copd - new diagnosis
Doctor Information
Allison Fisher, age 58
Past Medical History:
Recurrent chest infections
Breast cancer 1998, had local mastectomy and chemotherapy
Drug History:
Nil regular
Allergic to penicillin
Last consultation 8 weeks ago:
Seen by Dr Gonzalez: chesty cough again, sob, thick green sputum. Crepitations heard in right base, mild bilateral wheeze, Oxygen Sats 98% on Room Air, pulse 89. Given Clarithomycin for one week. Seems to have a lot of these infections. For Chest X-Ray, spirometry and review.
Chest X-Ray - normal lung marking and clear lung spaces.
Spirometry results - post bronchodilator (done 6 weeks later).
FEV 1 48%
FEV1/FVC 57%
Past Medical History:
Recurrent chest infections
Breast cancer 1998, had local mastectomy and chemotherapy
Drug History:
Nil regular
Allergic to penicillin
Last consultation 8 weeks ago:
Seen by Dr Gonzalez: chesty cough again, sob, thick green sputum. Crepitations heard in right base, mild bilateral wheeze, Oxygen Sats 98% on Room Air, pulse 89. Given Clarithomycin for one week. Seems to have a lot of these infections. For Chest X-Ray, spirometry and review.
Chest X-Ray - normal lung marking and clear lung spaces.
Spirometry results - post bronchodilator (done 6 weeks later).
FEV 1 48%
FEV1/FVC 57%
Patient Information
Allison Fisher age 58
Opening line: I’ve come for the results of that breathing test.
History: You had a chest infection a few weeks ago and got antibiotics. The other doctor said you were having too many of them and you needed a breathing test. You get 2-3 chest infections a year, but you have done for about 20 years and no-one has ever mentioned breathing tests before. In between these you are ok, sometimes you get breathless going up Carmichael Hill, but doesn't everyone?! No blood in your phlegm, no weight loss, no night sweats.
If asked only: Your chest has never been fantastic but then your mum always said some people are just a bit more prone to chest problems. You do smoke, about 10 cigarettes per day, and have done since your twenties. You are actually quite fit for your age - you do Pilates and a spinning class every week, and walk the dog every day. You worked for 30 years in Henley’s Bakery and retired when you were 55. You live with your husband Jim, and you are legal guardian for your two grandchildren who are 5 and 8 years old, as their mum has had some personal problems for the past couple of years (you do not wish to explain anymore). You don’t drink any alcohol. You cope well at home, and your mood is good, you have no anhedonia.
Ideas: you are one of those people who is prone to chest infections
Concerns: none really, you just have to live with it
Expectations: to come back every time you have a chest infection for some more antibiotics
If the diagnosis of COPD is discussed with you, you are quite concerned and want to know what it means, and how it will affect you. Will you be on medication forever? Does it get worse over time? Will it shorted your life? You are worried because you need to be well to look after your grandchildren. You take on board any advice about medication, and if smoking cessation is mentioned, you agree to it readily - you don’t need a clinic or anything, you will just do it.
Opening line: I’ve come for the results of that breathing test.
History: You had a chest infection a few weeks ago and got antibiotics. The other doctor said you were having too many of them and you needed a breathing test. You get 2-3 chest infections a year, but you have done for about 20 years and no-one has ever mentioned breathing tests before. In between these you are ok, sometimes you get breathless going up Carmichael Hill, but doesn't everyone?! No blood in your phlegm, no weight loss, no night sweats.
If asked only: Your chest has never been fantastic but then your mum always said some people are just a bit more prone to chest problems. You do smoke, about 10 cigarettes per day, and have done since your twenties. You are actually quite fit for your age - you do Pilates and a spinning class every week, and walk the dog every day. You worked for 30 years in Henley’s Bakery and retired when you were 55. You live with your husband Jim, and you are legal guardian for your two grandchildren who are 5 and 8 years old, as their mum has had some personal problems for the past couple of years (you do not wish to explain anymore). You don’t drink any alcohol. You cope well at home, and your mood is good, you have no anhedonia.
Ideas: you are one of those people who is prone to chest infections
Concerns: none really, you just have to live with it
Expectations: to come back every time you have a chest infection for some more antibiotics
If the diagnosis of COPD is discussed with you, you are quite concerned and want to know what it means, and how it will affect you. Will you be on medication forever? Does it get worse over time? Will it shorted your life? You are worried because you need to be well to look after your grandchildren. You take on board any advice about medication, and if smoking cessation is mentioned, you agree to it readily - you don’t need a clinic or anything, you will just do it.
Examination Findings
Pulse 76
Blood pressure 140/78
Sats 98% Room Air
Chest clear, equal breath sounds, normal heart sounds
RR 18
Blood pressure 140/78
Sats 98% Room Air
Chest clear, equal breath sounds, normal heart sounds
RR 18
Mark scheme
Data Gathering
|
POSITIVE INDICATORS
Organised and systematic in gathering information from history taking, examination and investigation Excludes red flag symptoms Identifies abnormal findings or results and/or recognises their implications - accurately interprets spirometry Data gathering does appears to be guided by the probabilities of disease Undertakes physical examination competently, or use instruments proficiently |
NEGATIVE INDICATORS
Makes immediate assumptions about the problem Intervenes rather than using appropriate expectant management Is disorganised/unsystematic in gathering information Data gathering does not appear to be guided by the probabilities of disease. Fails to identify abnormal data or correctly interpret them Appears unsure of how to operate/use instruments Appears disorganised/unsystematic in the application of the instruments or the conduct of physical examinations |
Clinical Management Skills
|
POSITIVE INDICATORS
Makes appropriate diagnosis Develops a management plan (including prescribing and referral) that is appropriate and in line with current best practice Management approaches reflect an appropriate assessment of risk - aware of red flags and discusses smoking cessation Makes appropriate prescribing decisions Manages risk effectively, safety netting appropriately Simultaneously manages multiple health problems, both acute & chronic |
NEGATIVE INDICATORS
Fails to consider common conditions in the differential diagnosis Does not suggest how the problem might develop or resolve Fails to make the patient aware of relative risks of different approaches Decisions on whether/what to prescribe are inappropriate or idiosyncratic. Follow-up arrangements are absent or disjointed Fails to take account of related issues or of co-morbidity |
Inter Personal Skills
|
POSITIVE INDICATORS
Identify patient’s agenda, health beliefs & preferences / does makes use of verbal & non-verbal cues. Works with the patient to develop a shared management plan or clarify the roles of doctor and patient Uses explanations that are relevant and understandable to the patient Shows sensitivity for the patient’s feelings in all aspects of the consultation including physical examination Does not allow own views/values to inappropriately influence dialogue Shows commitment to equality for all |
NEGATIVE INDICATORS
Doesn't enquire about patients ICE Takes a doctor centered approach towards management Uses an explanation that is filled with jargon, or forgets to explain at all Doesn't show any sympathy / empathy towards the patient's situation Fails to empower patient Inappropriately influences patient interaction through own views/values Quick to judge |
Management
Explanation:
Your test results show that you have something called COPD. This is a condition that affects your lungs, and is most commonly caused by smoke damage to them. Air doesn't move in and out of the lungs so well, and you tend to make a lot more mucus. Some people have repeated chest infections and a gradual worsening in their breathing. Although it is not curable, there are many things that can improve your symptoms. The best thing you can do is to stop smoking, as this will reduce any further damage to your lungs.
COPD is diagnosed in patients over the age of 35 who have typical symptoms, and a risk factor (e.g. smoking) and an obstructive picture on their spirometry. In this case you have to be able to interpret the spirometry results: in short, the two things you are looking for is an FEV1/FVC ratio < 70%, with symptoms. It used to be that an FEV1 of below 80% was required, however in the updated NICE guidelines in 2010 that was removed. FEV1 indicates how severe the disease is - >80% mild (stage 1), 79-50% moderate (stage 2) and 49-30% severe (stage 3), and <30% is very severe (stage 4). Remember that spirometry needs to be post bronchodilator.
Principles of management:
Smoking cessation - seems obvious but do encourage the patient to stop. You will not reverse the damage done, but you could stop any further damage to the lungs. Suggest the NHS stop smoking clinic or other local services if they are available.
Courses?
Other management options include the Pulmonary Rehabilitation Courses. These can be very helpful for patients. For end-stage COPD, your local hospice may also run palliative breathing classes.
Specialist Referral?
You do not need to refer a patient to a respiratory specialist unless the diagnosis is uncertain, the COPD is severe (FEV1<30%) or he patient presents with any complications (like cor pulmonale).
Oxygen therapy?
Oxygen therapy is only needed if either; SATS <92% on room air, FEV1<30%, evidence of heart failure, Cyanosis or secondary polycythaemia.
Drug treatments: This was always the part we got confused with, so we found a method to decide what to offer…
Look at the FEV1:
FEV1>50%:
It is best to use inhalers through a spacer if available. Advise patients not to clean their spacers more than monthly, as this may promote static buildup that can interfere with its effectiveness.
FEV1<50%
So in this case- the FEV1 is < 50%, start Salbutamol and reasonably you can give her a combination inhaler like fostair given the severity.
This lady has a lot of exacerbations - explain what to look for and what to do. Consider giving her some rescue medication (antibiotics and steroids) to start if her symptoms worsen.
It might also be worth thinking about a sputum sample, to check for organisms and sensitivities.
Go through inhaler technique and arrange follow-up with either yourself or the practice nurse.
Remember that COPD is a chronic disease, and as such patients are more prone to low mood, so ask about the effect it's having on her life. How is she coping? Any troubles with day to day life? Any low mood? Has she ever been bothered by not enjoying things recently? Is her breathing stopping her from doing anything?
Don't be afraid to plug exercise, the better we can get her cardiovascular fitness, the better her symptoms will be.
Further Reading:
NICE CKS
NICE guidelines
MIMS pictorial representation of the COPD management pathway
Your test results show that you have something called COPD. This is a condition that affects your lungs, and is most commonly caused by smoke damage to them. Air doesn't move in and out of the lungs so well, and you tend to make a lot more mucus. Some people have repeated chest infections and a gradual worsening in their breathing. Although it is not curable, there are many things that can improve your symptoms. The best thing you can do is to stop smoking, as this will reduce any further damage to your lungs.
COPD is diagnosed in patients over the age of 35 who have typical symptoms, and a risk factor (e.g. smoking) and an obstructive picture on their spirometry. In this case you have to be able to interpret the spirometry results: in short, the two things you are looking for is an FEV1/FVC ratio < 70%, with symptoms. It used to be that an FEV1 of below 80% was required, however in the updated NICE guidelines in 2010 that was removed. FEV1 indicates how severe the disease is - >80% mild (stage 1), 79-50% moderate (stage 2) and 49-30% severe (stage 3), and <30% is very severe (stage 4). Remember that spirometry needs to be post bronchodilator.
Principles of management:
Smoking cessation - seems obvious but do encourage the patient to stop. You will not reverse the damage done, but you could stop any further damage to the lungs. Suggest the NHS stop smoking clinic or other local services if they are available.
Courses?
Other management options include the Pulmonary Rehabilitation Courses. These can be very helpful for patients. For end-stage COPD, your local hospice may also run palliative breathing classes.
Specialist Referral?
You do not need to refer a patient to a respiratory specialist unless the diagnosis is uncertain, the COPD is severe (FEV1<30%) or he patient presents with any complications (like cor pulmonale).
Oxygen therapy?
Oxygen therapy is only needed if either; SATS <92% on room air, FEV1<30%, evidence of heart failure, Cyanosis or secondary polycythaemia.
Drug treatments: This was always the part we got confused with, so we found a method to decide what to offer…
Look at the FEV1:
FEV1>50%:
- Start with a short acting beta 2 agonist (SABA) or short acting muscarinic antagonist (SAMA). If they are still breathless after a trial of this, add in long acting medication - so either LAMA ( e.g. triotropium) or LABA ( e.g. salmeterol). Tiotropium has been shown to decrease infective exacerbations, therefore is a better bet in this case compared to salmeterol. Remember that unlike SABA and LABA, you can not combine a SAMA and LAMA. If you start a LAMA, stop the SAMA. SABA can be continued throughout the treatment ladder.
- If the patient is on a LABA and they are not controlled then add in Inhaled Corticosteroids (ICS). If they are still not controlled, then add in a LAMA. If the patient was on a LAMA and they were not controlled, then add in a LABA + ICS. Never give ICS alone in the management of COPD. We are now beginning to see inhalers that combine both a LAMA, LABA and ICS in one inhaler.
It is best to use inhalers through a spacer if available. Advise patients not to clean their spacers more than monthly, as this may promote static buildup that can interfere with its effectiveness.
FEV1<50%
- If the FEV1 is < 50%, start the same way with SABA or SAMA. If still breathless start a combined long acting beta 2 agonist with an inhaled corticosteroid (LABA/ICS) - for example Symbicort, Fostair, Flutiform, Seretide. Two recent large scale studies have shown that Symbicort is better than Seretide at reducing exacerbations, it is also cheaper. If the steroid aspect is not tolerated, go for LABA on its own and add in LAMA.
So in this case- the FEV1 is < 50%, start Salbutamol and reasonably you can give her a combination inhaler like fostair given the severity.
This lady has a lot of exacerbations - explain what to look for and what to do. Consider giving her some rescue medication (antibiotics and steroids) to start if her symptoms worsen.
It might also be worth thinking about a sputum sample, to check for organisms and sensitivities.
Go through inhaler technique and arrange follow-up with either yourself or the practice nurse.
Remember that COPD is a chronic disease, and as such patients are more prone to low mood, so ask about the effect it's having on her life. How is she coping? Any troubles with day to day life? Any low mood? Has she ever been bothered by not enjoying things recently? Is her breathing stopping her from doing anything?
Don't be afraid to plug exercise, the better we can get her cardiovascular fitness, the better her symptoms will be.
Further Reading:
NICE CKS
NICE guidelines
MIMS pictorial representation of the COPD management pathway