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Clinical Practice Keywords COPD/Spirometry/Lifestyle

interventions/Self-management
Case study
Respiratory This article has been
double-blind peer reviewed

In this article...
● A
 case study of a patient with chronic obstructive pulmonary disease
● Pathophysiology and diagnosis, including spirometry
● How the condition is managed through interventions and self-management

Diagnosis and management of

COPD: a case study
Key points
Authors Debbie Price is lead practice nurse, Llandrindod Wells Medical Practice; Nikki
Chronic obstructive Williams is associate professor of respiratory and sleep physiology, Swansea University.
pulmonary disease
is a progressive Abstract This article uses a case study to discuss the symptoms, causes and
respiratory management of chronic obstructive pulmonary disease, describing the patient’s
condition, projected associated pathophysiology. Diagnosis involves spirometry testing to measure the
to become the third volume of air that can be exhaled; it is often performed after administering a short-
leading cause of acting beta-agonist. Management of chronic obstructive pulmonary disease involves
death globally lifestyle interventions – vaccinations, smoking cessation and pulmonary rehabilitation
– pharmacological interventions and self-management.
Diagnosis involves
taking a patient Citation Price D, Williams N (2020) Diagnosis and management of COPD: a case
history and study. Nursing Times [online]; 116: 6, 36-38.
performing

T
spirometry testing
he term chronic obstructive pul- clinic for routine reviews. A widowed,
Spirometry monary disease (COPD) is used to 60-year-old, retired post office clerk, her
identifies airflow describe a number of conditions, main complaint is breathlessness after
obstruction by including chronic bronchitis and moderate exertion. She scored 3 on the
measuring the emphysema. Although common, prevent- modified Medical Research Council
volume of air that able and treatable, COPD was projected to (mMRC) scale (Fletcher et al, 1959), indi-
can be exhaled become the third leading cause of death cating she is unable to walk more than
globally by 2020 (Lozano et al, 2012). In the 100 yards without stopping due to breath-
Chronic obstructive UK in 2012, approximately 30,000 people lessness. Ms Parker also has a cough that
pulmonary disease died of COPD – 5.3% of the total number of produces yellow sputum (particularly in
is managed with deaths (Bit.ly/BLFCOPDdeaths2012). By 2016, the mornings) and an intermittent wheeze.
lifestyle and information published by the World Health Her symptoms have worsened over the last
pharmacological Organization (Bit.ly/WHOtop10deathcauses) six months. She feels anxious leaving
interventions, as well indicated that Lozano et al (2012)’s projec- the house alone because of her breathless-
as self-management tion had already come true. ness and reduced exercise tolerance, and
People with COPD experience persis- scored 26 on the COPD Assessment Test
tent respiratory symptoms and airflow (CAT, catestonline.org), indicating a high
limitation that can be due to airway or level of impact.
alveolar abnormalities, caused by signifi- Ms Parker smokes 10 cigarettes a day
cant exposure to noxious particles or and has a pack-year score of 29. She has not
gases, commonly from tobacco smoking. experienced any haemoptysis (coughing
The projected level of disease burden poses up blood) or chest pain, and her weight is
a major public-health challenge and pri- stable; a body mass index of 40kg/m2
mary care nurses can be pivotal in the early means she is classified as obese. She has
identification, assessment and manage- had three exacerbations of COPD in the
ment of COPD (Hooper et al, 2012). previous 12 months, each managed in the
Grace Parker (the patient’s name has community with antibiotics, steroids and
ALAMY

been changed) attends a nurse-led COPD salbutamol.

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Clinical Practice For more articles

on respiratory care, go to
Case study nursingtimes.net/respiratory

Diagnosis delicately balanced activity of these considered ‘normal’ for spirometry param-
Ms Parker was diagnosed with COPD five enzymes, resulting in the parenchymal eters but the lower limit of normal – equal
years ago. Using Epstein et al’s (2008) damage and small airways (with a lumen to the fifth percentile of a healthy, non-
guidelines, a nurse took a history from her, of <2mm in diameter) airways disease that smoking population – based on more
which provided 80% of the information is characteristic of emphysema. The robust statistical models is increasingly
needed for a COPD diagnosis; it was then severity of parenchymal damage or small being used (Cooper et al, 2017).
confirmed following spirometry testing as airways disease varies, with no pattern A reversibility test involves performing
per National Institute for Health and Care related to disease progression (Global Ini- spirometry before and after administering
Excellence (2018) guidance. tiative for Chronic Obstructive Lung Dis- a short-acting beta-agonist (SABA) such as
The nurse used the Calgary-Cambridge ease, 2018). salbutamol; the test is used to distinguish
consultation model, as it combines the Ms Parker also had a wheeze, heard between reversible and fixed airflow
pathological description of COPD with the through a stethoscope as a continuous obstruction. For symptomatic asthma, air-
patient’s subjective experience of the ill- whistling sound, which arises from turbu- flow obstruction due to airway smooth-
ness (Silverman et al, 2013). Effective com- lent airflow through constricted airway muscle contraction is reversible: adminis-
munication skills are essential in building smooth muscle, a process noted by tering a SABA results in smooth-muscle
a trusting therapeutic relationship, as the Mitchell (2015). The wheeze, her 29 pack- relaxation and improved airflow (Lumb,
quality of the relationship between year score, exertional breathlessness, 2016). However, COPD is associated with
Ms Parker and the nurse will have a direct cough, sputum production and tiredness, fixed airflow obstruction, resulting from
impact on the effectiveness of clinical out- and the findings from her physical exami- neutrophil-driven inflammatory changes,
comes (Fawcett and Rhynas, 2012). nation, were consistent with a diagnosis of excess mucus secretion and disrupted
In a national clinical audit report, COPD (GOLD, 2018; NICE, 2018). alveolar attachments, as opposed to airway
Baxter et al (2016) identified inaccurate his- smooth-muscle contraction.
tory taking and inadequately performed “COPD is a major public- Administering a SABA for COPD does
spirometry as important factors in the health challenge; nurses not usually produce bronchodilation to
inaccurate diagnosis of COPD on general
practice COPD registers; only 52.1% of
can be pivotal in early the extent seen in someone with asthma: a
person with asthma may demonstrate sig-
patients included in the report had identification, assessment nificant improvement in FEV1 (of >400ml)
received quality-assured spirometry. and management” after having a SABA, but this may not
change in someone with COPD (NICE,
Pathophysiology of COPD Spirometry 2018). However, a negative response does
Knowing the pathophysiology of COPD Spirometry is a tool used to identify airflow not rule out therapeutic benefit from long-
allowed the nurse to recognise and under- obstruction but does not identify the cause. term SABA use (Marín et al, 2014).
stand the physical symptoms and provide Commonly measured parameters are: NICE (2018) and GOLD (2018) guidelines
effective care (Mitchell, 2015). Continued l F orced expiratory volume – the volume advocate performing spirometry after
exposure to tobacco smoke is the likely of air that can be exhaled – in one administering a bronchodilator to diag-
cause of the damage to Ms Parker’s small second (FEV1), starting from a maximal nose COPD. Both suggest a FEV1/FVC of
airways, causing her cough and increased inspiration (in litres); <70% in a person with respiratory symp-
sputum production. She could also have l F orced vital capacity (FVC) – the total toms supports a diagnosis of COPD, and
chronic inflammation, resulting in airway volume of air that can be forcibly both grade the severity of the condition
smooth-muscle contraction, sluggish cil- exhaled – at timed intervals, starting using the predicted FEV1. Ms Parker’s
iary movement, hypertrophy and hyper- from a maximal inspiration (in litres). spirometry results showed an FEV1/FVC of
plasia of mucus-secreting goblet cells, as Calculating the FEV1 as a percentage of 56% and a predicted FEV1 of 57%, with no
well as release of inflammatory mediators the FVC gives the forced expiratory ratio significant improvement in these values
(Mitchell, 2015). (FEV1/FVC). This provides an index of air- with a reversibility test.
Ms Parker may also have emphysema, flow obstruction; the lower the ratio, the GOLD (2018) guidance is widely accepted
which leads to damaged parenchyma greater the degree of obstruction. In the and used internationally. However, it was
(alveoli and structures involved in gas absence of respiratory disease, FEV1 developed by medical practitioners with a
exchange) and loss of alveolar attachments should be ≥70% of FVC. An FEV1/FVC of medicalised approach, so there is potential
(elastic connective fibres). This causes <70% is commonly used to denote airflow for a bias towards pharmacological man-
gas trapping, dynamic hyperinflation, obstruction (Moore, 2012). agement of COPD. NICE (2018) guidance
decreased expiratory flow rates and airway As they are time dependent, FEV1 and may be more useful for practice nurses, as
collapse, particularly during expiration FEV1/FVC are reduced in diseases that it was developed by a multidisciplinary
(Kaufman, 2013). Ms Parker also displayed cause airways to narrow and expiration to team using evidence from systematic
pursed-lip breathing; this is a technique slow. FVC, however, is not time dependent: reviews or meta-analyses of randomised
used to lengthen the expiratory time and with enough expiratory time, a person can controlled trials, providing a holistic
improve gaseous exchange, and is a sign of usually exhale to their full FVC. Lung func- approach. NICE guidance may be outdated
dynamic hyperinflation (Douglas et al, 2013). tion parameters vary depending on age, on publication, but regular reviews are per-
In a healthy lung, the destruction and height, gender and ethnicity, so the degree formed and published online.
repair of alveolar tissue depends on pro- of FEV1 and FVC impairment is calculated NHS England (2016) holds a national
teases and antiproteases, mainly released by comparing a person’s recorded values register of all health professionals certified
by neutrophils and macrophages. Inhaling with predicted values. A recorded value of in spirometry. It was set up to raise spirom-
cigarette smoke disrupts the usually >80% of the predicted value has been etry standards across the country.

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Clinical Practice
Case study

Fig 1. ABCD assessment tool PR – a supervised programme including

exercise training, health education and
breathing techniques – is an evidence-
Spirometrically Assessment of Assessment of based, comprehensive, multidisciplinary
confirmed airflow symptoms and risk of
diagnosis limitation exacerbations
intervention that:
l I mproves exercise tolerance;
l R educes dyspnoea;
Moderate/severe l P romotes weight loss (Bolton et al, 2013).
exacerbation history C D These improvements often lead to an
GOLD FEV (% of ≥2 improved quality of life (Sciriha et al,
grade predicted) or 2015).
Post- GOLD 1 ≥80 ≥1 leading to
B
Most relevant for Ms Parker, PR has
bronchodilator hospital A
FEV1/FVC <70%
GOLD 2 50-79 administration been shown to reduce anxiety and depres-
GOLD 3 30-49 sion, which are linked to an increased risk
0 or 1 of exacerbations and poorer health status
GOLD 4 <30 mMRC 0-1 mMRC ≥2
not leading to
hospital CAT <10 CAT ≥10 (Miller and Davenport, 2015). People most
administration at risk of future exacerbations are those
Symptoms who already experience them (Agusti et al,
2010), as in Ms Parker’s case. Patients who
Source: Global Initiative for Chronic Obstructive Lung Disease (2018)
have frequent exacerbations have a lower
quality of life, quicker progression of dis-
Assessment and management l I mproves lung function; ease, reduced mobility and more-rapid
The goals of assessing and managing l I mproves survival rates; decline in lung function than those who do
Ms Parker’s COPD are to: l R  educes the risk of lung cancer; not (Donaldson et al, 2002).
l R  eview and determine the level of l R  educes the risk of coronary heart
airflow obstruction; disease risk (Qureshi et al, 2014). Pharmacological interventions
l A  ssess the disease’s impact on her life; Ms Parker accepted a referral to an All Ms Parker has been prescribed inhaled sal-
l R  isk assess future disease progression Wales Smoking Cessation Service adviser butamol as required; this is a SABA that
and exacerbations; based at her GP surgery. The adviser used mediates the increase of cyclic adenosine
l R  ecommend pharmacological and the internationally accepted ‘five As’ monophosphate in airway smooth-muscle
therapeutic management. approach: cells, leading to muscle relaxation and
GOLD’s (2018) ABCD assessment tool l A  sk – record the number of cigarettes bronchodilation. SABAs facilitate lung
(Fig 1) grades COPD severity using spirom- the individual smokes per day or week, emptying by dilatating the small airways,
etry results, number of exacerbations, CAT and the year they started smoking; reversing dynamic hyperinflation of the
score and mMRC score, and can be used to l A  dvise – urge them to quit. Advice lungs (Thomas et al, 2013). Ms Parker also
support evidence-based pharmacological should be clear and personalised; uses a long-acting muscarinic antagonist
management of COPD. l A  ssess – determine their willingness and (LAMA) inhaler, which works by blocking
When Ms Parker was diagnosed, her confidence to attempt to quit. Note the the bronchoconstrictor effects of acetyl-
predicted FEV1 of 57% categorised her as state of change; choline on M3 muscarinic receptors in
GOLD grade 2, and her mMRC score, CAT l A  ssist – help them to quit. Provide airway smooth muscle; release of acetyl-
score and exacerbation history placed her behavioural support and recommend choline by the parasympathetic nerves in
in group D. The mMRC scale only meas- or prescribe pharmacological aids. If the airways results in increased airway
ures breathlessness, but the CAT also they are not ready to quit, promote tone with reduced diameter.
assesses the impact COPD has on her life, motivation for a future attempt; At a routine review, Ms Parker admitted
meaning consecutive CAT scores can be l A  rrange – book a follow-up to only using the SABA and LAMA
compared, providing valuable informa- appointment within one week or, if inhalers, despite also being prescribed a
tion for follow-up and management (Zhao, appropriate, refer them to a specialist combined inhaled corticosteroid and long-
et al, 2014). cessation service for intensive support. acting beta2-agonist (ICS/LABA) inhaler.
After assessing the level of disease Document the intervention. She was unaware that ICS/LABA inhalers
burden, Ms Parker was then provided with NICE (2013) guidance recommends that are preferred over SABA inhalers, as they:
education for self-management and life- this be used at every opportunity. Stead et l L ast for 12 hours;
style interventions. al (2016) suggested that a combination of l I mprove the symptoms of
counselling and pharmacotherapy have breathlessness;
Lifestyle interventions proven to be the most effective strategy. l I ncrease exercise tolerance;
Smoking cessation l C an reduce the frequency of
Cessation of smoking alongside support Pulmonary rehabilitation exacerbations (Agusti et al, 2010).
and pharmacotherapy is the second-most Ms Parker’s positive response to smoking However, moderate-quality evidence
cost-effective intervention for COPD, cessation provided an ideal opportunity to shows that ICS/LABA combinations, par-
when compared with most other pharma- offer her pulmonary rehabilitation (PR) – as ticularly fluticasone, cause an increased
cological interventions (BTS and PCRS UK, indicated by Johnson et al (2014), changing risk of pneumonia (Suissa et al, 2013; Nan-
2012). Smoking cessation: one behaviour significantly increases a per- nini et al, 2007). Inhaler choice should,
l S lows the progression of COPD; son’s chance of changing another. therefore, be individualised, based on

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Clinical Practice
Case study

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