The PRAXIS Nexus The PRAXIS Nexus

A PRAXIS Case Study: Paul S.

Posted on February 25, 2020   |   
7 Comments   |   
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This post was authored by Stephanie Williams, BS, RRT, COPD Foundation Director of Community Programs.

Patient with doctor

Current Visit: Paul S. is a 60-year-old man with a diagnosis of COPD. He is being seen by his pulmonologist as a sick-visit due to a “cold” he has been unable to recover from for two weeks. Symptoms from this illness have become progressively worse, with increased green sputum production, and increased breathlessness at the time of this visit. Paul has had to take off work for the past three days due to impact of these symptoms and is worried about how much longer it will take him to feel well enough to return to work. This is a big concern for him because he is self-employed as a stone mason and no work means no income.

Past Utilization: Similar episodes have occurred every few months for the past seven years and have been routinely treated by his PCP. It was during of one of these episodes that he was diagnosed with COPD five years ago and was placed on a short acting beta agonist (SABA) to help with his daily symptoms. Paul was referred to a pulmonologist about two years ago to help manage the COPD symptoms since he also now deals with other chronic conditions including hypertension and diabetes.

Medical History: COPD, HTN, DM2, and arthritic joints in his hands. Last spirometry (1 year ago) FEV1= 56% of predicted. 60-pack-year cigarette history, still smoking. Negative for Alpha-1 Antitrypsin Deficiency.

Respiratory Medications: Albuterol PRN for symptom control

Family History: Father, age 80, with hypertension,hyperlipidemia, and prostate cancer. Mother, age 78, treated for diabetes, emphysema, atrial fibrillation, and depression. Paul has one sibling, a sister age 55 who has diabetes and hypertension.

Examination:

  • CXR: Severe hyperinflation, negative for pneumonia.
  • Pulse oximetry: Room air 90%.
  • Respirations: 18 breaths/minute
  • Heart rate: 105 Beats/minute
  • Breath sounds: rhonchi, clears with forceful cough

Questions:

  1. What are your impressions?
  2. How would you manage his current problem?
  3. What additional steps would you recommend for future disease management?
  4. Do you think non-pharmacological interventions are appropriate at this time? If so, what would you suggest? If no, why not?
  5. What education would you provide to Paul at this visit?

7 Comments



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  • Copd exacerbation, possibly bronchitis.

    Offer breathing treatment plus 5 day prednisone--(dose adjusted or could be contraindicated with the D2 and hypertension?) and broad-spectrum antibiotic--should do a sensitivity culture--and guaifenesin. CBC with differential, CMP. Needs a long-acting controller med added, maybe with an ICS.

    Future: CT scan preferebly HRCT, full PFT, six minute walk test or overnight pulse ox to see if he would be a candidate for Ox therapy after flare resolved.

    Non pharm: develop action plan,smoking cessation, discuss pulmonary rehab.

    Patient education action plan as above resources for COPD management and smoking cessation info.




    Reply
    • Oh, yes, he is a stone mason so workplace environment can also be contributing to the COPD and further damage, so that should be addressed and CT scan may reveal evidence of damage from stone dust.
      Reply
  • Copd exacerbation

    CT, full PFT's with pre and post bronchodilator. Add LABA-LAMA daily with Albuterol for rescue med. Question if he uses Albuterol and if so how often. Does he use with spacer? Add steroids.

    Counseling on smoking cessation, COPD education. Agree that he may need to change professions due to masonry dust exposure which may compound the COPD. 6 minute walk. Smoking cessation may help with DM2 and HTN.

    Pulmonary rehab.

    Reply
  • -What are your impressions?-COPD Exacerbation (Maybe due to another bacterial or viral infection or maybe not)

    -How would you manage his current problem? For his current issue, I would immediately check for vaccination history and swab/culture for any other infections and treat accordingly. I would also add additional inhalers and train the patient to use them appropriately via Incheck (or similar device) and placebos. Also introduce the regular use of a spacer.

    -What additional steps would you recommend for future disease management? Imaging, outpatient PFT's to check for disease progression. refer to pulmonary rehabilitation, get a cardiac consult, add LABA/LAMA and ICS if needed. Most importantly, I would check in about his living situation, family/friend structure, work environment and the depression that comes along with chronic diseases. Even asking about chronic diseases seem to be difficult for clinicians and could by far be the thing that opens up the door to more understanding and better outcomes for the patient.

    -Do you think non-pharmacological interventions are appropriate at this time? If so, what would you suggest? If no, why not? Addition-based nicotine cessation (with someone trained in the use of motivational interviewing in healthcare and the transtheoretical model of change). Consult with an exercise physiologist and dietician. Outpatient counseling.


    Reply
  • Paul still works full time and may not be able to take the time off to attend Pulmonary Rehab classes, but he may benefit from using the My COPD Action Plan to keep an eye on his day to day ability to perform his activities of daily living. It seems like maybe Paul needs to better understand the early warning signs of exacerbation so he doesn't allow himself to get sicker before seeking medical attention. My experience has been that most people don't understand that an exacerbation is simply defined a worsening of symptoms and they should seek care when they first notice the symptoms, and not wait to see if things get better on their own.

    I also agree with the others who have said he needs to be counseled on smoking cessation. As @Gabrielle Davis mentioned, motivational interviewing might be very helpful here to help Paul move from smoking to being a quitter with success.

    Would you be interested in hearing the rest of Paul's story?
    Reply
  • Paul does, indeed, need some information and education on avoiding COPD exacerbations.

    The COPD Foundation PCG app - Patient track is a good start. Paul can put his symptoms into the app and immediately get suggestions on what to do next in order to more likely avoid an exacerbation. He can also download the "Report Signs of Exacerbation" reminder. In addition to the this piece, he will find "facts sheets" and more on avoiding exacerbations.

    Because he works full time and may be unable to attend pulmonary rehab, he might benefit from the exercise videos that are also a part of the app. Here are links to these resources.
    PCG Patient app:
    https://www.copdfoundation.org/Learn-More/The-COPD-Pocket-Consultant-Guide/Patient-Caregiver-Track.aspx
    Downloads library: https://www.copdfoundation.org/Learn-More/Educational-Materials-Resources/Downloads.aspx



    Reply
    • I would suggest a mask while working
      I would suggest an allergy blood test to see if any allergies are making it worse.
      Acapella to use after work .
      smoking cessation give him a Phone number 1-800-784-8669.
      PFT to see how his air is moving .
      Ask how he is using his inhaler .
      see if he has had a pneumonia shot go over pursed lip breathing and huff technique
      Has he been tested for alpha deficiency
      Reply