A 67-year-old man with headache, nausea, and visual disturbance
During an afternoon visit, you see a 67-year-old man for onset of headache, nausea, and visual disturbance. The friend who accompanies him explains that both of them frequent the same senior center and that they have been preparing for a fund-raising event during the past 2 days. During this time, the patient spent between 6 and 9 hours per day reproducing fliers using a “spirit duplicator” (mimeograph machine). This activity took place in a small, unventilated room with the patient working alone most of the time.
On questioning, the patient says that he had eye irritation and lightheadedness after the first few hours of activity but considered these symptoms to be a minor annoyance. He also had nausea by the end of the first day but noted that this cleared overnight. During the second day of activity, he was again troubled by eye irritation, this time accompanied by vertigo, tinnitus, visual blurring, and photophobia. He tried to ventilate the room by placing a small fan near the door but continued to feel poorly despite a prolonged break. Late in the afternoon his friend insisted that he seek medical attention.
The patient is a widower and retired insurance salesman with a smoking history of one pack per day from age 27 to 62 (none for the last 5 years). He typically consumes a six-pack of beer per day, but he has felt poorly and has been abstinent for the past 10 days. Medical history includes coronary artery bypass surgery at age 63 with subsequent medical management of stable angina and a transurethral prostatectomy at age 65 with no recurrence of obstructive symptoms. Current medications include nitroglycerine patches used before exercise (with no patches used in the previous 4 days) and sublingual nitroglycerine, which he takes rarely. The review of symptoms is negative for other cardiopulmonary complaints. There is no family history of glaucoma, myopia, or diabetes mellitus.
On examination, the patient is alert and oriented to time, space, and person, although he appears somewhat distracted. His breath has a faint solvent-like smell. Vital signs are within normal range with the exception of a respiratory rate of 30/minute. The cardiopulmonary examination is unremarkable, but abdominal examination reveals mild tenderness in the epigastrium without rebound or guarding. Muscle tone, strength, sensation (pinprick, light touch, position sense) and reflexes are symmetrically intact. His gait is unsteady with a wide-based stance, and he shows a positive Romberg sign, heel-to-shin, and rapid alternating movements (bilaterally).
Ophthalmologic examination reveals a visual acuity of 20/200 bilaterally despite newly prescribed corrective lenses. The conjunctivae appear somewhat injected, nystagmus is present on lateral gaze, and the pupils are large and poorly reactive to light. Examination also reveals hyperemia of the optic nerve head with no hemorrhages or exudates.
Answers can be found on page 17.
A 52-year-old lady attends to discuss her COPD and specifically the problem she is having with exacerbations and time ‘off sick’. She is a heavy smoker, and her progressively deteriorating lung function suggests that she has moderate COPD, although she also has a history of childhood asthma, and had allergic rhinitis as a teenager. Recent spirometry showed a typical COPD flow-volume loop, although she had some reversibility (250 ml and 20%) with a post-bronchodilator FEV1 of 60% predicted.
She has a sedentary office job and, although she is breathless on exertion, this generally does not interfere with her lifestyle. The relatively frequent exacerbations are more troublesome. They are usually triggered by an upper respiratory infection and can take a couple of weeks to recover. She has had three exacerbations this winter, and as a result her employer is not happy with her sickness absence record and has asked her to seek advice from her general practitioner.
She has a short-acting β2-agonist, although she rarely uses it except during exacerbations. In the past, she has used an inhaled steroid, but stopped that some time ago as she was not convinced it was helping.
It is a welcome opportunity when a patient comes to discuss her COPD with a particular issue to address. With a history of childhood asthma, and serial COPD lung function tests, she has probably been offered many components of good primary care for COPD, but has not yet fully engaged with her management. We know that ~40% of people with COPD continue to smoke, and many are intermittent users of inhaled medications.45 It is easy to ignore breathlessness when both job and lifestyle are sedentary.
Understanding her diagnosis and setting goals
Her readiness to engage can be supported by a move to structured collaborative care, enabling the patient to have the knowledge, resources and support to make the necessary changes. Much of this can be done by the primary care COPD team, including the pharmacist. Regular recall to maintain engagement is essential.
The combination of childhood asthma, rhinitis and a long history of smoking requires diagnostic review. This might include serial peak flows over 2 weeks to look for variability, and a chest X-ray, if not done recently, to rule out lung cancer as a reason for recent exacerbations. Her spirometry suggests moderate COPD,1,46 but she also has some reversibility, not enough to place her in the asthma camp but, combined with her past medical history, being enough to explore an asthma COPD overlap syndrome. This is important to consider as it may guide decisions on inhaled medication, and there is evidence that lung function deteriorates faster in this group.47 It is estimated that up to 20% of patients have overlap diagnoses, although the exact prevalence depends on the definition.48
Reducing the frequency of exacerbations
Exacerbations in COPD are debilitating, often trigger hospital admission and hasten a progressive decline in pulmonary function.2 Written information on interventions that can slow down the course of COPD and reduce the frequency and impact of exacerbations will help to support progressive changes in management.
Few people are unaware that cessation of smoking is the key intervention for COPD. Reducing further decline in lung function will slow down the severity of exacerbations. Finding a smoking cessation programme that suits her working life, exploring previous attempts at cessation, offering pharmacotherapy and a non-judgemental approach to further attempts at stopping are crucial.
Many, but not all, exacerbations of COPD are triggered by viral upper respiratory tract infections. Annual flu immunisation is a part of regular COPD care and reduces exacerbations and hospitalisation when flu is circulating (Grade 1B). Pneumococcal immunisation should be offered, although evidence for reducing exacerbations is weak; those with COPD will be at greater risk for pneumococcal infection.2
Pulmonary rehabilitation improves symptoms, quality of life and reduces hospital admission.49 It is most efficacious in patients who are symptomatic (MRC dyspnoea scale 3 and above) and in terms of reducing exacerbations is most effective when delivered early after an exacerbation (Grade 1C).2 The major hurdle is encouraging patients to attend, with most programmes showing an attrition rate of 30% before the first appointment, and high rates of non-completion.45,50 Effective programmes that maintain the gains from aerobic exercise are more cost-effective than some of the inhaled medications in use (see Figure 3).50
Inhaled medication is likely to improve our patient’s breathlessness and contribute to a reduction in exacerbation frequency. Currently, she uses only a short-acting β2-agonist. One wonders if she has a spacer? How much of the medicine is reaching her lungs? Repeated observation and training in inhaler use is essential if patients are to benefit from expensive medications.
With her history of asthma and evidence of some reversibility, the best choice of regular medication may be a combination of inhaled corticosteroid and a LABA. Guidelines suggest the asthma component in asthma COPD overlap syndrome should be the initial treatment target,48 and a LABA alone should be avoided. Warn about oral thrush, and the increased risk for pneumonia.46 If she chooses not to use an inhaled steroid, then a trial of a LAMA is indicated. Both drugs reduce exacerbation rates.2,51
Finally, ensuring early treatment of exacerbations speeds up recovery.52 Prescribe rescue medication (a 5–7-day course of oral steroids and antibiotic) to be started when symptomatic, and encourage attendance at a post-exacerbation review.