CASE STUDY

                                              Gary T. Ferguson, MD, FCCP*

                   BACKGROUND                                    and can occasionally hear herself wheezing during
                                                                 these times. The dyspnea is partially alleviated with the
     A 59-year-old Caucasian female complains of                 use of her albuterol metered dose inhaler (MDI).
 increasing shortness of breath. She states that her             Other than using the albuterol MDI, she does not feel
 breathing problems began about 3 years ago after an             that her various inhalers relieve her dyspnea or
 upper respiratory tract infection that progressed               improve her activity level. On a good day, she can
 into a sinus infection and “walking” pneumonia. At              climb 1 flight of stairs and walk about 6 blocks. She
 that time, she received antibiotics, a corticosteroid           denies any history of hemoptysis or chest pain. In
 shot, and an albuterol inhaler to be used on an as-             terms of other systems, the patient reports occasional
 needed basis. Her breathing problems became pro-                headaches, arthritis, muscle aches, anxiety, depression,
 gressively worse, however, despite use of various               intermittent diarrhea, and 1 episode of nephrolithiasis.
 inhalers and repeated courses of antibiotics. Her                   The patient’s past medical history includes
 primary care physician diagnosed asthmatic bron-                osteoarthritis, anemia (prior to a hysterectomy), depres-
 chitis and then chronic bronchitis, prescribing more            sion (related to her inactivity), and gastroesophageal
 inhalers and advising her to quit smoking and to                reflux disease. She has had an appendectomy, cholecys-
 receive a pneumococcal vaccine and a yearly                     tectomy, hysterectomy, and ankle surgery. The family
 influenza vaccine. After several prior attempts, the            history is largely unknown as the patient is adopted. She
 patient finally quit smoking 8 months ago without               has 3 children; the eldest child has asthma.
 any assistance. Because of a continued increase in                  Her current medications include potassium chlo-
 dyspnea, she now seeks further evaluation.                      ride supplements, calcium, magnesium, fluoxetine,
                                                                 fexofenadine, celecoxib, albuterol as needed (about 2
                                                                 puffs 10 times a day), ipratropium plus albuterol (2
                                                                 puffs 2 times a day), and triamcinolone acetonide (2
 MEDICAL HISTORY                                                 puffs 2 times a day without using a spacer). She states
     On more detailed questioning, the patient admits            she is allergic to intravenous contrast dye and to
 to a persistent cough and 2 to 3 episodes of bronchitis         influenza vaccine.
 annually over the last 10 years, with each episode last-
 ing longer than normal and requiring antibiotics. She           SOCIAL HISTORY
 describes her current coughing as daily (predominant-                The patient smoked 1.5 packs of cigarettes per day
 ly in the morning) and productive (clear-to-white spu-          for approximately 40 years but quit 8 months ago. She
 tum). She notes dyspnea with any significant exertion           is currently exposed to moderate levels of secondhand
                                                                 smoke at work. She denies alcoholic beverage intake or
                                                                 illicit drug use. She worked for 15 years at an automo-
    *Director, Pulmonary Research Institute of Southwest
                                                                 tive plant with some exposure to coolant mists associ-
Michigan and Adjunct Associate Professor at Wayne                ated with machining car parts. She did not wear any
State University.                                                protective devices but did not directly work with the

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                                                               CASE STUDY

 machines. She has always lived in Michigan and has no                        3. Discontinue triamcinolone acetonide for now.
 illnesses associated with travel. She received the                           4. Perform walk test for desaturation with activity.
 influenza vaccine several years ago, became ill after-                          (Test was performed in the clinic and demon-
 wards, and has refused vaccination ever since. She did                          strated a fall in oxygen saturation to a low of 90%
 receive the pneumococcal vaccine 3 years ago.                                   on room air, not requiring oxygen supplementa-
 PHYSICAL EXAMINATION                                                         5. Obtain and review outside chest radiograph.
     The patient is a pleasant, alert, oriented female in no                  6. Order pulmonary function testing.
 acute distress. She is 5 feet 2 inches tall and weighs 129                   7. Follow up to review test results and patient status.
 pounds. Vital signs include respiratory rate of 18/min;
 heart rate, 84/min; blood pressure, 150/80 mm Hg;                          INTERIM REVIEW
 oxygen saturation, 94% on room air; and temperature,                           Since her previous visit, the patient has noticed a
 98.9ºF. Other than erythematous nasal mucosa, with                         modest improvement in her symptoms. She reports that
 some crusting bilaterally, findings from the head and                      regular usage of the ipratropium + albuterol resulted in
 neck examination were normal. Heart rate and rhythm                        a decrease in her dyspnea and an increase in her ability
 are regular, with normal SI and S2 and no murmurs, gal-                    to perform daily activities. She continues to have a mild
 lops, rubs, or heaves. Chest wall is symmetric, with                       cough and has occasional clear-to-white sputum pro-
 increased anteroposterior diameter of the chest, and is                    duction in the morning. She denies any chest pain or
 nontender to palpation. A lung examination showed                          other acute symptoms. Her oxygen saturation on room
 mild hyperresonance to percussion bilaterally. There is                    air at rest is now 95%. Her weight has increased 4
 no accessory muscle usage, retraction, or paradoxing.                      pounds since her last visit. Review of the new chest ra-
 Decreased breath sounds bilaterally; clear to auscultation                 diograph demonstrates severe hyperinflation with flat-
 and percussion in all lung fields. A chest radiograph per-                 tening of the diaphragms, prominent pulmonary
 formed 1 year ago at the patient’s primary care physi-                     arteries with rapid pruning, and increased bronchovas-
 cian’s office showed no abnormality.                                       cular markings at the bases. No acute masses, infiltrates,
                                                                            or adenopathy are present. There is no evidence of con-
 INITIAL IMPRESSION AND RECOMMENDATION                                      gestive heart failure or pleural effusions.
     This patient probably has moderate-to-severe
 chronic obstructive pulmonary disease (COPD). The                             Pulmonary Function Tests:
 predominant risk factor is past cigarette-smoking                             • Forced expiratory volume in 1 second (FEV1) -
 abuse, although past exposure to coolant mists at work                          0.95 L - 47% predicted
 may be a minor contributing factor. There is no clini-                        • Forced vital capacity (FVC) - 1.83 L - 67% pre-
 cal evidence of alpha-1-antiprotease deficiency or                              dicted
 other causes of chronic airways disease. She is also                          • FEV1/FVC ratio - 52%
 without overt evidence of cor pulmonale, hypoxemia,                           • Total lung capacity (TLC) - 120% predicted
 respiratory insufficiency, or systemic disease (cachexia                      • Functional residual capacity (FRC) - 158% predicted
 or deconditioning).                                                           • Residual volume (RV) - 160% predicted
     The priorities for this patient are to: (1) order tests                   • RV/TLC ratio (53%)
 to confirm the COPD diagnosis and rule out oxygen                             • Diffusion capacity (DLCO) - 49% predicted
 desaturation with activity; (2) modify the current sub-                       • No change in airflows after bronchodilators
 optimal pharmacologic therapy; (3) continue support                        Impression: Hyperinflation with airflow limitation
 and monitoring for smoking cessation to prevent                            and reduced diffusion capacity consistent with
 relapse of cigarette abuse; and (4) follow up. Specific                    COPD/emphysema.
 recommendations include:
                                                                            DIAGNOSIS AND TREATMENT RECOMMENDATION
    1. Increase bronchodilator (ipratropium +                                   This patient has COPD of moderate severity
       albuterol) usage to 3 puffs 4 times daily with a                     (according to spirometry) and significant elements of
       spacer.                                                              hyperinflation/overdistension. There is improvement
    2. Provide MDI and spacer education.                                    after regular bronchodilator use. The strong history of

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                                                          CASE STUDY

frequent exacerbations suggests a potential role for                   DISCUSSION
inhaled steroids. Other alternative therapies may be                       This case is all too typical: a patient with COPD with
considered, including theophylline, if rehabilitation                  known risk factors and long-standing moderate-to-
does not lead to further improvement. Oxygen thera-                    severe disease but with delayed identification, diagnosis,
py is not required at this time. Specific recommenda-                  and therapy. In this case, the patient presented with an
tions include the following:                                           apparent acute onset of symptoms, but a simple discus-
                                                                       sion revealed a long history of bouts of bronchitis and
  1. Continue support of recent smoking cessation                      recurrent exacerbations. She was already significantly
     efforts.                                                          limited by her dyspnea at her initial consultation.
  2. Continue current bronchodilator therapy.                              Institution of a more appropriate regimen of bron-
  3. Initiate therapy with long-acting inhaled cortico-                chodilators, with education and correct technique,
     steroid (fluticasone propionate, 110 mcg, 2 puffs                 immediately improved her symptoms. Pulmonary
     twice daily with a spacer), monitoring symptoms                   rehabilitation enhanced her overall improvement. The
     and outcomes including frequency of exacerba-                     role of inhaled corticosteroids in patients with COPD
     tions.                                                            remains controversial, but mounting evidence suggests
  4. Initiate pulmonary rehabilitation with exercise                   inhaled corticosteroids can reduce the frequency of
     and education.                                                    exacerbations and improve the quality of life in
  5. Order bone densitometry.                                          patients who have a more severe case of COPD and
  6. Patient followed up in 2 months or as needed.                     have a history of recurrent exacerbations. Therapy
  7. Primary care physician followed up as planned.                    with inhaled corticosteroids does require monitoring
                                                                       to insure a therapeutic response. The most notable
FOLLOW UP                                                              adverse effects are oral thrush and a tendency to bruise
    The patient participated in the pulmonary rehabil-                 easily. Although inhaled corticosteroids have minimal
itation and noted continued overall improvement in                     apparent effect on osteoporosis, bone densitometry is
function. She admitted missing several doses of the                    recommended for older women with COPD—espe-
fixed bronchodilator combination, which often led to                   cially if they are taking oral steroids—to identify those
increased symptoms. She was switched to a fixed com-                   patients who require supplements. The reliability of
bination of salmeterol plus fluticasone, provided as a                 bone densitometry results in patients taking inhaled
dry powder inhaler (1 puff twice daily).The bron-                      steroids is being evaluated.
chodilator combination was continued as prn usage                          Continued attention to preventive measures,
only and the fluticasone monotherapy was stopped.                      whether smoking cessation or occupational, will be
Compliance subsequently improved. Bone densitome-                      critical for minimizing this patient’s continued
try revealed no evidence of osteoporosis but a multivi-                declines in lung function over time. Further discus-
tamin containing vitamin D was recommended. The                        sions related to influenza vaccination are warranted,
patient has not resumed cigarette smoking, partici-                    and revaccination with pneumococcal vaccine should
pates in a home exercise program, and has not had an                   be performed when appropriate.
exacerbation since her initial consultation.

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