Asthma or Copd Case Study

CASE STUDY 1 A 52-Year-Old Woman With Asthma...or Is It COPD? Presentation Diane,, a 52-year Diane 52 -year old, post me menopausal nopausal whit whit e woman woman seeks see ks medical medical t reat me ment nt be because cause she is— in her her words— “hav “having ing t hat bron bronchit chit is t hin hing g again. again.” She rep report ort s having having t he hese se episode pisodess 1t 1 t o 3 t ime imess per year year during t he past 5 ye year ars. s. She den denie iess any feve fever wit h t his episode episode.. Diane Di ane speak speakss in full sent sent ence ncess and does does not appe appear ar t o be be in in acut e respirat respirat ory dist ress. She is curre curr ent ly a social smoker smoker but prev previously iously smoked smoked a pack per per day d ay for approximat el elyy 10 ye year ars. s. She has a brot he herr wit h ast hm hma a and a grandfat he herr who die died d of emph emphyse ysema ma at t he age of 6 8 . She She is is allergic alle rgic t o shellfish. shellfish. Diane Diane de descr scrib ibe es he herr sympt oms as be being ing worse worse in t he mornin morning g wit wit h lot s of coughing cough ing and heavy heavy phle phlegm gm product ion. She is also als o awake awakene ned d by cough a few t ime imess dur during ing t he nightt . She is nigh is concerned because because t he illne illness ss is recu r ecurr r ing more frequent frequent ly. In t he past , she has bee be en t reat ed wit wit h a var varie iett y of medicat medicat ion ions, s, inclu including ding inh inhale aled d cort icost eroids (IC ( ICS), S), long-act long-act ing bet a2 adrene adrenergic rgic agon agonist ist s (LABA), ( LABA), oral cor cor t icost eroids, and ant ib ibiot iot ics. Whe hen n asked asked about about any change chang es in her her symp s ymptt oms ove over t ime she me ment ion ionss t hat t he heyy used used t o be be seasonal bu butt no now w t he heyy occur sporadically, s poradically, ye year ar-r -roun ound. d. Whe hen n asked asked about about ex exercise, ercise, she report report s t hat she used used t o walk walk 3 t ime imess a week week wit h a frie fr iend nd but but can no long longer er keep keep up because because of breat hing dif difficult ficult ie ies; s; inst ead, she walks walks wit wit h an older older neighbo neighborr abou a boutt once a wee week. k. Diane at t r ibut es t he change t o “old “old age. age.” Physical Examination • Height 5 f t 6 in • Weight 15 2 lb • B MI 2 4 .5 kg/ m2 • BP 12 8 / 74 mm Hg • HR 74 bpm • RR 18 / min • Temper a t ur e 9 8 .4 .4 °F • HEENT Nor mal • Neck No jugula r venous dis t en ent io ion • Lungs Decre rea ase sed d bre rea at h so sou unds, sc sca at t ere red d end-e -exxpira ratt ory wheeze • Hea r t Regular ra rat e and r hy hyt hm, no mur mur s or gallops BMI = body mass index; index; BP = blood blood pressure; pressur e; HR = heart rat e; RR RR = respirat r espirat ion rat e; HEENT HEE NT = head, ear ears, s, eye eyes, s, nose, nose, and t hroat . Clinical Decision Point

What t est should be be ordere ordered d now? now? • Chest X-ra -rayy • Sp Spiiro rom met ry • Pulse oxim ime et ry • Al Alllerg rgyy t est ing • Non one e; re refer fer t o pul pulmo mono nolo logi gist st www.practicingclinicians www.practicing clinicians.com .com

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A s t h m a / C O P D

D P O C / a m h t s A

CASE STUDY A 52-Year-Old Woman With Asthma...or Is It COPD?

Comment Diane’s respirat ory sympt oms have never been fully evaluat ed despit e t heir repeat ed occurrence and t he variet y and number of medicat ions t hat have been prescribed. The sympt oms and hist ory present ed here most st rongly suggest t he possibilit y of ast hma or COPD (Table 1). 1,2 As might be expect ed wit h ast hma, Diane has int ermit t ent sympt oms t hat are worse at night and in early morning, she has a close relat ive wit h ast hma, and she has a hist ory of allergy. 1 As might be expect ed wit h COPD, Diane was in her lat e fort ies at onset of sympt oms, her sympt oms are progressive in t hat t hey now occur year-round, and she has modified Table 1. Diff erential and Overlapping her lifest yle t o accommodat e Features of Asthma and COPD reduced exercise t olerance.1,2 Diagnosis Typical Features Diane’s smoking hist ory is not definit ive for eit her disorder. She ➤ Onset in middle age COPD ➤ Slowly progressive symptoms smokes socially and has a 10 pack➤ History of heavy smoking year hist ory, but does not have t he ➤ Dyspnea with exercise 20 pack-year hist ory t hat is more ➤ Largely irreversible airflow limit ation clearly associat ed wit h COPD.3 ➤ Early onset (often childhood) Asthma Similarly, cough and wheezing are ➤ Variable, intermittent symptoms sympt oms of bot h disorders, ➤ Nocturnal and early-morning symptoms alt hough a cough producing large ➤ History of allergy, rhinitis, or eczema amount s of phlegm is more sugges➤ Family history of asthma ➤ Largely reversible airflow limit ation t ive of COPD.4 Spiromet ry is t he best t ool for different iat ing ast hma Both ➤ Wheezing ➤ Cough from COPD.1 Diane is not in acut e ➤ Chest tightness dist ress (ie, hypoxic), t herefore ➤ Dyspnea pulse oximet ry is not warrant ed. Global Strategy for the Diagnosis, Management, and Allergy t est ing or a chest X-ray Prevention of COPD 1; Doherty DE.2 may be desirable t o obt ain aft er a diagnosis is made but will not benefit t he diagnosis it self. Because Peak expiratory flow rate t hese t est s are all available in priPostbronchodilator 10 mary care pract ice, t here is no need Prebronchodilator 8 t o refer Diane t o a specialist . ) 6 s / 4 L ( e 2 t a R 0 w-2 o l F -4

FVC Volume (L) 1

2

3

4

5

6

7

-6 -8

Figure 1. Prototype of spirometry flow -volume loop.

2

Decision: Order spiromet ry t est ing. Prebronchodilat or and post bronchodilat or t est ing should be performed t o det ermine t he degree of revers ibilit y of any airf low obst ruct ion (Figure 1). Diane’s spiromet ry result s are present ed in Table 2.


The spiromet ry t racing must be Table 2. Diane’s Spirometry Results evaluat ed init ially t o det ermine if it is int erpret able: Is t here a good Prebronchodilator Postbronchodilator rapid st art wit h a 4- t o 6-second FEV1 2.02 2.27 blow t hat reaches a plat eau wit hout 52% of predicted 58% of predicted int errupt ions? An algorit hm may FVC 3.85 4.26 guide int erpret at ion of t he spirome70% of predicted 87% of predicted t ry result s (Figure 2).5 However, it is FEV1 /FVC 52% 53% import ant t o not e t hat in some ratio cases, ast hma may be difficult t o dist inguish from COPD—even wit h spiromet ry. Airflow obst ruct ion can be part ially reversible aft er bronchodilat or use in bot h disorders. The degree of reversibilit y and ot her clinical charact erist ics must be considered. Alt hough t he obst ruct ion in ast hma may not be fully reversible, it should approach complet e reversal. In COPD, post bronchodilat or airflow will never ret urn t o normal or near-normal values. A post bronchodilat or FEV /FVC rat io <.70 indicat es COPD.1,2 1 Clinical Decision Point

What is Diane’s diagnosis? • Bronchit is • Ast hma • COPD • React ive airway disease Acceptable spirogram Yes

Is FEV1/FVC rat io low ?

No

Obst ructi ve defect

Is FVC low ?

Is FVC low ? No

Yes M ixed obst ructive/ rest rict ive def ect or hyperinflation Furt her t est ing

Pure obstruction Reversible with use of beta agonist? Yes Ast hma

Yes

No

Restrictive defect

Normal

Further testing

No or part ial COPD

Figure 2. Algorithm for interpretation of spirometry results. Petty TL.5

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Comment Diane’s FEV /FVC rat io is low, so we proceed down t he left side of t he algorit hm. Her post bron1 chodilat or FVC is near normal at 8 7%, suggest ing a purely obst ruct ive defect . FVC and FEV1 were part ially reversible wit h a bet a agonist , but are st ill subst ant ially reduced from normal, and t he rat io is <.70 . Spiromet ry result s, in conjunct ion wit h Diane’s signs, sympt oms, and hist ory, suggest t hat COPD is t he correct diagnosis.

Decision: Diane’s diagnosis is COPD. The frequency of COPD in women has been increasing in recent years, and it is import ant not t o bias diagnost ic decisions because of gender. A r ecent st udy found t hat primary care physicians who were present ed wit h medical hist ories and physical examinat ion dat a on a hypot het ical COPD case were significant ly more likely t o diagnose COPD in male pat ient s t han in female pat ient s, even t hough t hey were given ident ical dat a wit h which t o make t he diagnosis. 6 In order t o proceed wit h appropriat e pharmacot herapy, Diane’s clinician must rank t he severit y of her disease and consult s t he Global Init iat ive for Chronic Obst ruct ive Lung Disease (GOLD) guidelines for st ep t herapy in COPD (Figure 3) . 1 Not e: GOLD guidelines ar e not necessar ily int erpret ed st rict ly as far as FEV1 t hreshold values for addit ion of ICS. St udy result s indicat e t hat t he addit ion of ICS t o LABA may be beneficial in pat ient s who have not yet reached an FEV1 of <5 0 % of predict ed.7 Clinical Decision Point

Which t ypes of pharmacot herapy do you consider f or Diane? • Short -act ing bronchodilat ors as needed • Long-act ing bronchodilat ors daily • Long-act ing bronchodilat ors daily plus short -act ing bronchodilat ors as needed • Long-act ing bronchodilat ors and ICS daily plus short -act ing bronchodilat ors as needed Background Asthma and COPD are common respiratory disorders that result in significant morbidity and mortality. It is estimated that there are over 17 million adults diagnosed with asthma 1 and 10 million adults diagnosed with COPD in the United States. 2 The number of individuals with undiagnosed COPD is estimated to be even higher, according to studies that used spirometry to screen nearly 14,000 adults. 2 The symptoms of asthma and COPD overlap, and distinguishing between the 2 conditions can be challenging. In order to make the correct diagnosis, the totality of signs, symptoms, risk factors, and patient characteristics must be considered. Correct diagnosis is crucial because optimal management of COPD and asthma require substantially different approaches. References 1. Adult self-reported current asthma prevalence rate (percent) and prevalence (number) by state or t erritory, BRFSS 2004. Centers for Disease Control and Prevention. http://www.cdc.gov/asthma/brfss/04/current/ current.pdf. Accessed September 15, 2008. 2. Mannino DM, Homa DM, Akinbami LJ, Ford ES, Redd SC. Chronic obstructive pulmonary disease surveillance—United States, 1971-2000. MMWR Surveill Summ. 2002;51(SS-6):1-16.

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I. Mild

II. Moderate

III. Severe

IV. Very Severe ➤

➤ ➤ ➤ ➤

FEV1/FVC <0.70 FEV1 ≥80% predicted

➤

FEV1/FVC <0.70 50% ≤FEV1 <80% predicted

➤

FEV1/FVC <0.70 30% ≤FEV1 <50% predicted


➤

FEV1/FVC <0.70 FEV1 <30% predicted or FEV1 <50% predicted plus chronic respiratory failure

Act ive reduct ion of risk f act or(s); inf luenza vaccinat ion Add short-acting bronchodilator (when needed) Add regular

treat ment w it h one or more long-acti ng bronchodilat ors (when needed): Add rehabilit ation Add inhaled

glu cocort icost eroids if repeated exacerbati ons Add long-term

oxygen if chronic respiratory failure Consider surgical treatment Figure 3. GOLD guideline s for step therapy in COPD. Global Strategy for the Diagnosis, Management, and Prevention of COPD.1

Comment According t o t he GOLD guidelines, Diane has moderat e COPD (FEV1 is bet ween 50 %and 80 %of predict ed). At t his severit y of disease, it is appropriat e t o st art Diane on daily inhaled longact ing bronchodilat ors, which are usually t he most effect ive and convenient t reat ment s. 1 There are 2 t ypes t o choose from: LABAs and ant icholinergics. Eit her can be used first ; and if t he init ial t herapy does not improve sympt oms enough, t hese t herapies can be combined before moving up t o t he next st ep in t herapy. Addit ionally, short -act ing bronchodilat ors (short -act ing bet a2 agonist s [SABAs] or ant icholinergics) can be used as needed for sympt oms.1 It is import ant t o not e t hat one of t he many reasons t hat t he correct diagnosis is imperat ive is t hat t he order of t herapies used in COPD and in ast hma is different . For ast hma, t he first medicat ion t o be added t o a short -act ing bronchodilat or is an ICS, not a LABA (Figure 4). 8

Decision: Prescribe daily LABA and a short-acting anticholinergic to be used as needed for symptoms. Pharmacot herapy is only one component of eff ect ive COPD management . COPD is ass ociat ed wit h significant morbidit y and mort alit y, and a mult ifacet ed approach t o management is required. It is t he 4t h-leading cause of deat h in t he Unit ed St at es; and among t he t op 6 causes, it is t he one t hat is most st rongly associat ed wit h an increase in mort alit y over t he past few decades.9 Mort alit y in women has increased at an even st eeper rat e t han it has in men (Figure 5, page 7). 10 The increase in COPD in women is likely relat ed t o an increase in t heir smoking rat es and t he pot ent ially higher suscept ibilit y of women t o t he eff ect s of t obacco smoke in t he lungs.1 Opt imal management of COPD should include nonpharmacologic int ervent ions in order t o slow t he disease process and improve sympt oms. www.practicingclinicians.com

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Intermittent Asthma

Persistent Asthma Daily Medication Consult with asthma specialist if step 4 care or higher is required Consider consultation at step 3

Step 2 Preferred:

Step 1 Preferred:

Low-dose ICS

SABA PRN

Alternative:

Cromolyn, nedocromil, LTRA, or theophylline

Step 4 Preferred:

Step 5 Preferred:

Step 6 Preferred:

Step up if needed

High-dose ICS (First, check + LABA + oral High-dose ICS adherence, corticosteroids + LABA Medium-dose environmental AND Medium-dose ICS + LABA AND control, and Consider ICS Consider comorbid omalizumab OR omalizumab Alternative: conditions) for patients Low-dose Medium-dose for patients who have ICS + LABA who have ICS + either Assess Control allergies allergies Alternative: LTRA, Step down, if Low-dose ICS theophylline, possible + either LTRA, or zileuton (and if asthma theophylline, is well or zileuton controlled at least 3 months)

Step 3 Preferred:

Patient Education and Environmental Control at Each Step

Quick-Relief Medication for All Patients ➤ SABA as needed for symptoms. Intensity of treatment depends on severity of sympt oms: up t o 3 tr eatm ent s at 20-min ut e int ervals as needed. Shor t cour se of syst emic oral cor t icost erio ds may be needed. prevention of EIB) ➤ Use of beta -agonist >2 days a week for sympt om contr ol (not 2 indicates inadequate control and the need to step up treatment.

Figure 4. National Asthma Education and Prevention Program (NAEPP) guideline s for stepwise management of a sthma in adole scent s (≥12 years) and adult s. LTRA = leukotriene receptor agonist; EIB = exercise-induced bronchospasm. US Department of Health and Human Services. 8 Clinical Decision Point

What nonpharmacologic approaches should be recommended as a part of Diane’s COPD management plan? • Prevent at ive vaccines and smoking cessat ion • Prevent at ive vaccines, smoking cessat ion, and pulmonary rehabilit at ion • Prevent at ive vaccines, smoking cessat ion, and t rigger ident ificat ion and avoidance • Prevent at ive vaccines, smoking cessat ion, pulmonary rehabilit at ion, and t rigger ident ificat ion and avoidance Comment Smoking cessat ion is t he single most useful int ervent ion t o slow COPD progression and prolong life.1 All smokers should be offered an int ensive smoking cessat ion int ervent ion. The US Public Healt h Service recommends a 5-st ep int ervent ion (Table 3).1 Numerous pharmacot herapies (including nicot ine replacement , bupropion, and varenicline) are now available for pat ient s for whom counseling alone is insufficient .1 Addit ionally, t he Advisory Commit t ee on Immunizat ion Pract ices (ACIP) recommends t hat pat ient s wit h COPD should receive a flu shot every year and a pneumococcal polysaccharide vaccine.11 Triggers t hat worsen sympt oms or cause exacerbat ions 6

(such as second-hand smoke, air pollut ion, perfumes, or ot her irrit ant s) should be ident ified and avoided if possible. Since Diane is current ly experiencing a COPD exacerbat ion, it may not be appropriat e t o begin pulmonary rehabilit at ion just yet , but it should be recommended and briefly discussed for fut ure implement at ion.


70 0 0 60 0

Female Male

1

x r 50 a e Y / 40 s h t a e 30 D f o r 20 e

Decision : Recom m end b m10 prevent at ive vaccines, u N smoking cessation, 0 pulmonary rehabilitat ion, 1980 1985 1990 1995 2000 and t rigger identification and avoidance. Figure 5. Deaths due to COPD by gender. Mannino DM et al.10 Diane ret urns for follow-up aft er 4 weeks, t o ensure t hat she unders t and her diagnosis, is t aking t he medicat ions as prescr ibed, t hat t he medicat ions are improving her s ympt oms and t hat she is using proper inhaler t echnique. Diane report s t hat she is able t o walk furt her, is not coughing at night , and her breat hing feels easier. She has been t aking her medicat ions and comment s t hat she is glad she has insurance because t hey are expensive. Upon demonst rat ion, it is not ed t hat Diane’s inhaler t echnique cont inues t o be very good. Diane is reminded t hat she will need t o t ake t hese medicat ions (and possibly some addit ional ones) f or t he rest of her life because COPD is a chronic condit ion. This firs t follow-up visit also provides an opport unit y t o discuss pulmonary rehabilit at ion more t horoughly and refer Diane t o a program. Pat ient s wit h moderat e or severe levels of COPD should be st rongly encouraged t o part icipat e in pulmonary rehabilit at ion if it is available in t he communit y. Pulmonary rehabilit at ion programs are imporTable 3. Str at egies for Encouragin g t ant t o help address needs t hat Sm oki ng Cessat ion are not addressed by medical 1. Ask: Systematically identify all smokers at every t herapy, including social isolat ion, visit and document status. poor mood, exercise decondit ion2. Advise: Strongly urge smokers to quit, using a ing, muscle wast ing, and weight clear, personalized message. loss. These various negat ive fea3. Assess: Ask the smokers if they are willing to t ures of COPD can int eract and make a quit attempt. 4. Assist: Help the smokers quit by providing a quit reinforce each ot her (Figure 6 ). 1 plan, practical counseling, social support, and Rehabilit at ion programs vary as supplemental materials for each; recommend use far as t heir part icular compoof approved pharmacotherapy, if appropriate. nent s, but t hey generally include 5. Arrange: Schedule follow-up contact. exercise t raining, nut rit ional counGlobal Strategy for the Diagnosis, Management, and seling, and pat ient educat ion. Prevention of COPD.1 Exercise capacit y, qualit y of life, www.practicingclinicians.com

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muscle st rengt h (respirat ory and ot her muscles), mood, and survival may be Lack o f Fit ness 1 improved wit h pulmonary rehabilit at ion. Because Diane’s sympt oms have COPD Dyspnea Immobilit y improved and she report s no side eff ect s, her medicat ions are not changed. She is referred for pulmonary rehabilit at ion aft er Depression Social Isolat ion a full discussion of it s pot ent ial benefit s. At t his and fut ure follow-ups, Diane should be asked about any change in risk Figure 6. Interrelation of phy sical, social, and psychosocial features of COPD. Global Strategy for the fact ors, including smoking st at us. Diane Diagnosis, Management, and Prevention of COPD .1 report s t hat she is st ill smoking socially (approximat ely a pack each week) and is not willing t o t ry t o quit complet ely. Hist ory of exacerbat ions and changes in comorbid condit ions should also be followed up at each visit .1 Comorbidit ies, such as cardiovascular disease, bronchial carcinoma, and depression, are common in COPD, in part , because t hey are indirect ly relat ed t o t he disease and, addit ionally, because COPD usually occurs in older individuals who t end t o have more disorders independent of COPD. Current ly, t here are no specific guidelines for t reat ing comorbidit ies in COPD pat ient s. However, t hey may be more difficult t o manage because COPD increases t he level of disabilit y and COPD t reat ment s can negat ively affect comorbidit ies. Guidelines for t reat ment of t he part icular comorbidit y should be followed. 1 Diane’s next visit is scheduled for 2 mont hs lat er, and if s he cont inues t o do well, follow-ups will be scheduled for every 3 t o 6 mont hs. Diane ret urns f or rout ine follow-up and cont inues t o do reasonably well over t he next year and a half; however, at a follow-up appoint ment about 2 years aft er t he init ial diagnosis, she report s 3 mild exacerbat ions in t he past 10 mont hs t hat she self-t reat ed using addit ional doses of her short -act ing ant icholinergic. Her current drug regimen includes a LABA and a long-act ing ant icholinergic daily plus a short -act ing ant icholinergic as needed. She has reduced her exercise level t o her pret reat ment baseline, some weeks even less, alt hough she had been quit e act ive for about a year following pulmonary rehabilit at ion. She blames t he backslide on “lack of t ime”. She also report s an increase in daily cough and phlegm product ion, alt hough she claims t o have reduced her s moking t o 10 t o 15 cigaret t es per week. She does not appear t o be experiencing acut e respirat ory dist ress at t he t ime of her visit . Temperat ure is 9 8 .5°F; BP, 13 0 /8 2 mm Hg; HR, 78 bpm; and RR, 19 /minut e. Clinical Decision Point

In addit ion t o t he procedures performed at rout ine follow-ups, what ot her procedure(s) should be perf ormed at t his visit ? • Art erial blood gases • Pulse oximet ry • Spiromet ry • Chest X-ray and ECG • No addit ional t est s are needed 8

Comment It is appropriat e t o obt ain pulse oximet ry or ar t erial blood gases for a pat ient experiencing a severe exacerbat ion. Chest X-ray and ECG may be necessar y t o diff erent iat e an exacerbat ion from ot her (part icularly cardiac-relat ed) diagnoses t hat may mimic it . However, Diane is not current ly experiencing an exacerbat ion, and only spiromet ry is indicat ed. Conversely, spiromet ry is not usually appropriat e during an exacerbat ion because it is st ressful and diff icult for a sick pat ient t o complet e and t herefore unlikely t o be accurat e. 1

Decision: Order spirom et ry t est ing. Spiromet ry t est ing reveals t hat Diane’s current post bronchodilat or FEV1 is 5 4% of predict ed, reduced fr om 58 % at diagnosis and 56 % at her 1-year follow-up. Clinical Decision Point

What changes in t herapy should be considered, if any? • Add ICS, int ensive smoking cessat ion counseling • Add oral cort icost eroids, int ensive smoking cessat ion counseling • Begin O2 t herapy, int ensive smoking cessat ion counseling • No changes are indicat ed Comment Her FEV1 value indicat es t hat t he severit y of her COPD is approaching st age III (severe). Alt hough not st at ed specifically in GOLD guidelines, in pat ient s who have repeat ed exacerbat ions, t he addit ion of ICS may be recommended, even if t he FEV1 has not quit e decreased t o 50 %.7 Longt erm t herapy wit h oral cort icost eroids is not recommended because of side effect s and lack of proven benefit . Short -t erm use of oral cort icost eroids can be beneficial for exacerbat ions, however. Oxygen t herapy would be indicat ed if t he pat ient were in chronic respirat ory failure. 1

Decision: Add ICS to the regimen and initiate intensive smoking cessation counseling. ICS can be added as a separat e Current smoker Previo us smoker agent , or a combinat ion agent (ICS ) 2.9 L ( + LABA) can be prescribed as an V alt ernat ive t o t aking ICS and LABA E 2.8 F separat ely. A short -act ing bron r o t chodilat or should also be available a 2.7 l i t o Diane for use as needed. d o The increase in severit y of h 2.6 c n Diane’s COPD warrant s an even o r 2.5 st ronger approach t o t he rout ine b t s recommendat ion of smoking o P 2.4 cessat ion. Even t hough she is Screen 2 1 2 3 4 5 smoking very light ly according t o her own admiss ion, complet e Annual Visit cessat ion is essent ial t o improve prognosis and pot ent ially reduce Figure 7. Decline in FEV1 in smokers and previous smokers exacerbat ions. Pat ient s t ypically with COPD. Anthonisen NR et al.13 1

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go t hrough several st ages of change before t hey are ready t o quit , 12 and Diane may be ready at t his point , even t hough she wasn’t earlier. A renewed effor t t o encourage Diane t o st op smoking complet ely should be undert aken. Addit ionally, pat ient educat ion should be cont inued and t ailored t o t he advancing st age of her disease. Educat ion on self-management skills— including t echniques f or minimizing breat hing difficult y— and recommendat ions f or management of exacerbat ions— including advice on when t o seek medical care— are required.1 Educat ion pert aining t o t he eff ect s of smoking on COPD sympt oms may also encourage a quit at t empt . Specifically, knowledge of t he reduced decline in FEV1 t hat is associat ed wit h smoking cessat ion may be especially mot ivat ing t o a pat ient whose FEV1 is nearing t he t hreshold for severe COPD (Figure 7).13 Finally, because Diane’s COPD is cont inuing t o advance, consult at ion wit h a pulmonologist would be prudent at t his point . Addit ionally, a recommendat ion for pulmonary rehabilit at ion may be appropriat e again at t his t ime because Diane is no longer exercising at all. At t acking all t he aspect s of COPD, bot h pharmacologically and nonpharmacologically, is at least as import ant in lat er st ages of COPD as it is during earlier st ages of t he disease.

References 1. Global Strategy for the Diagnosis, Management, and Prevention of COPD. Global Initiative for Chronic Obstr uctive Lung Disease (GOLD) 2007. http://www.goldcopd.com/Guidelineitem.asp?l1=2&l 2=1&intId=989. Updated December 2007.Accessed October 3, 2008. 2. Doherty DE. The pathophysiology of airway dysfunction. Am J Med. 2004;117(12A):11S-23S. 3. Briggs DD Jr, Kuritzky L, Boland C, et al. Early detection and management of COPD. Guidelines from the National COPD Awareness Panel (NCAP). J Respir Dis. 2000;21(suppl 9A):S1-S21. 4. Tinkelman DG, Price DB, Nordyke RJ, et al. Symptom-based questionnaire for differentiating COPD and asthma. Respiration. 2006;73(3):296-305. 5. Petty TL. Spirometry made simple. National Lung Health Education Program Web site. http://www.nlhep.org/resources/SpirometryMade Simple.htm. Published Januar y 1999. Accessed October 1, 2008. 6. Miravitlles M, de la Roza C, Naberan K, et al. Attitud es toward the diagnosis of chronic obstructive pulmonary disease in primary care. Arch Bronconeumol. 2006;42(1):3-8. 7. Hanania NA. The impact of inhaled corticosteroid and long-acting beta-agonist combination therapy on outcomes in COPD. Pulm Pharmacol Ther. 2008;21(3):540-550. 8. US Department of Health and Human Services. National Asthma Education and Prevention

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Program Expert Panel report 3: guidelines for the diagnosis and management of asthma. NIH publication number 08-5846. http://www.nhlbi.nih.gov/ guidelines/asthma/asthsumm.pdf. Published October 2007. Accessed September 15, 2008. 9. Jemal A, Ward E, Hao Y, Thun M. Trends in the leading causes of death in the United States, 19702002. JAMA. 2005;294(10):1255-1259. 10. Mannino DM, Homa DM, Akinbami LJ, Ford ES, Redd SC. Chronic obstructive pulmonary disease surveillance—United States, 1971-2000. MMWR Surveill Summ. 2002;51(SS-6):1-16. 11. Centers for Disease Control an d Prevention. Update on adult immun ization recommendations of the immun ization pr actices advisory committee (ACIP). MMWR Recommendations and Reports. 1991;40(RR12);1-52. http://www.cdc.gov/ mmwr/preview/mmwrhtml/00025228.htm. Accessed Septem ber 15, 2007. 12. Spencer L, Pagell F, Hallion ME, Adams TB. Applying the transtheoretical model to tobacco cessation and prevention: a review of literature. Am J Health Promot. 2002;17(1):7-71. 13. Anthon isen NR, Connett JE, Kiley JP, et al. Effects of smoking intervention and the use of an inhaled anticholinergic bronchodilator on the r ate of decline of FEV1. The Lung Health Study. JAMA. 1994;272(19):1497-1505.

Asthma or Copd Case Study

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