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A COPD Case Study: Susan M.

Posted on December 05, 2017   |   
12 Comments   |   
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COPD case study

Meet Susan M! Share your impressions in our latest COPD case study.

Summary of in-patient admission: Susan M. is being discharged today following a 6-day ICU and step-down admission for acute exacerbation of COPD with bacterial pneumonia requiring intubation and mechanical ventilation for a period of 32 hours. Subsequent to her extubation and transfer to the step down unit she was treated with oral antibiotics and Albuterol and Ipratropium nebulizer q 4 hrs. and prn at noc.

Past utilization: Susan was admitted to the hospital for eight days last winter for acute exacerbation of COPD with bacterial pneumonia requiring 48-hour intubation and mechanical ventilation. Since then she has been seen in the ER x 2 for extreme shortness of breath with anxiety with no evidence of infection. On both occasions her shortness of breath subsided with nebulizer treatments, low flow O2, and coaching in relaxation techniques. On one of those visits Susan reported that her shortness of breath “ramped up” when she was unable to contact her daughter who, at the time, was driving alone, long-distance. “I worry a lot. I try to tell myself not to worry, but I just can’t help it.”

Medical history: COPD, systemic hypertension, hip replacement 5 years ago. FEV1 is 50% normal predicted. 35-pack year cigarette history, quit at age 50. Bone density: T score: -2 (low bone density possibly leading to osteoporosis).

Family history: Father died of stroke at age 80, mother died of injuries due to a MVA at age 75. Has three adult children with no known medical problems.

CXR at discharge: Mild hyperinflation, no pneumonia.

Pulse oximetry: Room air 95%.

Height: 65” Weight: 130 lbs. Susan has lost 5 lbs. within the last year with no intention of losing weight.

Psych/Social: Widowed. Lives alone. Husband died of internal injuries following a MVA 2 years ago. Spends meal times alone. “I used to make big meals when everybody was here but now, why make a big deal out of cooking when I’m the only one?” Our youngest son and his family live 15 miles away. “They’re so busy, I hate to bother them.” Susan drives her car only during the day and when “absolutely necessary,” sometime not leaving the house for up to 6 days at a time.

Here are a few questions for your consideration.

  • What are your impressions?
  • What are your post-acute recommendations for this patient?
  • What follow up would you conduct with this patient and within what time frame?
  • What education would you ensure this patient has at discharge?
  • Would you recommend any consults in addition to nutrition and behavioral health?

Share your thoughts in the comments below!

12 Comments



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  • Personally, I would give her a hug and some type of friendship and my contact number just in case she needs to talk. I didn't want to give a lengthy medical explination without first showing Susan I truly cared!
    Reply
    • Thank you for your comment, Bill66. Yes, I think a hug might be a good start!
      Reply
  • Poor Susan! It seems that her anxiety is really causing her to isolate herself. No doubt the tragedies with multiple family member dying in MVAs impacts her willingness to travel, and her anxiety when loved ones travel. And she likely has depression as well. She needs a lot of attention, immediately. She is really falling through the cracks. It is unfortunate that she gets so much care when she is really sick, but seems to drop off the radar after discharge.
    I would recommend behavioral health and nutrition consults. She could definitely use Pulmonary Rehab, too. The social relationships she would likely form there would be invaluable. The PR exercise program would help with bone strength and the anxiety/depression.
    Reply
    • Thank you, Chaffee, for your comment. She is absolutely falling through the cracks!
      Reply
  • I certainly agree that her anxiety is probably her biggest problem, along with depression, and would strongly recommend a referral to a good talk therapist, probably a cognitive behavioral therapist who could work with her on the anxiety and all the emotional issues associated with losing her husband, not to mention the issues of social isolation, isolation from her family and ways she can build community again. She could also get ideas on how to engage her son more in her life without feeling like she's asking for help or "bothering them". Greif counseling is probably also necessary to help her deal with her husband's death. That's another place where she could begin to build a support system. Certainly a nutritionist will help so she knows what she should be eating and perhaps ideas on how to cook interesting things for one person.

    A referral to Pulmonary Rehab is certainly appropriate, because she would learn breathing techniques that would help her when she begins to feel panicky, as well as becoming educated regarding COPD and learning an exercise routine which will help with the anxiety, depression and isolation. It would also provide another avenue to develop some relationships and be less isolated. A visit with her pulmonologist to develop an action is necessary so she can learn to catch things early before she lands in the hospital.
    Reply
    • Thank you for your comments, Jean. All of you are bringing in great observations and suggestions. I like your idea of getting her son involved and visiting a pulmonologist.
      Reply
    • Susan was given nothing but nebulizer treatments throughout this most recent hospital stay. Upon discharge do you think she should be set up with a home nebulizer or MDI's?
      Reply
  • Where to begin...

    She is clearly GOLD class D COPD and in need of a dramatic increase in her medication management. Considerations for "triple therapy" can be argued, although she has had a qualified pneumonia making the use of an inhaled steroid cautious in light of gross under treatment before her intubation. With this in mind, I would lean in favor of LABA/ LAMA upfront, consider her ability to use an MDI vs. Dry Powder delivery, and consider use of an inhaled steroid at a later date.

    I whole heartedly agree with all the comments and would love to see Susan in our Pulmonary Rehab where we can begin to tackle the social isolation, exacerbation, education, and return her to active life.

    Reply
    • Thank you, Dr. Robinson. You make some great points, but especially the one about considering her ability to use various inhaler devices.

      Something that struck me in this case study was that Susan was given nebulizer treatments all through her hospital stay, then sent home with prescriptions for inhalers. This creates a huge gap in her medication regimen because how is Susan supposed to learn how to take these effectively, and how is her doc going to know if Susan is taking these inhalers correctly?

      Furthermore, she seems to have a history of working through her bad episodes of anxiety with nebulizer treatments. Sending this lady home, living alone, with a new med plan is setting her up for less than optimal management, if not failure. :-(
      Reply
  • It would have been great if Susan could have been sent home with a home health care team. Medicare covers it. She would have had access to physical therapy, respiratory therapy a speech pathologist and a nurse. All would have helped with her breathing techniques, meds and her overall confidence. I do agree that Susan needs to see a cognitive behavioral therapist (Phd) level). Bill, I agree a hug would definitely be in order.
    Reply
  • I think that most of Susan's issues have already been addressed, but one thing stands out to me. She does not leave the house for 6 days at a time. This is a very easy pattern to fall into. She should try to break down her grocery shopping and errands so that she goes out multiple times per week.

    Being with people even if they are strangers is a boost to me and I think might also be a boost to Susan.

    I also think that she is very under medicated. It does not seem that she has a way to continue her nebulizer treatments at home. I also like the idea of a home health care team. I have found them to be extremely helpful.
    Reply
  • I’ve encountered quite a few patients that has Susans case; i think a good support group and patient education on how tonprevent COPD exacerbations can be discussed with Susan. Encouraging her that she can still be active with proper respiratory treatments, overnight testing maybe she needs nocturnal oxygen theraphy, an in-dial check of her inspiratory flow maybe the ROA of her dpi or mdi isnt sufficient enough that she can use an alternative route of svn theraphy. Also, I have multiple successes stories with my own patients that are currently on NHV therapy that kept them out of multiple readmissions in the hospital. A follow-up homecare visit of an RT teaching her how cope up with SOB especially when her anxiety kicks in may be a life changing way of her on overcoming her anxiety.
    Reply

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