Chronic Obstructive Pulmonary Disease Paper
Chronic Obstructive Pulmonary Disease
The most likely diagnosis for R. W. is chronic obstructive pulmonary disease (COPD). The patient’s current presentation with progressive difficulty in breathing while performing simple tasks is one of the major COPD symptoms. He also struggles to do manual work. The patient also reports cough, fatigue, having lost some wight recently and wheezing experiences. On physical examination, the patient has clubbing of fingers, use of accessory muscles for respiration and upon lung percussion, the patient exhibits hyperresonance. An exam of his pulmonary function reveals that he has an FEV1 of 58%. Physical signs are quite sensitive and specific to severe disease. Mild to moderate COPD has poor sensitivity to physical examination and findings such as use of accessory muscles for respiration may suggest that he has severe disease. However, the formal diagnosis and staging of COPD is made with spirometry. The patient is at Stage II of the disease based on his spirometry results. Stage II is classified as FEV1 of 50-79% (Marçôa, 2018 Chronic Obstructive Pulmonary Disease Paper). The patient’s FEV1 is 58%.
The goals of treatment are to improve the patient’s quality of life and functional status. This can be done by improving symptoms and preserving optimal lung function (Mosenifar et al., 2020). Another goal is to prevent exacerbations and optimize the drug therapy. This can be achieved by smoking cessation which is aided by nicotine replacement. Impairment can be reduced by giving oxygen therapy to reduce the chances of developing hypoxemia (Mosenifar et al., 2020). Patients exhibit reduced impairment characterized by the inability to perform normal activities, often without developing symptoms. Oral and inhaled medications are used to reduce dyspnea which in turn improves exercise tolerance. Another aim of pharmacotherapy is to reverse causes of airway function limitation, which is often attributable to such factors as airway inflammation, congestion of the bronchial mucosal, edema, increased secretions within the airways, and “bronchial smooth muscle contraction” (Mosenifar et al., 2020).
Bronchodilation is another goal and bronchodilators must be prescribed in the pharmacological treatment as the backbone of any COPD treatment regimen. These drugs are used to provide symptomatic relief and to decrease morbidity and mortality. Inflammation is also a crucial factor in the pathogenesis of COPD and therefore anti-inflammatory agents should be considered in pharmacotherapy. Chronic infection is also common in patients with COPD as there is frequent colonization of the lower airways. The use of antibiotics to minimize the risk of infection and prevent exacerbation of the conditions should be considered. Another goal of therapy is to reduce the severity of symptoms. The patient should be able to do his manual work without experiencing any difficulties and should also have to sit behind his desk and perform his duties without experiencing any symptoms (Mosenifar et al., 2020).
The patient has a diagnosis of stage II COPD as evidenced by the symptoms presented in this case study. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) (2019) recommends COPD treatment with medications that provide relief from symptoms and prevent the exacerbation of disease. These are the cornerstones of COPD management since there is no definitive cure for the disease. Bronchodilators such as beta2 agonists, theophylline and anticholinergics are central to management of COPD at every level of disease severity and should be prescribed (Oba et al., 2018). Inhaled short acting beta 2-agonists such as albuterol are preferred as they take a shorter time, around 3 to 5 minutes to start working. They are usually referred to as rescue medicines because of their quick relief to breathlessness. As such, patients can use them before engaging in activities that tend to worsen their symptoms. They, however, do not have a 24-hour lasting effect. For this reason, long-acting agents (LABA) such as salmeterol are used for long term control of the disease (Arcangelo & Peterson, 2017).
Inhaled long-acting anticholinergic medication (LAMA) such as glycopyrronium can also be prescribed but not in instances where quick relief is the desired goal. Combination therapy (LAMA/LABA) is used to achieve optimal bronchodilation over a long period of time (Bollmeier & Hartmann, 2020). Inhalation corticosteroids (ICS) can also be prescribed to reduce airway inflammation and the swelling that may narrow the airway. They take longer to be effective and are used for long term control and to prevent exacerbation of the disease. Long term antibiotics such as azithromycin can be prescribed to minimize the risk of infection that may cause exacerbations of symptoms. A nicotine patch can also be recommended to help with the cessation of smoking. A combination therapy of salmeterol and inhaled corticosteroid (LABA/ICS) is ideal and is considered first line therapy.
The GOLD guidelines (2019) recommend that patients should be assessed 4-12 weeks after initiation of the treatment regimen and then routinely every three to 12 months thereafter. The NP should assess the patient to determine the need for medication adjustment and recommend a more intensive regimen should the patient exhibit exacerbation of COPD symptoms. The parameters that could be used to monitor the success of therapy are FEV1, respiratory rate, oxygen saturation, vital signs, and breathe sounds. The goal is to achieve an FEV1 value of more than 70% using spirometry. The absence of wheezes and crackles indicate no labored breathing and minimal resistance to airflow. The target SpO2 is between 88% to 92% in COPD patients. The NP to assess the patient for the presence of risk factors such as smoking which may lead to exacerbation of symptoms. The NP should also ask about adherence to medication and the response to the medication. Poor adherence to medication is common among COPD patients. A history of exacerbation of symptoms should be taken to know the effectiveness of the treatment (GOLD, 2019).
The patient should be educated about the medication prescribed. When prescribing, a review on how to take the medicines should be done with the patient. Bronchodilators and corticosteroids are taken via the inhalation route using inhalers. The patient should be taught on how to use the inhalers as incorrect use may lead to the patient not getting the full dose. The patient should bring their inhaler with him during the next visit and a review on how to use it done. The patient should also be aware of the side effects of the medications. Beta 2-agonists cause a fast heartbeat which lasts a few minutes and go away after repeated use of the medication (Arcangelo & Peterson, 2017). The patient should be made aware of this as this may cause feelings of anxiety which worsens breathlessness. LABA should not be used in combination with other medications that contain LABA as this can lead to an overdose. Also, the patient should not use the drugs at higher doses than recommended. Anticholinergics causes a dry mouth (Arcangelo & Peterson, 2017). Inhaled steroids may cause a sore throat and infection in the mouth. The patient should therefore be encouraged to use a spacer when taking steroids to minimize these side effects and rinse the mouth after ingestion.
Long-acting beta 2-agonists (LABA) should not be used for long periods. Paradoxical bronchospasm, laryngeal spasm, swelling, and stridor may occur and should be treated immediately with an inhaled, short-acting bronchodilator. Treatment with the LABA should be discontinued and an alternative therapy of LABA started. An alternative to LABA would be anticholinergic bronchodilators such as glycopyrronium. These drugs have a slower onset of action and therefore cannot be used for quick relief. For this reason, Patel et al. (2019 Chronic Obstructive Pulmonary Disease Paper) recommends a switch from LABA/ICS to LAMA/LABA.
The patient should be aware of health promotion that pertains to self-monitoring and knowing his risk factors for COPD. Mosenifar et al., (2020) recommends that the patient should be educated on the common risk factors of COPD which include smoking and the benefits that cessation would have on their health. Repeated reinforcement and education on the technique of use of the inhaler is critical in ensuring effective management of the patient’s condition. This greatly influences adherence to medication as it will help improve the patient’s satisfaction with the inhaler. The patient should be educated on pulmonary rehabilitation programs. It should be multidisciplinary and exercise therapy should be a mandatory component. Patient should perform endurance exercise regularly to reduce dyspnea and enhance tolerance to daily activities (Mosenifar et al., 2020). Breathing retraining techniques can also be taught to the patient so as to prevent dynamic airway compression and improve the ventilatory pattern. The plan should be reviewed with the family so that they may actively participate in the patient’s management. The patient should also be educated on symptoms to look out for and to seek early medical attention.
Metoprolol is a cardioselective beta-blocker and therefore would not affect the choice of treatment for this patient. However, the patient must discontinue the use of Metoprolol immediately as it has been associated with “worsening dyspnea and of the overall burden of COPD symptoms, as measured by the shortness-of-breath questionnaire and the COPD assessment test,” (Dransfield et al., 2019).
References for Chronic Obstructive Pulmonary Disease Paper
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Oba, Y., Keeney, E., Ghatehorde, N. & Dias, S. (2018). Dual combination therapy versus long‐acting bronchodilators alone for chronic obstructive pulmonary disease (COPD): a systematic review and network meta‐analysis. Cochrane Database of Systematic Review. https://doi.org/10.1002/14651858.CD012620.pub2
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