Endgames Case report

A woman attending for routine review of her chronic obstructive pulmonary disease

BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b70 (Published 15 January 2009) Cite this as: BMJ 2009;338:b70
  1. Hilary Pinnock, senior clinical research fellow
  1. 1Allergy and Respiratory Research Group, Division of Community Health Sciences: GP Section, University of Edinburgh, Edinburgh EH8 9DX
  1. hilary.pinnock{at}ed.ac.uk

    Case study

    A 57 year old woman attended for routine review of her chronic obstructive pulmonary disease (COPD) complaining that she had recently been more breathless. She was a postal worker and was finding her daily “walk” delivering mail increasingly difficult. She had seen a locum in the practice a few weeks previously who had changed her salmeterol for a combination inhaler containing 100 µg fluticasone and 25 µg salmeterol. The new treatment had not improved her symptoms, and she was worried about the side effects after reading about steroids on the internet.

    Her records showed that she requested her treatment regularly, and the nurse noticed that she had had two courses of antibiotics and steroids for exacerbations since the diagnosis had been confirmed five years ago. At the previous year’s review she had been given a prescription for nicotine replacement to help her stop smoking. Post-bronchodilator spirometry showed a forced expiratory volume in one second (FEV1) of 1.18 litres (40% of predicted) with an FEV1/FVC ratio of 51%. Her MRC (Medical Research Council) dyspnoea score was 3.

    Questions

    • 1 How would you approach the problem of her increasing breathlessness?

    • 2 What advice would you give her about her treatment?

    • 3 What other options should you consider for her?

    Answers

    Short answers

    • 1 Increasing breathlessness is a feature of the inexorable progression of chronic obstructive pulmonary disease, especially in patients who continue to smoke. Other common comorbidities need to be considered—especially heart failure and lung cancer.

    • 2 Although she has moderate COPD, she is not having frequent exacerbations so is unlikely to benefit from inhaled steroids. Reverting to her previous treatment of a long acting β agonist and adding a long acting anticholinergic might be a better option.

    • 3 Pulmonary rehabilitation could improve her exercise tolerance. Consider the possibility of depression, which is …

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