You're still reminiscing over that fantastic pizza you had last night as you walk into your office, partly because it's going to mean extra hours at the gym. "Definitely worth it," you tell yourself.
The first consult this afternoon is Mr. Robertson, a smiling 72-year-old man referred by his family physician with complaints of dyspnea. As he describes his problem, you take note that he is dyspneic even for ordinary activities like climbing a single flight of stairs. He also complains of an unproductive cough that worsens in the evening. "Do you have any other issues with your health, Mr. Robertson?" you ask, and he tells you he has hypertension ("Always well controlled, doctor!" he beams), dyslipidemia ("Well controlled also!") and a "hay fever" since the age of fifteen. On further questioning, he says that he has been smoking since he was 21 years old, a total of 39 pack-years. He also drinks a glass of red wine with lunch and dinner. He proudly adds that he has never been hospitalized. He lays his medication out on the table and you see boxes of telmisartan 40mg/day, atorvastatin 10mg/day and hydroxyzine 25mg as necessary.
You request to examine him and he nods in assent. Mr. Robertson's BP is 136/82 mmHg, pulse is 74 bpm and saturation on ambient air is 93%. He has bimaleolar edema. Cardiopulmonary auscultation is unremarkable, as is the rest of the systemic exam.
You discuss the possible differentials, and the need for further tests. For his next visit, you request a basic blood analysis, spirometry, echocardiography, ECG and CT of the thorax. As you hand him the prescription for the tests and schedule a follow up appointment, Mr. Robertson looks puzzled. "How about some medication, doctor? Won't you give me something for my breathlessness?"
It's Mr. Robertson's next appointment, and he's feeling much better. His cough and dyspnea have subsided, as has the ankle swelling. You go over his test results. The spirometry, echocardiogram and EKG are all normal. The blood tests show a slightly elevated creatinine and urea (these were normal a month ago as per previous reports). "So doctor, what's wrong with me?" You now realize your grave error. The furosemide may have reduced his edema, but it has simultaneously worsened his renal function. Besides, the echocardiogram shows no evidence of heart failure, ruling out cardiogenic dyspnea. His dyspnea may therefore be due to asthma or COPD or both, but the spirometry is normal as well, most probably because he was using an inhaler prior to taking the test. You jerk out of your lucid dream, realizing that you were about to make a very serious mistake. At least you've caught yourself in time and Mr. Robertson hasn't noticed you zoning out.
Mr. Robertson seems only partially convinced with your explanation, so you add, "Starting medications before the tests may alter the results. It's worth the wait Mr. Robertson." "Try and avoid too much physical effort and I'll see you as soon as your reports come in so we can start you on some treatment." "Ok, doctor," responds Mr. Robertson, looking reassured. "Goodbye for now!"
Mr. Robertson returns for his follow-up. He has been clinically stable and the findings on his physical exam are similar as before. You begin going through his test results. Spirometry shows a post-bronchodilator increase in FEV1 of 13% and 200 ml from baseline, an FEV1/FVC of 0.5 and an FEV1 of 76%. The echocardiogram, EKG and blood tests are all within normal parameters.
What course of treatment will you recommend?
As you write out the prescription, it strikes you that long-term monotherapy with inhaled corticosteroids is not recommended for patients with COPD; formoterol alone is not appropriate either, in the event that Mr. Robertson turns out to have an asthma COPD overlap syndrome (ACOS). Thus, you change your prescription to a combination inhaler.
You assume a probable diagnosis of COPD or an asthma COPD overlap syndrome (ACOS) from the spirometry results. You now need to make a decision regarding the type of inhaler to prescribe. You consider the following: Mr. Robertson is 72 years old and his hand-inhalation coordination is probably getting worse; however, he has a high inspiratory flow.
It occurs to you that a pressurized metered-dose inhaler requires good hand-inhalation coordination and a nebulizer, while appropriate for this type of patient, entails a far longer nebulization time. You therefore opt for a dry powder inhaler.
You hand Mr. Robertson his prescription and describe the correct use of the inhaler. Before scheduling an appointment for the following month, you advise Mr. Robertson about nonpharmacologic treatments, namely smoking cessation, physical activity and flu and pneumococcal vaccinations.
At his next appointment, Mr. Robertson doesn't seem very happy. He still complains of dyspnea for ordinary activities and an unproductive cough that is worse in the evenings. Mr. Robertson denies having experienced any respiratory infections over the past few weeks. His physical examination is within normal parameters once again. He assures you that he has been carefully adherent to your prescribed treatment regimen.
You change Mr. Robertson's prescription and schedule another appointment for a month later. However, after two weeks of his starting the new medication, you receive a somewhat angry phone call from your patient. "Hello doctor, this new medication doesn't seem to be working at all. Sometimes I think I am actually getting worse. Is there anything you can do for me?" "Will you be able to come in to my office this afternoon, Mr. Robertson?" "Sure, I'll come in again, I suppose," he sighs. "See you, then." "Goodbye, Mr. Robertson." You hang up, realizing that you should have checked his inhalation technique during his last appointment.
"Mr. Robertson, it's hard to use these inhalers correctly, and I probably didn't explain it well enough during our last appointment. This could be why you're not feeling any better on the medication. Would you mind showing me how you use it?" Mr. Robertson picks up his inhaler and takes a puff. You realize that he is not exhaling fully into the room to functional residual capacity before inhaling. He is also gradually increasing his speed of inhalation, rather than inhaling forcefully from the start. You point these things out to him, asking him to practice the inhalation technique until it is correct. You reassure him that this should work, and schedule the next appointment for two months down the line, asking him to give you a call if his symptoms do not improve in a week.
One morning, you receive a worried phone call from Mr. Robertson's wife. "My husband doesn't feel well at all, doctor. He has a productive cough and a fever." You ask request her to bring him to the ER. When Mr. Robertson arrives, he tells you that he has had a productive cough with purulent sputum and a fever of around 38 ºC for three days. He is more dyspneic than usual and has had no relief with his usual medications. On examination, he is tachypneic with a BP of 148/88 mm Hg, a pulse of 107 bpm and saturation on room air of 85%. Pulmonary auscultation reveals rhonchi and wheezes, which are more pronounced on the right side.
As you order tests for Mr. Robertson, you it occurs to you that spirometry is not recommended during an exacerbation because aside from being difficult to perform, the results may be inaccurate.
A blood-gas analysis shows a pH of 7.34, pO2 55 mmHg, pCO2 55 mmHg, HCO3- 27.4 mEq/L, and saturation 85%. The chest X-ray is clear. The blood analysis shows a C-reactive protein level of 1.4 mg/dL (0-10) and is otherwise normal. You decide to start Mr. Robertson on supplementary oxygen to a target saturation of 88-92%, along with 40mg of prednisone.
What additional treatment options will you consider?
As you prescribe Mr. Robertson's medication, it dawns on you that short-acting inhaled beta-2 agonists with or without short-acting anticholinergics are the preferred bronchodilators when treating an exacerbation. Additionally, antibiotics should be given to patients with dyspnea, increased sputum volume and purulence, and those in need of mechanical ventilation.
Mr. Robertson begins showing signs of improvement within a few minutes and you admit him for observation. The next day, your colleague shifts him to the general ward and you later hear that he was discharged, to follow up with you in two weeks.
"Not yet, Mr. Robertson. In order to accurately diagnose the cause of your breathlessness, I'll need you to do these tests first", you tell him while writing down the relevant investigations.