Phase II Pulmonary Rehab intake interview appearing disheveled, wearing a sweatshirt, pajama pants and bedroom slippers. He is accompanied by his wife and adult daughter who appear neat, clean and well dressed. Patient states, “I don’t think you people can do anything to help me. I’m only here because they (referring to wife and daughter) made me go.” Jim states that he has been doing less and less at home since discharged from the hospital last winter. Wife states, “He walked outside a little with our grandchildren last Sunday and got so short of breath, he almost collapsed.” Became emotional when saying, “It scared the kids. It tore me up for them to see me that way. Besides that, with this darn shoulder I can’t even pick up the little ones anymore.”

COPD case study

Social: Lives at home with his wife of 43 years who works as an artist. Two out of his six children live within 30 miles of Jim’s home.

Occupation: Building contractor, retired three years ago. Jim states, “I made a good living. All the kids were able to go to college. I was strong. I could work circles around anybody in my crew. And now look at me. I’m tied to that darn breathing machine (referring to nebulizer) and I might as well hang it up.” Wife states, “He used to have all kinds of energy. Now all he does is sit in his chair watching TV, eating potato chips and peanuts.”

Tell us your impressions!

  1. What co-morbidities should be explored?
  2. How would you change Jim’s medication regime?
  3. What psych/social recommendations would you make?
  4. What other medical disciplines should do a consult on this patient?
  5. This is a real case. What are your thoughts on what took place following Jim’s pulmonary rehab intake interview?

14 Comments



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  • I'd do an x-ray to rule out pneumonia (all those crackles and diminished breath sounds).

    He sounds and looks depressed, so a mental health assessment is probably in order. Then a referral to a good talk therapist who's well versed in chronic conditions and cognitive behavioral therapy (because he's going to want to see something "right now" that he can at least try, even if it's just to say this is not worth my time). Also a psychiatric consult for possible med prescription and monitoring.

    Why is he on nebulized medication? He sounds like a good candidate for a LABA/LAMA combination and maybe an ICS to help him get off the oral prednisone.

    What are his O2 sats moving around? He does use O2, apparently, so that's what he's attached to, not his nebulizer.

    I'm guessing that he went home or was admitted for pneumonia after the x-ray. You'd need to get him at least dressed appropriately for a gym before you could get him actually moving!


    Reply
    • Hello Jean, Debbie, Kay,5674, and all who are have joined us in exploring this case study.

      "Jim" was on nebulized medication because it was cheaper and his primary care provider (rural family doctor) felt that he would get more of the meds with a nebulizer than if he had struggled with an inhaler.

      Actually, Jean, he doesn't use O2. His sats are moving around like this at this time due to his irregular breathing pattern and so little control over his shortness of breath.
      Reply
  • My uneducated guesses....

    My first thought is depression, he has a family history. Maybe a psychiatrists should be considered, that is assuming anti-depressants might be in order. His father died at the same age of emphysema, his mother and grandfather at a younger age, on some level this might be effecting him. Smoking can often mask depression because of the elevated dopamine level. It can go unnoticed and diagnosed until the person quits smoking. Quitting itself can also cause some intense mood swings and depression. One year for the smoker is not really that long. This could be a contributing factor. I wouldn't assume he is good with his quit, that it is done and over. And then there is the part about being diagnosed with a chronic illness for which there is no cure. Someone in the mental health field should be consulted.

    I don't understand the ibuprofen, I don't see any reason why he would be taking it. I did a quick check and that can cause depression and shortness of breath.

    I also do not understand the prednisone 10mg q day with an FEV1 of 38% unless he is having another exacerbation. That would contribute to his poor mental state.

    I don't understand the nebulizer at all. I believe that includes an anticholinergic and albuterol but not a LABA and not a ICS. I am surprised that I not to see one of the very common standard issue inhalers. The use of an inhaler rather than a nebulizer might help him psychologically. Having to use the nebulizer every 4 hours is obviously having an impact on him. An inhaler, used once or twice a day with a rescue inhaler in his pocket might give him back a sense of freedom and independence.

    His heart rate runs on high side, normal but on the high end. Same with the blood pressure. The edema could be an indication of heart or it could be a side effect of the nebulizer. I would think a cardiologist would be in order. The higher heart rate would contribute to his shortness of breath; something to lower his blood pressure and slow down his heart rate would help him feel better. If the edema is a side effect of the medications, less albuterol which I might be possible if he was on a LABA and possibly an ICS.

    He needs rehab; not only help him get moving again but to learn pursed lipped breathing. He needs to learn how to manage his shortness of breath so it is less intimidating. He needs to build up both his endurance and his strength, lots of strength. PR can help with that.

    If he needs O2 to exercise or for any kind of activity, he should get a POC. If the nebulizer is too much for him, I can't imagine what a tank would do to his spirits.

    Hopefully his situation improves and he can regain some quality of life.

    Reply
    • Hi Clipper, the ibuprofen is Jim's way of controlling his constant shoulder pain and lack of shoulder mobility. Assuming that Jim would be a "non-compliant" patient and have poor inhaler technique, his primary doc prescribed daily prednisone. Similar reasons for the nebulizer vs. inhaler in addition to it being much more affordable.
      Might the edema be related to his frequent snacking habits?
      Reply
  • My hope is that he became engaged in phase 2 pulmonary rehab and a star in his group. He invested the hard work and dedication he put into his former career into his PR. He began taking care of his appearance and charge of his health as well as feeling purposeful again.

    I hope his docs explore depression as a comorbidity and help him to achieve small successes in his every day that are rewarding to him so that he can feel valued and in charge of his own life again.

    What was the role of his PCP?
    Reply
    • Kay5674, you give us some hope with the possibility of this patient really taking ownership of his COPD and his place in the pulmonary rehab program!

      You see that he was a real "take charge" kind of guy and now he sees himself as being at the mercy of his COPD and kind of resenting the role his wife and children are starting to take on. He and his wife have always had a great relationship, and he has respect for her, but yet, he wants to take care of himself as well as possible.
      Reply
  • I would get a HRCT done. His symptoms were dry hacking cough, discomfort in his chest, weakness and he looks very thin by his picture. It stated he is taking Tums along with his RT meds. Does he have a history of acid reflux? Plus, he had pneumonia. The HRCT might show UIP (usual interstitial pneumonia) If crackles are heard in bases I wonder if the HRCT will show honeycomb on the sides of the parenchymal of the lung bases. Since he had pneumonia and nothing was mentioned if it was bacterial pneumonia. IIP (Idiopathic interstitial pneumonias where the lung tissue becomes inflamed and that is when scarring occurs. Then I would get a PFT to see if his numbers lean towards restrictive.
    Reply
    • Thank you for those great observations and suggestions, Vickie!
      Reply
    • Thank you also, Higuy, for your input! Very interesting and helpful!


      Reply
  • Jim B. presents as a healthy, well developed 68 y/o m experiencing no to minimal improvement in his breathing since his hospitalization. Unfortunately for him, apparently he was not offered, or refused, P.R. post hospitalization, the lack of which has contributed to his stagnation and depressed mood. Combine this with a negative change in his habitus (not consumed by his building contractor work) it is easy to understand his increasing resentment (with his condition, toward those (wife and daughter) who don't really know how to help him get better). Enrollment in P.R. as soon as possible is desperately needed by Jim B. and his family.
    Based on history and physical assessment my impression is COPD with probable Asthma Overlap Syndrome. Co-morbidities probably include Pulmonary Hypertension secondary to Congestive Heart Failure. I suspect his sleep habitus is worsening due to shoulder pain, acid reflux, and increasing work of breathing. Probable acid reflux with symptom flare when first laying down to sleep, could be leading to micro-aspiration contributing to his increasing dry hacking cough.

    Treatment recommendations:
    Wean prednisone to discontinued.
    Duoneb q6 w/a
    Budesonide BID
    Spiriva q day
    Albuterol HFA prn
    Nexium 20mg Q day x 4 week trial

    Consults:
    Pulmonologist, Board certified in Sleep Medicine preferred. - for management of pulmonary disease and investigation of probable sleep dis-ordered breathing.
    Orthopedic Specialist - for work-up of shoulder pain and treatment.
    Dietician - for nutritional assessment and dietary recommendations.
    Social Worker - for possible help with medication obtainment and referral to local COPD support group.
    Community counseling - for clinical help with probable depression.
    Gastroenterologist if acid reflux symptoms do not abate.

    Direct patient and family to COPD360 Social for social support.

    Wishing Jim B. and his family improved health and happiness in the year to come.

    Reply
  • I forgot to add referral to a cardiologist for cardiac work-up for probable congestive heart failure.
    Reply
    • Thank you also, Higuy, for your input! Very interesting and helpful!
      Reply
  • Patients like "Jim" are the reason that PR is so valuable!!

    He is an individual with a lot of potential. One of the primary things that he needs is education that his COPD is treatable. It may be that he needs some counseling and/or an anti-depressant to be able to "hear" that message, but I have enormous hope for him.

    Ideally, he would be on a LABA + ICS. A SABA inhaler rather than a nebulizer would be optimal, as has been mentioned.

    If he doesn't already have a pulmonologist, he should be referred. Perhaps he could benefit from a nutritionist and either COPD360 or a community support group.

    In many ways, he is in a great position. He isn't gravely ill, and he has lots of family support. He just needs to be empowered. The psychosocial benefits of PR will likely motivate him--just being with others that are facing the same issues and making progress may inspire him.

    Right off the bat, learning techniques like pursed-lip breathing should make him see a little progress.

    Great case, thanks for sharing!!
    Reply
  • Hello all...

    Thank you for your participation in the discussion of the Jim B. case study! You had a lot of good input on how to help this patient a well as valuable insights on working with an individual who presented initially as less than receptive to the help we all knew we could provide.

    Here are the impressions and plan.
    Impression:
    1. Advanced COPD
    2. Depression
    3. CHF
    4. GERD
    5. Deconditioning with muscle weakness
    6. Frozen shoulder

    PR Team, Physician Plan:
    1. Begin Pulmonary Rehabilitation, emphasize the importance of consistent attendance.
    2. Discontinue Prednisone (step-down protocol). Start Symbicort. Train with holding chamber requiring return demonstration.
    3. Schedule Echocardiogram, High resolution chest CT.
    4. Evaluate shoulder range-of-motion in first two exercise sessions with possible PT referral.
    5. Psych consult and Pulmonology consult after settled into rehab.
    6. Nutrition consult. Follow up two weeks later to evaluate use of Tums vs. Pantoprazole.
    7. Instruct in exercise log protocol.
    8. Provide frequent opportunities for patient to make decisions in the course of his therapeutic exercise.
    9. Encourage him to go on easy outings with his wife and report to PR staff.
    10. Provide caregiver educational materials and support information to wife.
    11. Encourage interaction with PR classmates.
    12. Emphasize importance of attending all classroom sessions.
    13. Cardiac monitor first 4 sessions, then evaluate if continued monitoring is needed.

    As for this actual case, "Jim" entered into pulmonary rehab a number of years ago. We were a bit taken aback by what we saw in the initial interview but pleasantly surprised when he showed up to exercise class the next day. "Jim" completed pulmonary rehab phase II, started in our phase III maintenance program right away, and attended faithfully for many years. He was cheerful with a fun sense of humor, and always a great support to our staff and his fellow classmates. We were surprised when he had missed a week of maintenance class, and even more surprised when we learned the next day that he had fallen very ill and passed away peacefully - on his own terms.

    Reply

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