Chronic Obstructive Pulmonary Disease

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Chronic Obstructive Pulmonary Disease
Christopher R. Leon-Guerrero MS III
Accessible via www.med.unc.edu/chrislg
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Case

• Gary is a 63 y.o. male presenting with SOB.

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Case

• Gary is a 63 y.o. male with a long standing
  history of COPD (10 yrs) presenting with SOB.
  

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Case

• Gary is a 63 y.o. male with a long standing
  history of COPD (10 yrs) and a 50 pack year
  history of smoking presenting with SOB.
  

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Case

• Gary is a disabled 63 y.o. male with a long
  standing history of COPD (10 yrs) and a 50 pack
  year history of smoking presenting with SOB.
  

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Who is Gary?

• SH
• -50 pack/year history of smoking cigarettes
• -denies alcohol use
• -denies illicit drugs

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Who really is Gary?

• SH
• Gary lives alone in the North Charlotte area. In
  his formative years he worked on his familys
  farm and later started his own landscaping
  business at the age of 40. At the age of 11, Mr.
  Galloway suffered disabling injuries to his left
  leg due to a tractor accident. Since then he has
  been classified as disabled. He was once married
  but has been divorced for over 20 years. He has
  two daughters who both live in the area and are
  actively involved in his medical care. He
  currently does not work but regularly volunteers
  at the local Fire Department. His only income
  source is from disability which is less than
  1,200 dollars per month. He attends Mallard
  Creek Presbyterian Church were he is highly
  involved with church events. He attends church
  regularly with his 82 year old mother who is in
  relatively good health. Gary has smoked since the
  age of 13. He is strongly attached to cigarette
  smoking and today has no interest in quitting.
  Smoking for Gary is his one guilty pleasure in
  life and he doesnt know (I dont know) of any
  other way to live.
• But even this does not suffice

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Garys Family

• FH
• -Father died from an unspecified accident
• -Mother good health
• -Oldest Daughter Good Heatlh
• -Youngest Daughter Good Health

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Genogram
FH
M 1970 D 1985
63 (03/19/44)
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Garys History

• PMHx
• -COPD (Dx 1993)

If only it were that simple
-HTN (Dx 1993) -CVA (Dx 2004) -Squamous Cell Car
cinoma (Dx 2006) -Basal Cell Carcinoma (Dx 2006)

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The Science of COPD

• Definitions
• COPD is a chronic respiratory disorder primarily
  caused by smoking
  
• COPD is a disease state characterized by airflow
  limitation that is not fully reversible, but is
  usually both progressive and associated with an
  abnormal inflammatory response to noxious
  particles of gases

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The Science of COPD
Symptoms - Dyspnea that is Progressive (wor
sens over time) Usually worse with exercise Pers
istent (present every day) Described by the patie
nt as an increased effort to breathe,
heaviness, air hunger, or gasping.
- Chronic cough May be intermittent and may be
unproductive. - Chronic sputum Any pattern
of chronic sputum production may indicate COPD.
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Global Initiative for Chronic Lung Disease
(GOLD) Classification of Severity
All stages have an FEV1/FVC 14
Garys Spirometry
FVC 90 predicted (2.97 L) FEV1 36 predicted (
0.94 L)
FEV1/FVC 0.32
Interpretation Stage III- Severe
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GOLD Treatment Guidelines

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Garys Medications
Meds Fluticasone/Salmeterol 250 mcg/50 mcg INH B
ID Albuterol/Ipratropium 120mcg /21 mcg INH QID
2 puffs PRN Amlodipine/Benazepril 10 mg/40 mg INH
QDay Aspirin 81 mg PO QDay
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Garys Monthly Medication Bill
Meds Advair ? 185.82 Combivent ? 98.42 Lot
rel ? 101.11 Aspirin ? 1.75 MONTHLY TOTAL
387.10

prices from www.drugstore.com
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Assessment
Assessment Gary is a disabled 63 y.o. male with
a long standing history of COPD (10 yrs). Today
he presents with complaints of shortness of
breath and ineffectiveness of his medications.
He is concerned about his health but is also
concerned about the cost of his medication. He
knows it is important for him to continue taking
medications but with the high price tag and his
low income (1200/month) he is hoping there is
some way to reduce his monthly medication bill.
Gary also knows cessation of smoking would be ex
tremely beneficial for his health but mentally he
is not prepared to make that change.
Gary is extremely grateful that we made a
house-call because he does not have
transportation. His oldest daughter normally
drives him where he needs but this week she is
out of town.
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Plan

• Plan
• Access to medications- provided samples and
  applications to receive medication donations from
  pharmaceutical companies
  
• www.drugassistant.com
• (2) Medication Changes
• - Tiotropium (18 mcg/cap) 1 cap INH QDay
• - Levalbuterol 1.5 mg NEB Q6-8h PRN
• (3) Smoking cessation- counseling was provided
  and varenicline was discussed with patient
  
• (4) Access to care discussed delivery of
  medications and home health transportation
  services
  
• (5) Finances discussed assistance from church
  and discussed applications to medicare/medicaid
  
• (6) Prevention discussed Flu shot in October

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References
Global Initiative for Chronic Obstructive Lung
Disease. Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive
Pulmonary Disease. NHLBI/WHO workshop report.
Bethesda, MD National Heart, Lung and Blood
Institute 2001. Available at www.goldcopd.com
National Heart, Lung, and Blood Institute,
National Institutes of Health.
Chronic obstructive pulmonary disease data fact
sheet. Available at www.nhlbi.nih.gov/health/pu
blic/lung/other/copd_fact.htm.
Preventing Chronic Obstructive Pulmonary Disease
What is Known and What Needs to Be Done to Make
a Difference to the Patient? RA Wise and DP
Tashkin. The American Journal of Medicine. Vol.
120 Issue 8A August 2007. S14-S22.
An Approach to Interpreting Spirometry. TJ Barre
iro and I Perillo. American Family Physician.
Vol. 69. No. 5 March 2004. 1107-1114.