Download Asthma-COPD-Smoking-cessation-case-studies

Asthma/COPD/Smoking Cessation Case Studies:
Case I: Eight year old Bobby: (25 points)
Question 1: Describe the signs and symptoms of mild-intermittent asthma in the young
school-aged child. (5 points)
Signs and symptoms include: wheezing, cough at night, chest tightness, and some
difficulty in breathing, yearly occurrence.
Question 2: Based on guidelines, after symptom identification, how is asthma diagnosed
in the young school aged child? (5 points)
Asthma is diagnosed when all other causes are ruled out, and spirometry is performed.
Spirometry is the golden standard of diagnosis.
Question 3: What is the recommended treatment plan for a child like Bobby with mild,
intermittent asthma? (5 points)
A short acting beta agonist inhaler is the recommended treatment for intermittent asthma.
If he uses it more than 2 days a week, a lose dose inhaled corticosteroid would be
recommended. In addition, identifying and avoiding triggers, using the inhaler before
exposure and monitoring of symptoms will all help in managing his exacerbations.
Bobby’s mother has some questions for you:
Question 4: What causes asthma? (5 points)
Asthma is a chronic lung disease that results in airway inflammation. When an irritant
(such as smoke, pollen) get into his lungs, this causes inflammation and irritation. This
makes his breathing more difficult. The exact cause of asthma is not known. Research has
shown a family history mixed with some environmental factors cause this. Plus, your
husband has allergies and you have asthma, which is typically found in children who
develop asthma. It is hard to say what exactly caused your sons asthma.
Question 5: Is there anything I can do to help minimize his symptoms? For any
recommendations that you make, explain the rationale. (5 points)
First, if you would quit smoking in the house, you would see an improvement in his
symptoms. Smoke is an inhaled irritant. He inhales the smoke, which will trigger his
asthma to get worse. Also, changing the filter on his air conditioner would also help. The
filter acts as a barrier to prevent irritants from getting to him. Regularly changing the
filter will assure that these particles are being filtered out. You could also try minimizing
the time spent outside when his symptoms get the worse, or at least using the inhaler
before exposure. This limits the time he could be exposed to the environmental irritants
and may help cut back how severe his exacerbation is. Finally, making sure you
regularly wash sheets, curtains, vacuum frequently and keep dust at a minimum is equally
important. These steps will further minimize his exposure to potential triggers which will
make his asthma worse.
Case II: Asthma in a teenager (25 points)
Question 1: What type of asthma does Cindy have and why? (5 points)
She has moderate persistent asthma. Her symptoms include: she awakens two nights a
week at minimum, has some activity limitations, 4-5 days with active symptoms in the
fall, and uses her inhaler twice a day most times.
Question 2: What is the recommended treatment plan for a teenager like Cindy? (5
points)
Treatment plan would be step 3, a low dose inhaled corticosteroid and long acting beta
antagonist or a medium dose inhaled corticosteroid (pulmicort). It appears she was on a
low dose ICS inhaler which she was not very compliant with. She would also continue to
use her rescue inhaler, but would need to focus more on using the ICS.
Question 3: At what point would you consider referring Cindy to a pulmonary specialist?
(2 points)
If this course (medium ICS) didn’t see improvement in three weeks, then I would
recommend a pulmonary specialist. Just looking at the case, she may need to see one at
this point anyways but I’d try to re educated and increase the dose to see what
improvement it would make.
Cindy has a few questions for you.
Question 4: Does exercise cause asthma? Explain your answer. (3 points)
Exercise doesn’t cause asthma. When exercising, people breathe through their mouths;
this makes it more likely to get irritants in the lungs. These irritants cause asthma.
Exercise is a stress on the lungs, so it makes them more vulnerable to getting irritated.
Question 5: Am I going to grow hair or get pimples or get fat from my medication? I've
heard that steroids are bad for me. (5 points)
Long term use of steroids (higher dose) orally is more likely to have some side effects
like you are talking about. The low dose inhaled ones from your inhaler are not absorbed
in your body. Only the lungs use the. Getting pimples is quite common in your age group
due to your developing body. You might notice some hair growth, pimples and different
amounts of weight in different place because your body is growing. I assure you these are
normal changes related to your age, not your medications.
Question 6: Is asthma or the medication going to affect my period? Explain your answer.
(5 points)
Some women may notice they develop an exacerbation right before they get their period.
It is not known why this happens as of yet. If this tends to be the case with you, using
your inhaler, or starting birth control pills may help prevent this. Asthma medication
itself could cause worsening symptoms because your hormones are shifting. A different
medication could be used (leukotriene) if these symptoms become bothersome. The most
important thing to remember is to take your inhaler as prescribed. This will help keep
your asthma under control. Call me if your period becomes unmanageable and we will
start something else.
Case III: COPD (40 points)
What is the rationale for ordering each of the tests listed below? (5 points)
Labs: Will determine is infection is present, shows how much hemoglobin is present
PFTs: Evaluates lung function, determines amount of damage in lungs.
ABGs: measures the amount of oxygen and carbon dioxide in blood, shows pH, bicarb
levels. Aids in determining if oxygen therapy is necessary.
CXR: Shows structure of lungs. Rules out some other causes, determines progression of
disease.
Here are the results:
Labs: WBC....9700; Hgb.....17.2; Hct......53.5; Plt......356,000
Pulmonary function tests: pulmonary function tests reveal an FEV1 of < 50% predicted,
airflow obstruction, hyperinflation, severe air trapping. Pulse oximetry is 87%. Exercise
tolerance is poor with O2 saturation dropping on 2 L O2 with any exertion.
ABGs on room air: pH 7.33 pCO2 48 pO2 64 HCO3 29
CXR: Pending
1. Why does this patient have an elevated hemoglobin and hematocrit, even though
his physical exam reveals signs of overhydration? Analyze his ABG values and
pulse oximetry reading. What does the PFT results tell you? What would you be
looking for on CXR? (10 points)
Since COPD impairs gas exchange, the body is not getting enough oxygen
from the cells, the body then starts to make more to compensate for the lack of
oxygen. This results in an elevated H/H. The over hydration is a result of the flow
of blood from the heart to the lungs. There is increased pressure due to increased
volumes of blood. This causes fluid to leak from the vessels into other areas
(lungs, extremities) causing over hydration symptoms.
ABG values indicate that he has respiratory acidosis which is partially
compensated. He is retaining CO2 and low on O2. His pulse ox indicated he is
hypoxic. His PFTs confirm he is obstructed severely, retaining and not perfusing
adequately. His results look pretty crummy. His chest x-ray would probably
indicate hyperinflated lungs, flattened diaphragm, and increased blackening (loss
of lung tissue).
2. Describe the 4 stages of COPD (these were revised in 2008). Which stage would
you classify this patient, and why? What factors contributed to the development
of COPD? (10 points)
Stage 1: Mild. FEV1 is 80% of normal. Most wouldn’t notice symptoms.
Stage 2: Moderate. FEV1 is 50-80% of normal. Most have SOB with exertion,
may or may not have a chronic cough.
Stage 3: Severe. FEV1 is 30-50% of normal. Most are often tired and short of
breath, may need hospitalization.
Stage 4: Very Severe. FEV1 is less than 30% of normal. Most require chronic
oxygen therapy, are always short of breath.
This gentleman fits in stage 3, severe. His FEV1 is less than 50%, is noticeable
symptomatic and is hypoxic. His major factors that contributed were smoking and
farming. His farming history more than likely exposed him to pesticides, and
other inhaled irritants. His one pack a day for 50 years would more than likely be
the biggest cause.
3. What is your specific treatment plan for this patient, including rationale. If
you choose pharmacologic intervention, be specific in the medication and dosing
you would select. (15 points)
Treatment at this stage includes: A LABA and glutocorticosteroid inhaler
(formoterol/budesonide 80/4.5) 2 inhalations twice daily. In addition, an albuterol inhaler
can be used prn (two puffs). These recommendations come from the GOLD standard
2008. In addition, he would need rehab to help maintain his current lung strength,
vaccines to help prevent respiratory infections, and to diminish any remaining risk factors
in his environment to prevent further disease progression and exacerbations. He would
also need education on how to manage exacerbations and when to seek medical
treatment.
Case IV: Smoking cessation (10 points)
64 year old John has indicated to you that he is ready to stop smoking now that he and his
wife will be taking care of his grandson while his son and wife work. He asks you for
help, as he has tried to quit in the past and knows it will be hard. He asks you about
medications that might help. Your three options include nicotine replacement, bupropion
and varenicline. Discuss each of the options. Which would you recommend for John and
why?
Nicotine replacement: May be done using a gum, patch or lozenge. All are available over
the counter. Must not be used while smoking. Patch must be changed every 24 hours,
starts a higher strength, weans down to a lower to eliminate the side effects of nicotine
withdrawal. Cannot eat or drink 15 minutes before chewing. Chew the gum, and then
leave it in-between cheek and gum. Reduces the craving for cigarettes. The lozenge is
like a hard candy. Suck on it for 15-20 min to reduce cravings. Few side effects with
these methods. Relatively cheap method. Tobacco cessation hotline offers free products
to help you get started from time to time. Cost is reasonable $4-12 per day.
Buproprion: Commonly used as and antidepressant, found it greatly reduced craving in
smokers as a side effect. Needs a prescription. This is started one week before quitting, if
no results seen by week seven, it should be stopped. Side effects: dizziness, dry mouth.
Cost reasonable $2-4 per day.
Varenicline: newest drug to be passed by FDA. Taken twice daily for 12 weeks. Help
reduce pleasure involved with smoking, reduces cravings. Side effects: gas, nausea,
headaches. Cost: $6 per day. Warnings with anger management, suicide.
For this gentleman, not knowing any other history (years smoking, how much, his
insurance, income etc). I would recommend a course of Chantix. The research supports it
and from what I’ve heard it leaves the most people feeling confident that they have
kicked the habit for good. I’ve had friends and patients tell me how well it worked for
them. I would give this a try, and let me know if it’s not quite cutting it. Other than the
pill, join a support group, get your wife involved and take up a new hobby. Replacing
your cravings with something that interests you might make it easier. Increase activity
and stay motivated. Call the quit line and get a coach to help support you along the way.