See attach case study and answer the question pertaining to the question below:
Question: Create a list of the patient’s drug therapy problems and prioritize them. Include assessment of medication appropriateness, effectiveness, safety,and patient adherence.
2 peer reviewed references less than 5 years old
Chapter 31: Chronic Obstructive Pulmonary Disease: Treading on Thin Air Level II
Sarah L. Anderson; Joel C. Marrs
Instructors can request access to the Casebook Instructor’s Guide on Access Pharmacy. Email User Services (userservices@mheducation.com) for more
information.
LEARNING OBJECTIVES
After completing this case study, the reader should be able to:
Recognize modifiable risk factors for the development of chronic obstructive pulmonary disease (COPD).
Interpret spirometry readings and patientspecific factors to evaluate and appropriately classify an individual patient’s COPD.
Identify the importance of nonpharmacologic therapy in patients with COPD.
Develop an appropriate medication regimen for a patient with COPD based on disease classification.
PATIENT PRESENTATION
Chief Complaint
“My wife says I need to get my lungs checked. Ever since we moved, I’m having a hard time breathing.”
HPI
Dwayne Morrison is a 59yearold man who is presenting to a new provider at the family medicine clinic today with complaints of increasing shortness of breath. He points out that he first noticed some difficulty catching his breath at his job 3 years ago. He had been able to carry heavy loads up and down a flight of stairs daily for the past 35 years without any problem. However, his shortness of breath began to make this very difficult. Coincidentally at that time, he accepted a managerial position at his company that significantly reduced his activity level. After taking this position, he no longer noticed any problems, but he admits that he avoids activities that cause him to physically exert himself. He noticed significant shortness of breath again after he moved to Colorado from a lower elevation 2 months ago to be closer to his grandchildren. His shortness of breath is worst when he is outside playing with his grandchildren. He maintained his same managerial position with the move and does not physically exert himself at work.
His previous physician had placed him on budesonide/formoterol (Symbicort) two inhalations twice daily 2 years ago. He thinks his physician initiated the medication for the shortness of breath, but he is not entirely sure. He is hoping to get a good medication that will help relieve his shortness of breath because the gardening season is right around the corner, and he enjoys this hobby.
PMH
Coronary artery disease (CAD; MI 7 years ago, resulting in a drugeluting stent [DES] placement at that time; additional DES placed 2 years ago; normal
echocardiogram and stress test 3 months ago)
Chronic bronchitis × 8 years (has had one exacerbation in the past 12 months; received oral antibiotic treatment but was not hospitalized)
Cervical radiculopathy FH
Father (alive) with COPD (smoked a pipe for 40 years). Mother (alive) with CAD and cerebrovascular disease.
SH
He lives with his wife, who is a nurse. He has a 40 packyear history of smoking. When he had an MI at age 52, he quit smoking temporarily. At present,
he continues to smoke five to six cigarettes per day. He drinks two beers most nights of the workweek and two to three glasses of wine on the weekends.
Meds
Aspirin 81 mg PO once daily
Bupropion SR 150 mg PO twice daily
Clopidogrel 75 mg PO once daily
Budesonide/formoterol 80 mcg/4.5 mcg, two inhalations twice daily
OTC naproxen 220 mg PO every 12 hours PRN neck pain
Rosuvastatin 20 mg PO once daily
Metoprolol succinate 50 mg PO once daily
Seasonal influenza vaccine (previous year)
All
NKDA
ROS
(+) Chronic cough with sputum production; (+) exercise intolerance
Physical Examination
G e n
WDWN man in NAD
V S
BP 110/68, P 60, RR 16, T 37°C; Wt 82 kg, Ht 5′9′′; pulse ox 93% on RA
S k i n
Warm, dry; no rashes
HEENT
Normocephalic; PERRLA, EOMI; normal sclerae; mucous membranes are moist; TMs intact; oropharynx clear.
Neck/Lymph Nodes
Supple without lymphadenopathy
Lungs
Decreased breath sounds; no rales, rhonchi, or crackles
C V
RRR without murmur; normal S1 and S2
A b d
Soft, NT/ND; (+) bowel sounds; no organomegaly
Genit/Rect
No back or flank tenderness; normal male genitalia
MS/Ext
No CCE; pulses 2+ throughout
Neuro
A&O × 3; CN II–XII intact; DTRs 2+; normal mood and affect
Labs
Na 135 mEq/L Hgb 13.5 g/dL AST 40 IU/L Ca 9.6 mg/L
K 4.2 mEq/L Hct 41.2% ALT 19 IU/L Mg 3.6 mg/L
Cl 108 mEq/L Plt 195 × 103/mm3 T. bili 1.1 mg/dL Phos 2.9 mg/dL
CO2 26 mEq/L WBC 5.4 × 103/mm3 Alb 3.8 g/dL
BUN 19 mg/dL
SCr 1.1 mg/dL
Glu 89 mg/dL
NT proBNP 0 pg/mL
Troponin 0 ng/mL
Pulmonary Function Tests (During Clinic Visit Today)
Prebronchodilator FEV1 = 2.98 L (predicted is 4.02 L)
FVC = 4.5 L
Postbronchodilator FEV1 = 2.75 L
Assessment
This is a normalappearing 59yearold man presenting to the clinic with complaints of shortness of breath that is limiting his activity and affecting his
quality of life. Given the results of spirometry and patient history, patient has COPD in addition to a history of CAD, daily pain from cervical
radiculopathy, and chronic cough. Cardiac pathology as a cause of current symptoms is unlikely, given lack of chest pain and recent normal
cardiovascular stress test. The patient states that he is adherent to his current medication regimen.
QUESTIONS
Collect Information
1.a. What subjective and objective information indicates the presence of COPD?
1.b. What additional information is needed to fully assess this patient’s COPD?
Assess the Information
2.a. Assess the severity of COPD based on the subjective and objective information available.
2.b. Create a list of the patient’s drug therapy problems and prioritize them. Include assessment of medication appropriateness, effectiveness, safety,
and patient adherence.
2c. What economic and psychosocial considerations are applicable to this patient?
Develop a Care Plan
3.a. What are the goals of pharmacotherapy in this case?
3.b. What nondrug therapies might be useful for this patient?
3.c. What feasible pharmacotherapeutic alternatives are available for treating COPD?
3.d. Create an individualized, patientcentered, teambased care plan to optimize medication therapy for this patient’s COPD and other drug therapy
problems. Include specific drugs, dosage forms, doses, schedules, and durations of therapy.
Implement the Care Plan
4.a. What information should be provided to the patient to enhance adherence, ensure successful therapy, and minimize adverse effects?
4.b. Describe how care should be coordinated with other healthcare providers.
Followup: Monitor and Evaluate
5.a. What clinical and laboratory parameters should be used to evaluate the therapy for achievement of the desired therapeutic outcome and to detect and prevent adverse effects?
5.b. Develop a plan for followup that includes appropriate time frames to assess progress toward achievement of the goals of therapy.
SELFSTUDY ASSIGNMENTS
1 . Describe and compare the expectations for deterioration in pulmonary function in patients with COPD who have quit smoking with those who
continue smoking. In particular, emphasis should be placed on expected patterns of change in FEV1, FVC, and general health over time in years.
2 . Research and describe the appropriate use of inhaled corticosteroids for the management of stable COPD. Be able to compare and contrast the
benefits and risks of this therapy.
3 . Analyze the safety surrounding the use of βblockers in patients with COPD versus those with asthma.
CLINICAL PEARL
COPD can lead to exercise deconditioning, mood disorders such as depression, progressive muscle loss, and weight loss. A pulmonary rehabilitation
program including mandatory exercise training of the muscles used in respiration is recommended for patients with COPD because of the established
benefit related to improvements seen in dyspnea symptoms, healthrelated quality of life, reduced anxiety and depression, reduced number of
hospital days secondary to exacerbations, and improved response to bronchodilators.
REFERENCES
Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive
pulmonary disease: 2019 Report. Available at: http://www.goldcopd.org . Accessed December 27, 2018.
Qaseem A, Wilt TJ, Weinberger SE, et al. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline
update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society.
Ann Intern Med 2011;155:179–191. [PubMed: 21810710]
Reynolds NA, Perry CM, Keating GM. Budesonide/formoterol: in chronic obstructive pulmonary disease. Drugs 2004;64(4):431–41. [PubMed:
14969576]
Szafranski W, Cukier A, Ramirez A, et al. Efficacy and safety of budesonide/formoterol in the management of chronic obstructive pulmonary
disease. Eur Respir J 2003;21:74–81. [PubMed: 12570112]
Jones PW, Willits LR, Burge PS, Calverley P. Disease severity and the effect of fluticasone propionate on chronic obstructive pulmonary disease
exacerbations. Eur Respir J 2003;21:68–73. [PubMed: 12570111]
Kew KM, Mavergames C, Walters JA. Longacting beta2agonists for chronic obstructive pulmonary disease. Cochrane Database Syst Rev
2013;10:CD010177.
Tashkin DP, Pearle J, Iezzoni D, Varghese ST. Formoterol and tiotropium compared with tiotropium alone for treatment of COPD. COPD 2009;6:17–
25. [PubMed: 19229704]
van Noord JA, Aumann JL, Janssens E, et al. Comparison of tiotropium once daily, formoterol twice daily, and both combined once daily in patients
with COPD. Eur Respir J 2005;26:214–222. [PubMed: 16055868]
Karner C, Cates CJ. Longacting beta(2)agonist in addition to tiotropium versus either tiotropium or longacting beta(2)agonist alone for chronic
obstructive pulmonary disease. Cochrane Database Syst Rev 2012;4:CD008989.
Recommended Immunization Schedule for Adults Aged 19 Years of Older, United States, 2018. Available at: https://wwwcdc
gov.ezproxylocal.library.nova.edu/vaccines/schedules/hcp/imz/adult.html . Accessed April 14, 2019.Nova Southeastern University
Access Provided by:Downloaded 2022113 2:11 A Your IP is 137.52.76.29
Chapter 31: Chronic Obstructive Pulmonary Disease: Treading on Thin Air Level II, Sarah L. Anderson; Joel C. Marrs
©2022 McGraw Hill. All Rights Reserved. Terms of Use • Privacy Policy • Notice • AccessibilityPage 1 / 5
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Pharmacotherapy Casebook: A PatientFocused Approach, 11e
Chapter 31: Chronic Obstructive Pulmonary Disease: Treading on Thin Air Level II
Sarah L. Anderson; Joel C. Marrs
Instructors can request access to the Casebook Instructor’s Guide on AccessPharmacy. Email User Services (userservices@mheducation.com) for more
information.
LEARNING OBJECTIVES
After completing this case study, the reader should be able to:
Recognize modifiable risk factors for the development of chronic obstructive pulmonary disease (COPD).
Interpret spirometry readings and patientspecific factors to evaluate and appropriately classify an individual patient’s COPD.
Identify the importance of nonpharmacologic therapy in patients with COPD.
Develop an appropriate medication regimen for a patient with COPD based on disease classification.
PATIENT PRESENTATION
Chief Complaint
“My wife says I need to get my lungs checked. Ever since we moved, I’m having a hard time breathing.”
HPI
Dwayne Morrison is a 59yearold man who is presenting to a new provider at the family medicine clinic today with complaints of increasing shortness
of breath. He points out that he first noticed some difficulty catching his breath at his job 3 years ago. He had been able to carry heavy loads up and
down a flight of stairs daily for the past 35 years without any problem. However, his shortness of breath began to make this very difficult. Coincidentally
at that time, he accepted a managerial position at his company that significantly reduced his activity level. After taking this position, he no longer
noticed any problems, but he admits that he avoids activities that cause him to physically exert himself. He noticed significant shortness of breath again
after he moved to Colorado from a lower elevation 2 months ago to be closer to his grandchildren. His shortness of breath is worst when he is outside
playing with his grandchildren. He maintained his same managerial position with the move and does not physically exert himself at work. His previous
physician had placed him on budesonide/formoterol (Symbicort) two inhalations twice daily 2 years ago. He thinks his physician initiated the
medication for the shortness of breath, but he is not entirely sure. He is hoping to get a good medication that will help relieve his shortness of breath
because the gardening season is right around the corner, and he enjoys this hobby.
PMH
Coronary artery disease (CAD; MI 7 years ago, resulting in a drugeluting stent [DES] placement at that time; additional DES placed 2 years ago; normal
echocardiogram and stress test 3 months ago)
Chronic bronchitis × 8 years (has had one exacerbation in the past 12 months; received oral antibiotic treatment but was not hospitalized)
Cervical radiculopathy
FH
Father (alive) with COPD (smoked a pipe for 40 years). Mother (alive) with CAD and cerebrovascular disease.
SH
He lives with his wife, who is a nurse. He has a 40 packyear history of smoking. When he had an MI at age 52, he quit smoking temporarily. At present,
he continues to smoke five to six cigarettes per day. He drinks two beers most nights of the workweek and two to three glasses of wine on the
weekends.
Meds
Aspirin 81 mg PO once daily
Bupropion SR 150 mg PO twice daily
Clopidogrel 75 mg PO once daily
Budesonide/formoterol 80 mcg/4.5 mcg, two inhalations twice daily
OTC naproxen 220 mg PO every 12 hours PRN neck pain
Rosuvastatin 20 mg PO once daily
Metoprolol succinate 50 mg PO once daily
Seasonal influenza vaccine (previous year)
All
NKDA
ROS
(+) Chronic cough with sputum production; (+) exercise intolerance
Physical Examination
G e n
WDWN man in NAD
V S
BP 110/68, P 60, RR 16, T 37°C; Wt 82 kg, Ht 5′9′′; pulse ox 93% on RA
S k i n
Warm, dry; no rashes
HEENT
Normocephalic; PERRLA, EOMI; normal sclerae; mucous membranes are moist; TMs intact; oropharynx clear.
Neck/Lymph Nodes
Supple without lymphadenopathy
Lungs
Decreased breath sounds; no rales, rhonchi, or crackles
C V
RRR without murmur; normal S1 and S2
A b d
Soft, NT/ND; (+) bowel sounds; no organomegaly
Genit/Rect
No back or flank tenderness; normal male genitalia
MS/Ext
No CCE; pulses 2+ throughout
Neuro
A&O × 3; CN II–XII intact; DTRs 2+; normal mood and affect
Labs
Na 135 mEq/L Hgb 13.5 g/dL AST 40 IU/L Ca 9.6 mg/L
K 4.2 mEq/L Hct 41.2% ALT 19 IU/L Mg 3.6 mg/L
Cl 108 mEq/L Plt 195 × 103/mm3 T. bili 1.1 mg/dL Phos 2.9 mg/dL
CO2 26 mEq/L WBC 5.4 × 103/mm3 Alb 3.8 g/dL
BUN 19 mg/dL
SCr 1.1 mg/dL
Glu 89 mg/dL
NT proBNP 0 pg/mL
Troponin 0 ng/mL
Pulmonary Function Tests (During Clinic Visit Today)
Prebronchodilator FEV1 = 2.98 L (predicted is 4.02 L)
FVC = 4.5 L
Postbronchodilator FEV1 = 2.75 L
Assessment
This is a normalappearing 59yearold man presenting to the clinic with complaints of shortness of breath that is limiting his activity and affecting his
quality of life. Given the results of spirometry and patient history, patient has COPD in addition to a history of CAD, daily pain from cervical
radiculopathy, and chronic cough. Cardiac pathology as a cause of current symptoms is unlikely, given lack of chest pain and recent normal
cardiovascular stress test. The patient states that he is adherent to his current medication regimen.
QUESTIONS
Collect Information
1.a. What subjective and objective information indicates the presence of COPD?
1.b. What additional information is needed to fully assess this patient’s COPD?
Assess the Information
2.a. Assess the severity of COPD based on the subjective and objective information available.
2.b. Create a list of the patient’s drug therapy problems and prioritize them. Include assessment of medication appropriateness, effectiveness, safety,
and patient adherence.
2c. What economic and psychosocial considerations are applicable to this patient?
Develop a Care Plan
3.a. What are the goals of pharmacotherapy in this case?
3.b. What nondrug therapies might be useful for this patient?
3.c. What feasible pharmacotherapeutic alternatives are available for treating COPD?
3.d. Create an individualized, patientcentered, teambased care plan to optimize medication therapy for this patient’s COPD and other drug therapy
problems. Include specific drugs, dosage forms, doses, schedules, and durations of therapy.
Implement the Care Plan
4.a. What information should be provided to the patient to enhance adherence, ensure successful therapy, and minimize adverse effects?
4.b. Describe how care should be coordinated with other healthcare providers.
Followup: Monitor and Evaluate
5.a. What clinical and laboratory parameters should be used to evaluate the therapy for achievement of the desired therapeutic outcome and to detect
and prevent adverse effects?
5.b. Develop a plan for followup that includes appropriate time frames to assess progress toward achievement of the goals of therapy.
SELFSTUDY ASSIGNMENTS
1 . Describe and compare the expectations for deterioration in pulmonary function in patients with COPD who have quit smoking with those who
continue smoking. In particular, emphasis should be placed on expected patterns of change in FEV1, FVC, and general health over time in years.
2 . Research and describe the appropriate use of inhaled corticosteroids for the management of stable COPD. Be able to compare and contrast the
benefits and risks of this therapy.
3 . Analyze the safety surrounding the use of βblockers in patients with COPD versus those with asthma.
CLINICAL PEARL
COPD can lead to exercise deconditioning, mood disorders such as depression, progressive muscle loss, and weight loss. A pulmonary rehabilitation
program including mandatory exercise training of the muscles used in respiration is recommended for patients with COPD because of the established
benefit related to improvements seen in dyspnea symptoms, healthrelated quality of life, reduced anxiety and depression, reduced number of
hospital days secondary to exacerbations, and improved response to bronchodilators.
REFERENCES
Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive
pulmonary disease: 2019 Report. Available at: http://www.goldcopd.org . Accessed December 27, 2018.
Qaseem A, Wilt TJ, Weinberger SE, et al. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline
update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society.
Ann Intern Med 2011;155:179–191. [PubMed: 21810710]
Reynolds NA, Perry CM, Keating GM. Budesonide/formoterol: in chronic obstructive pulmonary disease. Drugs 2004;64(4):431–41. [PubMed:
14969576]
Szafranski W, Cukier A, Ramirez A, et al. Efficacy and safety of budesonide/formoterol in the management of chronic obstructive pulmonary
disease. Eur Respir J 2003;21:74–81. [PubMed: 12570112]
Jones PW, Willits LR, Burge PS, Calverley P. Disease severity and the effect of fluticasone propionate on chronic obstructive pulmonary disease
exacerbations. Eur Respir J 2003;21:68–73. [PubMed: 12570111]
Kew KM, Mavergames C, Walters JA. Longacting beta2agonists for chronic obstructive pulmonary disease. Cochrane Database Syst Rev
2013;10:CD010177.
Tashkin DP, Pearle J, Iezzoni D, Varghese ST. Formoterol and tiotropium compared with tiotropium alone for treatment of COPD. COPD 2009;6:17–
25. [PubMed: 19229704]
van Noord JA, Aumann JL, Janssens E, et al. Comparison of tiotropium once daily, formoterol twice daily, and both combined once daily in patients
with COPD. Eur Respir J 2005;26:214–222. [PubMed: 16055868]
Karner C, Cates CJ. Longacting beta(2)agonist in addition to tiotropium versus either tiotropium or longacting beta(2)agonist alone for chronic
obstructive pulmonary disease. Cochrane Database Syst Rev 2012;4:CD008989.
Recommended Immunization Schedule for Adults Aged 19 Years of Older, United States, 2018. Available at: https://wwwcdc
gov.ezproxylocal.library.nova.edu/vaccines/schedules/hcp/imz/adult.html . Accessed April 14, 2019.Nova Southeastern University
Access Provided by:Downloaded 2022113 2:11 A Your IP is 137.52.76.29
Chapter 31: Chronic Obstructive Pulmonary Disease: Treading on Thin Air Level II, Sarah L. Anderson; Joel C. Marrs
©2022 McGraw Hill. All Rights Reserved. Terms of Use • Privacy Policy • Notice • AccessibilityPage 2 / 5
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Pharmacotherapy Casebook: A PatientFocused Approach, 11e
Chapter 31: Chronic Obstructive Pulmonary Disease: Treading on Thin Air Level II
Sarah L. Anderson; Joel C. Marrs
Instructors can request access to the Casebook Instructor’s Guide on AccessPharmacy. Email User Services (userservices@mheducation.com) for more
information.
LEARNING OBJECTIVES
After completing this case study, the reader should be able to:
Recognize modifiable risk factors for the development of chronic obstructive pulmonary disease (COPD).
Interpret spirometry readings and patientspecific factors to evaluate and appropriately classify an individual patient’s COPD.
Identify the importance of nonpharmacologic therapy in patients with COPD.
Develop an appropriate medication regimen for a patient with COPD based on disease classification.
PATIENT PRESENTATION
Chief Complaint
“My wife says I need to get my lungs checked. Ever since we moved, I’m having a hard time breathing.”
HPI
Dwayne Morrison is a 59yearold man who is presenting to a new provider at the family medicine clinic today with complaints of increasing shortness
of breath. He points out that he first noticed some difficulty catching his breath at his job 3 years ago. He had been able to carry heavy loads up and
down a flight of stairs daily for the past 35 years without any problem. However, his shortness of breath began to make this very difficult. Coincidentally
at that time, he accepted a managerial position at his company that significantly reduced his activity level. After taking this position, he no longer
noticed any problems, but he admits that he avoids activities that cause him to physically exert himself. He noticed significant shortness of breath again
after he moved to Colorado from a lower elevation 2 months ago to be closer to his grandchildren. His shortness of breath is worst when he is outside
playing with his grandchildren. He maintained his same managerial position with the move and does not physically exert himself at work. His previous
physician had placed him on budesonide/formoterol (Symbicort) two inhalations twice daily 2 years ago. He thinks his physician initiated the
medication for the shortness of breath, but he is not entirely sure. He is hoping to get a good medication that will help relieve his shortness of breath
because the gardening season is right around the corner, and he enjoys this hobby.
PMH
Coronary artery disease (CAD; MI 7 years ago, resulting in a drugeluting stent [DES] placement at that time; additional DES placed 2 years ago; normal
echocardiogram and stress test 3 months ago)
Chronic bronchitis × 8 years (has had one exacerbation in the past 12 months; received oral antibiotic treatment but was not hospitalized)
Cervical radiculopathy
FH
Father (alive) with COPD (smoked a pipe for 40 years). Mother (alive) with CAD and cerebrovascular disease.
SH
He lives with his wife, who is a nurse. He has a 40 packyear history of smoking. When he had an MI at age 52, he quit smoking temporarily. At present,
he continues to smoke five to six cigarettes per day. He drinks two beers most nights of the workweek and two to three glasses of wine on the
weekends.
Meds
Aspirin 81 mg PO once daily
Bupropion SR 150 mg PO twice daily
Clopidogrel 75 mg PO once daily
Budesonide/formoterol 80 mcg/4.5 mcg, two inhalations twice daily
OTC naproxen 220 mg PO every 12 hours PRN neck pain
Rosuvastatin 20 mg PO once daily
Metoprolol succinate 50 mg PO once daily
Seasonal influenza vaccine (previous year)
All
NKDA
ROS
(+) Chronic cough with sputum production; (+) exercise intolerance
Physical Examination
G e n
WDWN man in NAD
V S
BP 110/68, P 60, RR 16, T 37°C; Wt 82 kg, Ht 5′9′′; pulse ox 93% on RA
S k i n
Warm, dry; no rashes
HEENT
Normocephalic; PERRLA, EOMI; normal sclerae; mucous membranes are moist; TMs intact; oropharynx clear.
Neck/Lymph Nodes
Supple without lymphadenopathy
Lungs
Decreased breath sounds; no rales, rhonchi, or crackles
C V
RRR without murmur; normal S1 and S2
A b d
Soft, NT/ND; (+) bowel sounds; no organomegaly
Genit/Rect
No back or flank tenderness; normal male genitalia
MS/Ext
No CCE; pulses 2+ throughout
Neuro
A&O × 3; CN II–XII intact; DTRs 2+; normal mood and affect
Labs
Na 135 mEq/L Hgb 13.5 g/dL AST 40 IU/L Ca 9.6 mg/L
K 4.2 mEq/L Hct 41.2% ALT 19 IU/L Mg 3.6 mg/L
Cl 108 mEq/L Plt 195 × 103/mm3 T. bili 1.1 mg/dL Phos 2.9 mg/dL
CO2 26 mEq/L WBC 5.4 × 103/mm3 Alb 3.8 g/dL
BUN 19 mg/dL
SCr 1.1 mg/dL
Glu 89 mg/dL
NT proBNP 0 pg/mL
Troponin 0 ng/mL
Pulmonary Function Tests (During Clinic Visit Today)
Prebronchodilator FEV1 = 2.98 L (predicted is 4.02 L)
FVC = 4.5 L
Postbronchodilator FEV1 = 2.75 L
Assessment
This is a normalappearing 59yearold man presenting to the clinic with complaints of shortness of breath that is limiting his activity and affecting his
quality of life. Given the results of spirometry and patient history, patient has COPD in addition to a history of CAD, daily pain from cervical
radiculopathy, and chronic cough. Cardiac pathology as a cause of current symptoms is unlikely, given lack of chest pain and recent normal
cardiovascular stress test. The patient states that he is adherent to his current medication regimen.
QUESTIONS
Collect Information
1.a. What subjective and objective information indicates the presence of COPD?
1.b. What additional information is needed to fully assess this patient’s COPD?
Assess the Information
2.a. Assess the severity of COPD based on the subjective and objective information available.
2.b. Create a list of the patient’s drug therapy problems and prioritize them. Include assessment of medication appropriateness, effectiveness, safety,
and patient adherence.
2c. What economic and psychosocial considerations are applicable to this patient?
Develop a Care Plan
3.a. What are the goals of pharmacotherapy in this case?
3.b. What nondrug therapies might be useful for this patient?
3.c. What feasible pharmacotherapeutic alternatives are available for treating COPD?
3.d. Create an individualized, patientcentered, teambased care plan to optimize medication therapy for this patient’s COPD and other drug therapy
problems. Include specific drugs, dosage forms, doses, schedules, and durations of therapy.
Implement the Care Plan
4.a. What information should be provided to the patient to enhance adherence, ensure successful therapy, and minimize adverse effects?
4.b. Describe how care should be coordinated with other healthcare providers.
Followup: Monitor and Evaluate
5.a. What clinical and laboratory parameters should be used to evaluate the therapy for achievement of the desired therapeutic outcome and to detect
and prevent adverse effects?
5.b. Develop a plan for followup that includes appropriate time frames to assess progress toward achievement of the goals of therapy.
SELFSTUDY ASSIGNMENTS
1 . Describe and compare the expectations for deterioration in pulmonary function in patients with COPD who have quit smoking with those who
continue smoking. In particular, emphasis should be placed on expected patterns of change in FEV1, FVC, and general health over time in years.
2 . Research and describe the appropriate use of inhaled corticosteroids for the management of stable COPD. Be able to compare and contrast the
benefits and risks of this therapy.
3 . Analyze the safety surrounding the use of βblockers in patients with COPD versus those with asthma.
CLINICAL PEARL
COPD can lead to exercise deconditioning, mood disorders such as depression, progressive muscle loss, and weight loss. A pulmonary rehabilitation
program including mandatory exercise training of the muscles used in respiration is recommended for patients with COPD because of the established
benefit related to improvements seen in dyspnea symptoms, healthrelated quality of life, reduced anxiety and depression, reduced number of
hospital days secondary to exacerbations, and improved response to bronchodilators.
REFERENCES
Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive
pulmonary disease: 2019 Report. Available at: http://www.goldcopd.org . Accessed December 27, 2018.
Qaseem A, Wilt TJ, Weinberger SE, et al. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline
update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society.
Ann Intern Med 2011;155:179–191. [PubMed: 21810710]
Reynolds NA, Perry CM, Keating GM. Budesonide/formoterol: in chronic obstructive pulmonary disease. Drugs 2004;64(4):431–41. [PubMed:
14969576]
Szafranski W, Cukier A, Ramirez A, et al. Efficacy and safety of budesonide/formoterol in the management of chronic obstructive pulmonary
disease. Eur Respir J 2003;21:74–81. [PubMed: 12570112]
Jones PW, Willits LR, Burge PS, Calverley P. Disease severity and the effect of fluticasone propionate on chronic obstructive pulmonary disease
exacerbations. Eur Respir J 2003;21:68–73. [PubMed: 12570111]
Kew KM, Mavergames C, Walters JA. Longacting beta2agonists for chronic obstructive pulmonary disease. Cochrane Database Syst Rev
2013;10:CD010177.
Tashkin DP, Pearle J, Iezzoni D, Varghese ST. Formoterol and tiotropium compared with tiotropium alone for treatment of COPD. COPD 2009;6:17–
25. [PubMed: 19229704]
van Noord JA, Aumann JL, Janssens E, et al. Comparison of tiotropium once daily, formoterol twice daily, and both combined once daily in patients
with COPD. Eur Respir J 2005;26:214–222. [PubMed: 16055868]
Karner C, Cates CJ. Longacting beta(2)agonist in addition to tiotropium versus either tiotropium or longacting beta(2)agonist alone for chronic
obstructive pulmonary disease. Cochrane Database Syst Rev 2012;4:CD008989.
Recommended Immunization Schedule for Adults Aged 19 Years of Older, United States, 2018. Available at: https://wwwcdc
gov.ezproxylocal.library.nova.edu/vaccines/schedules/hcp/imz/adult.html . Accessed April 14, 2019.Nova Southeastern University
Access Provided by:Downloaded 2022113 2:11 A Your IP is 137.52.76.29
Chapter 31: Chronic Obstructive Pulmonary Disease: Treading on Thin Air Level II, Sarah L. Anderson; Joel C. Marrs
©2022 McGraw Hill. All Rights Reserved. Terms of Use • Privacy Policy • Notice • AccessibilityPage 3 / 5
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2.
3.
4.
5.
6.
7.
8.
9.
10.
Pharmacotherapy Casebook: A PatientFocused Approach, 11e
Chapter 31: Chronic Obstructive Pulmonary Disease: Treading on Thin Air Level II
Sarah L. Anderson; Joel C. Marrs
Instructors can request access to the Casebook Instructor’s Guide on AccessPharmacy. Email User Services (userservices@mheducation.com) for more
information.
LEARNING OBJECTIVES
After completing this case study, the reader should be able to:
Recognize modifiable risk factors for the development of chronic obstructive pulmonary disease (COPD).
Interpret spirometry readings and patientspecific factors to evaluate and appropriately classify an individual patient’s COPD.
Identify the importance of nonpharmacologic therapy in patients with COPD.
Develop an appropriate medication regimen for a patient with COPD based on disease classification.
PATIENT PRESENTATION
Chief Complaint
“My wife says I need to get my lungs checked. Ever since we moved, I’m having a hard time breathing.”
HPI
Dwayne Morrison is a 59yearold man who is presenting to a new provider at the family medicine clinic today with complaints of increasing shortness
of breath. He points out that he first noticed some difficulty catching his breath at his job 3 years ago. He had been able to carry heavy loads up and
down a flight of stairs daily for the past 35 years without any problem. However, his shortness of breath began to make this very difficult. Coincidentally
at that time, he accepted a managerial position at his company that significantly reduced his activity level. After taking this position, he no longer
noticed any problems, but he admits that he avoids activities that cause him to physically exert himself. He noticed significant shortness of breath again
after he moved to Colorado from a lower elevation 2 months ago to be closer to his grandchildren. His shortness of breath is worst when he is outside
playing with his grandchildren. He maintained his same managerial position with the move and does not physically exert himself at work. His previous
physician had placed him on budesonide/formoterol (Symbicort) two inhalations twice daily 2 years ago. He thinks his physician initiated the
medication for the shortness of breath, but he is not entirely sure. He is hoping to get a good medication that will help relieve his shortness of breath
because the gardening season is right around the corner, and he enjoys this hobby.
PMH
Coronary artery disease (CAD; MI 7 years ago, resulting in a drugeluting stent [DES] placement at that time; additional DES placed 2 years ago; normal
echocardiogram and stress test 3 months ago)
Chronic bronchitis × 8 years (has had one exacerbation in the past 12 months; received oral antibiotic treatment but was not hospitalized)
Cervical radiculopathy
FH
Father (alive) with COPD (smoked a pipe for 40 years). Mother (alive) with CAD and cerebrovascular disease.
SH
He lives with his wife, who is a nurse. He has a 40 packyear history of smoking. When he had an MI at age 52, he quit smoking temporarily. At present,
he continues to smoke five to six cigarettes per day. He drinks two beers most nights of the workweek and two to three glasses of wine on the
weekends.
Meds
Aspirin 81 mg PO once daily
Bupropion SR 150 mg PO twice daily
Clopidogrel 75 mg PO once daily
Budesonide/formoterol 80 mcg/4.5 mcg, two inhalations twice daily
OTC naproxen 220 mg PO every 12 hours PRN neck pain
Rosuvastatin 20 mg PO once daily
Metoprolol succinate 50 mg PO once daily
Seasonal influenza vaccine (previous year)
All
NKDA
ROS
(+) Chronic cough with sputum production; (+) exercise intolerance
Physical Examination
G e n
WDWN man in NAD
V S
BP 110/68, P 60, RR 16, T 37°C; Wt 82 kg, Ht 5′9′′; pulse ox 93% on RA
S k i n
Warm, dry; no rashes
HEENT
Normocephalic; PERRLA, EOMI; normal sclerae; mucous membranes are moist; TMs intact; oropharynx clear.
Neck/Lymph Nodes
Supple without lymphadenopathy
Lungs
Decreased breath sounds; no rales, rhonchi, or crackles
C V
RRR without murmur; normal S1 and S2
A b d
Soft, NT/ND; (+) bowel sounds; no organomegaly
Genit/Rect
No back or flank tenderness; normal male genitalia
MS/Ext
No CCE; pulses 2+ throughout
Neuro
A&O × 3; CN II–XII intact; DTRs 2+; normal mood and affect
Labs
Na 135 mEq/L Hgb 13.5 g/dL AST 40 IU/L Ca 9.6 mg/L
K 4.2 mEq/L Hct 41.2% ALT 19 IU/L Mg 3.6 mg/L
Cl 108 mEq/L Plt 195 × 103/mm3 T. bili 1.1 mg/dL Phos 2.9 mg/dL
CO2 26 mEq/L WBC 5.4 × 103/mm3 Alb 3.8 g/dL
BUN 19 mg/dL
SCr 1.1 mg/dL
Glu 89 mg/dL
NT proBNP 0 pg/mL
Troponin 0 ng/mL
Pulmonary Function Tests (During Clinic Visit Today)
Prebronchodilator FEV1 = 2.98 L (predicted is 4.02 L)
FVC = 4.5 L
Postbronchodilator FEV1 = 2.75 L
Assessment
This is a normalappearing 59yearold man presenting to the clinic with complaints of shortness of breath that is limiting his activity and affecting his
quality of life. Given the results of spirometry and patient history, patient has COPD in addition to a history of CAD, daily pain from cervical
radiculopathy, and chronic cough. Cardiac pathology as a cause of current symptoms is unlikely, given lack of chest pain and recent normal
cardiovascular stress test. The patient states that he is adherent to his current medication regimen.
QUESTIONS
Collect Information
1.a. What subjective and objective information indicates the presence of COPD?
1.b. What additional information is needed to fully assess this patient’s COPD?
Assess the Information
2.a. Assess the severity of COPD based on the subjective and objective information available.
2.b. Create a list of the patient’s drug therapy problems and prioritize them. Include assessment of medication appropriateness, effectiveness, safety,
and patient adherence.
2c. What economic and psychosocial considerations are applicable to this patient?
Develop a Care Plan
3.a. What are the goals of pharmacotherapy in this case?
3.b. What nondrug therapies might be useful for this patient?
3.c. What feasible pharmacotherapeutic alternatives are available for treating COPD?
3.d. Create an individualized, patientcentered, teambased care plan to optimize medication therapy for this patient’s COPD and other drug therapy
problems. Include specific drugs, dosage forms, doses, schedules, and durations of therapy.
Implement the Care Plan
4.a. What information should be provided to the patient to enhance adherence, ensure successful therapy, and minimize adverse effects?
4.b. Describe how care should be coordinated with other healthcare providers.
Followup: Monitor and Evaluate
5.a. What clinical and laboratory parameters should be used to evaluate the therapy for achievement of the desired therapeutic outcome and to detect
and prevent adverse effects?
5.b. Develop a plan for followup that includes appropriate time frames to assess progress toward achievement of the goals of therapy.
SELFSTUDY ASSIGNMENTS
1 . Describe and compare the expectations for deterioration in pulmonary function in patients with COPD who have quit smoking with those who
continue smoking. In particular, emphasis should be placed on expected patterns of change in FEV1, FVC, and general health over time in years.
2 . Research and describe the appropriate use of inhaled corticosteroids for the management of stable COPD. Be able to compare and contrast the
benefits and risks of this therapy.
3 . Analyze the safety surrounding the use of βblockers in patients with COPD versus those with asthma.
CLINICAL PEARL
COPD can lead to exercise deconditioning, mood disorders such as depression, progressive muscle loss, and weight loss. A pulmonary rehabilitation
program including mandatory exercise training of the muscles used in respiration is recommended for patients with COPD because of the established
benefit related to improvements seen in dyspnea symptoms, healthrelated quality of life, reduced anxiety and depression, reduced number of
hospital days secondary to exacerbations, and improved response to bronchodilators.
REFERENCES
Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive
pulmonary disease: 2019 Report. Available at: http://www.goldcopd.org . Accessed December 27, 2018.
Qaseem A, Wilt TJ, Weinberger SE, et al. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline
update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society.
Ann Intern Med 2011;155:179–191. [PubMed: 21810710]
Reynolds NA, Perry CM, Keating GM. Budesonide/formoterol: in chronic obstructive pulmonary disease. Drugs 2004;64(4):431–41. [PubMed:
14969576]
Szafranski W, Cukier A, Ramirez A, et al. Efficacy and safety of budesonide/formoterol in the management of chronic obstructive pulmonary
disease. Eur Respir J 2003;21:74–81. [PubMed: 12570112]
Jones PW, Willits LR, Burge PS, Calverley P. Disease severity and the effect of fluticasone propionate on chronic obstructive pulmonary disease
exacerbations. Eur Respir J 2003;21:68–73. [PubMed: 12570111]
Kew KM, Mavergames C, Walters JA. Longacting beta2agonists for chronic obstructive pulmonary disease. Cochrane Database Syst Rev
2013;10:CD010177.
Tashkin DP, Pearle J, Iezzoni D, Varghese ST. Formoterol and tiotropium compared with tiotropium alone for treatment of COPD. COPD 2009;6:17–
25. [PubMed: 19229704]
van Noord JA, Aumann JL, Janssens E, et al. Comparison of tiotropium once daily, formoterol twice daily, and both combined once daily in patients
with COPD. Eur Respir J 2005;26:214–222. [PubMed: 16055868]
Karner C, Cates CJ. Longacting beta(2)agonist in addition to tiotropium versus either tiotropium or longacting beta(2)agonist alone for chronic
obstructive pulmonary disease. Cochrane Database Syst Rev 2012;4:CD008989.
Recommended Immunization Schedule for Adults Aged 19 Years of Older, United States, 2018. Available at: https://wwwcdc
gov.ezproxylocal.library.nova.edu/vaccines/schedules/hcp/imz/adult.html . Accessed April 14, 2019.Nova Southeastern University
Access Provided by:Downloaded 2022113 2:11 A Your IP is 137.52.76.29
Chapter 31: Chronic Obstructive Pulmonary Disease: Treading on Thin Air Level II, Sarah L. Anderson; Joel C. Marrs
©2022 McGraw Hill. All Rights Reserved. Terms of Use • Privacy Policy • Notice • AccessibilityPage 4 / 5
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Pharmacotherapy Casebook: A PatientFocused Approach, 11e
Chapter 31: Chronic Obstructive Pulmonary Disease: Treading on Thin Air Level II
Sarah L. Anderson; Joel C. Marrs
Instructors can request access to the Casebook Instructor’s Guide on AccessPharmacy. Email User Services (userservices@mheducation.com) for more
information.
LEARNING OBJECTIVES
After completing this case study, the reader should be able to:
Recognize modifiable risk factors for the development of chronic obstructive pulmonary disease (COPD).
Interpret spirometry readings and patientspecific factors to evaluate and appropriately classify an individual patient’s COPD.
Identify the importance of nonpharmacologic therapy in patients with COPD.
Develop an appropriate medication regimen for a patient with COPD based on disease classification.
PATIENT PRESENTATION
Chief Complaint
“My wife says I need to get my lungs checked. Ever since we moved, I’m having a hard time breathing.”
HPI
Dwayne Morrison is a 59yearold man who is presenting to a new provider at the family medicine clinic today with complaints of increasing shortness
of breath. He points out that he first noticed some difficulty catching his breath at his job 3 years ago. He had been able to carry heavy loads up and
down a flight of stairs daily for the past 35 years without any problem. However, his shortness of breath began to make this very difficult. Coincidentally
at that time, he accepted a managerial position at his company that significantly reduced his activity level. After taking this position, he no longer
noticed any problems, but he admits that he avoids activities that cause him to physically exert himself. He noticed significant shortness of breath again
after he moved to Colorado from a lower elevation 2 months ago to be closer to his grandchildren. His shortness of breath is worst when he is outside
playing with his grandchildren. He maintained his same managerial position with the move and does not physically exert himself at work. His previous
physician had placed him on budesonide/formoterol (Symbicort) two inhalations twice daily 2 years ago. He thinks his physician initiated the
medication for the shortness of breath, but he is not entirely sure. He is hoping to get a good medication that will help relieve his shortness of breath
because the gardening season is right around the corner, and he enjoys this hobby.
PMH
Coronary artery disease (CAD; MI 7 years ago, resulting in a drugeluting stent [DES] placement at that time; additional DES placed 2 years ago; normal
echocardiogram and stress test 3 months ago)
Chronic bronchitis × 8 years (has had one exacerbation in the past 12 months; received oral antibiotic treatment but was not hospitalized)
Cervical radiculopathy
FH
Father (alive) with COPD (smoked a pipe for 40 years). Mother (alive) with CAD and cerebrovascular disease.
SH
He lives with his wife, who is a nurse. He has a 40 packyear history of smoking. When he had an MI at age 52, he quit smoking temporarily. At present,
he continues to smoke five to six cigarettes per day. He drinks two beers most nights of the workweek and two to three glasses of wine on the
weekends.
Meds
Aspirin 81 mg PO once daily
Bupropion SR 150 mg PO twice daily
Clopidogrel 75 mg PO once daily
Budesonide/formoterol 80 mcg/4.5 mcg, two inhalations twice daily
OTC naproxen 220 mg PO every 12 hours PRN neck pain
Rosuvastatin 20 mg PO once daily
Metoprolol succinate 50 mg PO once daily
Seasonal influenza vaccine (previous year)
All
NKDA
ROS
(+) Chronic cough with sputum production; (+) exercise intolerance
Physical Examination
G e n
WDWN man in NAD
V S
BP 110/68, P 60, RR 16, T 37°C; Wt 82 kg, Ht 5′9′′; pulse ox 93% on RA
S k i n
Warm, dry; no rashes
HEENT
Normocephalic; PERRLA, EOMI; normal sclerae; mucous membranes are moist; TMs intact; oropharynx clear.
Neck/Lymph Nodes
Supple without lymphadenopathy
Lungs
Decreased breath sounds; no rales, rhonchi, or crackles
C V
RRR without murmur; normal S1 and S2
A b d
Soft, NT/ND; (+) bowel sounds; no organomegaly
Genit/Rect
No back or flank tenderness; normal male genitalia
MS/Ext
No CCE; pulses 2+ throughout
Neuro
A&O × 3; CN II–XII intact; DTRs 2+; normal mood and affect
Labs
Na 135 mEq/L Hgb 13.5 g/dL AST 40 IU/L Ca 9.6 mg/L
K 4.2 mEq/L Hct 41.2% ALT 19 IU/L Mg 3.6 mg/L
Cl 108 mEq/L Plt 195 × 103/mm3 T. bili 1.1 mg/dL Phos 2.9 mg/dL
CO2 26 mEq/L WBC 5.4 × 103/mm3 Alb 3.8 g/dL
BUN 19 mg/dL
SCr 1.1 mg/dL
Glu 89 mg/dL
NT proBNP 0 pg/mL
Troponin 0 ng/mL
Pulmonary Function Tests (During Clinic Visit Today)
Prebronchodilator FEV1 = 2.98 L (predicted is 4.02 L)
FVC = 4.5 L
Postbronchodilator FEV1 = 2.75 L
Assessment
This is a normalappearing 59yearold man presenting to the clinic with complaints of shortness of breath that is limiting his activity and affecting his
quality of life. Given the results of spirometry and patient history, patient has COPD in addition to a history of CAD, daily pain from cervical
radiculopathy, and chronic cough. Cardiac pathology as a cause of current symptoms is unlikely, given lack of chest pain and recent normal
cardiovascular stress test. The patient states that he is adherent to his current medication regimen.
QUESTIONS
Collect Information
1.a. What subjective and objective information indicates the presence of COPD?
1.b. What additional information is needed to fully assess this patient’s COPD?
Assess the Information
2.a. Assess the severity of COPD based on the subjective and objective information available.
2.b. Create a list of the patient’s drug therapy problems and prioritize them. Include assessment of medication appropriateness, effectiveness, safety,
and patient adherence.
2c. What economic and psychosocial considerations are applicable to this patient?
Develop a Care Plan
3.a. What are the goals of pharmacotherapy in this case?
3.b. What nondrug therapies might be useful for this patient?
3.c. What feasible pharmacotherapeutic alternatives are available for treating COPD?
3.d. Create an individualized, patientcentered, teambased care plan to optimize medication therapy for this patient’s COPD and other drug therapy
problems. Include specific drugs, dosage forms, doses, schedules, and durations of therapy.
Implement the Care Plan
4.a. What information should be provided to the patient to enhance adherence, ensure successful therapy, and minimize adverse effects?
4.b. Describe how care should be coordinated with other healthcare providers.
Followup: Monitor and Evaluate
5.a. What clinical and laboratory parameters should be used to evaluate the therapy for achievement of the desired therapeutic outcome and to detect
and prevent adverse effects?
5.b. Develop a plan for followup that includes appropriate time frames to assess progress toward achievement of the goals of therapy.
SELFSTUDY ASSIGNMENTS
1 . Describe and compare the expectations for deterioration in pulmonary function in patients with COPD who have quit smoking with those who
continue smoking. In particular, emphasis should be placed on expected patterns of change in FEV1, FVC, and general health over time in years.
2 . Research and describe the appropriate use of inhaled corticosteroids for the management of stable COPD. Be able to compare and contrast the
benefits and risks of this therapy.
3 . Analyze the safety surrounding the use of βblockers in patients with COPD versus those with asthma.
CLINICAL PEARL
COPD can lead to exercise deconditioning, mood disorders such as depression, progressive muscle loss, and weight loss. A pulmonary rehabilitation
program including mandatory exercise training of the muscles used in respiration is recommended for patients with COPD because of the established
benefit related to improvements seen in dyspnea symptoms, healthrelated quality of life, reduced anxiety and depression, reduced number of
hospital days secondary to exacerbations, and improved response to bronchodilators
