Case Summary:

A 61-year-old female (1.58m, 52kg) was admitted as an emergency with pleuritic chest pain and shortness of breath. On admission inflammatory markers (WCC and Neutrophils) were raised but bloods including troponin and D-dimer were otherwise unremarkable. A chest x-ray showed mild consolidation at the left base. She was diagnosed with an acute exacerbation of COPD according to the chest x-ray and blood gases test. The patient was initially treated with 28% oxygen, salbutamol 2.5mg nebulizer, clarithromycin 500mg tablet, symbicort 400/12 inhaler one puff, prednisolone 40mg tablet, ipratropium 500 microgram nebulizer as required and ondansetron 4 mg as required.

On discharge, the patient was instructed to continue clarithromycin and prednisolone according the great Glasgow and Clyde (GGC) guidelines. The patient was to continue to use the same drugs she was taking prior to her admission to the hospital, these are a symbicort inhaler one puff twice daily, a tiotropium inhaler once daily and a salbutamol inhaler as required.

History of presenting complaint:

The patient was admitted to the hospital, she has been complained of chest pain, shortness of breath (SOB), sore throat and fever since 1 day.

Past Medical History:

The patient past medical history including chronic obstructive pulmonary disease (COPD).

Social History:

The patient lives alone and can mobilize without aid.

Family History:

No relevant family history.

Medication History:

The patient had been using a symbicort inhaler one puff twice daily, a tiotropium inhaler once daily and a salbutamol inhaler as required.

Details from Examination:

The patient was experiencing shortness of breath, coughing and chest pain.

Further observations included:

• An oxygen saturation (SpO₂) level of 84% in air
• Respiration rate (RR) 28 breathes per minute
• Heart rate (HR) 110 beats per minute

Investigations:

1. A chest X-ray
2. Measuring the arterial blood gas tensions and recording the inspired oxygen concentration
3. Blood tests and cultures sent to laboratory
4. Throat swabs taken and sent to virology

Diagnosis:

The patient was diagnosed with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD). This diagnosis was reached using the patient’s past medical history and presenting respiratory and pain symptoms.

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is an episode in the usual period of the disease described by a variation in the patient’s baseline cough, shortness of breath, and/or sputum beyond the regular variability to the extent that it warrants a difference in control(1). Numerous clinical components must be considered while assessing patients with excoriations.These contain the history of past exacerbation, the severity of the COPD, and the existence of co-morbidity (2). Based on these clinical components the AECOPD may be classification into two major levels, of which the patient is classified as Level II (2):

• Level I: patient who can be treated at home.
• Level II: patient needs hospitalization if existence of co-morbidity. Therefor, increase short of breath, lack of appetite and sleep due to symptoms of hypoxaemia and inadequate home care, as for this patient.

Relevant clinical progress:

Day 1

The patient was initially treated with 1L/min of oxygen 28%. The patient was also receiving a number of different medicines on this first day: a 40mg oral dose of prednisolone once a day, a 2.5mg salbutamol nebuliser four times a day and 500mg of the antibiotic clarithromycin twice per day.

Day 2

The patient remained on the same combination of medicines as described under “Day 1”. Oxygen saturation for this patient was measured at 92% in air, which means without the use of an oxygen mask. It was found on this day that the patient had improved to the extent that an oxygen mask was no longer necessary. The blood pressure of the patient was 107/75. The respiratory rate for this patient was 20 and the heart rate was 90bpm.

Day 3

The patient was discharged on the third day, as there were considerable improvements to the patient’s condition. The patient was back to the patient COPD baseline. The patient was observed to have:

• HR: 92
• RR: 21
• Sp02: 93 % in air

The patient was discharged and advised to complete the remaining two days of clarithromycin and prednisolone. The patient was instructed to continue to use the same drugs they were taking before admission, which are: a salbutamol inhaler 100mcg 2 puff PRN; a symbicort inhaler 400/12 1puff and a tiotropium 18mcg 1 tablet inhaler.

Discussion

Acute exacerbation of chronic obstructive pulmonary disease management

The term “exacerbation” refers to a sustained worsening of a patient’s symptoms from their normal stable state (1). In terms of AECOPD, common reported symptoms include increasing breathlessness, wheezing, a cough, increased sputum production and changes in color of sputum.

Patients admitted into hospital with COPD will be treated through the AECOPD disease protocol. Initially, management for all patients admitted will involve Oxygen 28% until gases are checked(3,4). Then the oxygen will be titrated according to arterial blood gases, with the aim being between PaO₂ >7.5-10PKa. The bronchodilators given to patients will be: Salbutamol 5mg nebules four times daily (but can be given up to 2 hourly as needed), Ipratropium 0.5mg nebules four times daily (this will be added if there is a poor response to salbutamol); IV bronchodilators: Aminophylline may be considered if there is no response to nebuliser therapy(3,4).Corticosteroids, such as Prednisolone oral 30mg-50mgs should be taken each morning(1,3,4). Antibiotics should be used in the case of purulent sputum, raised inflammatory markers or focal radiological changes(1,3,4). They should be given orally unless there is a clinical reason for giving IV antibiotics.

From the patient’s initial examination, it was found that she was experiencing chest pain, she had a heart rate of 110 beats per minute and her respiration rate was at 28 breaths per minute. The patient therefore had her treatment adapted so that she would now receive oxygen 28% and nebuliser salbutamol, in accordance with the AECOPD protocol. Furthermore, patients who respond poorly to initial doses of beta2-agonists should then receive both nebuliser salbutamol and ipratropium bromide. After the patient has shown improvement, they should then begin to receive a salbutamol inhaler.

Oxygen therapy:

The national and local guidelines state that patients with an AECOPD should be treated with oxygen 28% via Venturi mask, then titrate the oxygen according to the arterial blood gases (ABGs) (4). During oxygen therapy the ABGs should be monitored for pO2, pCO2. The aim of oxygen therapy is to maintain pO2 >8 kPa or SpO2 between 88-92% in order to avoid tissue hypoxia on the other hand increase pO2 values more than 8kPa may rise danger of Co2 retention which lead to respiratory acidosis (2).

The patient has treated with oxygen therapy 28% on the day of admission. On the next day, the patient improved and became able to breathe without the need for oxygen and her SpO2 about 92%(4,3).

Bronchodilators:

The national institute for health and care excellence (NICE) guidelines recommend that patients with an AECOPD should be treated with short-acting bronchodilators nebulisers, hand-held inhalers or both can be used to manage inhaled treatment during acute exacerbations of COPD(3). Short-acting bronchodilators such as salbutamol 2.5mg as nebulisers are recommended and its may repeat up to four times daily and the dose may be increased to 5mg if needed(4,5). If the patient has poor response to salbutamol then using other short-acting bronchodilators like ipratropium 0.5mg nebules recommended four times a day by taking into account using moth-piece or close fitting mask to avoid risk of acute angle-closure glaucoma(4,6). Although long-acting B2-agonist (LABAs) and long-acting anti-muscarinic antagonist (LAMA) have been all shown decrease exacerbation percentages in patient with COPD by approximately 20%(7).

The patient has treated with salbutamol 2.5mg nebuliser four times daily for two days, then the patient back to salbutamol 100micrograms hand-held inhalers according to the NICE recommendation the patient should be switched to hand-held inhalers as soon as her condition has stabilized because preparing for the patient to leave the hospital(3). In addition, the patient on symbicort inhaler (LABAs+corticosteroids) one puff twice daily as per NICE guidelines (3).

Corticosteroids:

The local and national guidelines state that patients with an AECOPD should be on systemic corticosteroid in conjunction with other treatments. Oral corticosteroids (prednisone 30-40 mg) for 7-14 days should be used for moderate to severe periods of AECOPD (1).In case the patient cannot administer prednisone orally, instead of that intervenes hydrocortisone 100mg then 50-100mg three times a day if the patient needed for continuing the intervenes treatment(4).

The patient was treated with prednisone 40mg once a day for seven days as per in the NICE guideline(3).

Antibiotics:

The NICE guidelines state that antibiotic should be used in patients with AECOPD with a history of extra purulent sputum, those how without don’t need for an antibiotic (3). The NICE guidelines recommend a macrolide, aminopenicillin or tetracycline as first-line treatment, though participation from local microbiologist should be considered (3).

The patient had fever and the WBC was high and the chest x-ray highlighted a minor consolidation in the lung, which was likely caused by the current infection. Accordingly, the patient was treated with clarithromycin 500mg twice daily as per in the Great Glasgow and Clyde (GGC) chronic pulmonary disease Guideline (8). This was considered to be the most appropriate medicine for the patient, as she had an allergy to penicillin. Clarithromycin is an antibiotic which covers some of the most likely organisms causing this infection, including Pneumococcus, Haemophilus influenza and Moraxella catarrhalis (1,4).

Role of the pharmacist

1. Medicine reconciliation

As the patient was admitted, I carried out a medicine reconciliation. This is a vital procedure, as I can make sure that any important medication taken by the patient at home continues to be taken by them in hospital. I chose to confirm that the patient was taking no medication by using two sources: the patient herself and her electronic care summary.

1. Monitoring

The patient on clarithromycin and ondansetron (as needed for nausea and vomiting) both have been associated with QT prolongation, an ECG has been done and the QT didn’t prolonged and no further action indicated unless the patient has further regular ondansetron.

1. Counselling

I gave the patient counseling on inhaler technique and the advantages of taking the COPD medication correctly for the maximum benefit. A reason for counseling the patient on inhaler technique is that this will enhance the management of COPD and help to reduce any exacerbations.

The course of antibiotics being taken by the patient should be carried on until the end, as this can ward off a recurrence of symptoms, the strengthening of antimicrobial resistance. It is also important that the patient is counselled about the course of prednisolone, as this can reduce the likelihood of the recurrence of symptoms.

1. Discharge

The discharge prescription of the patient was checked against the relevant prescription and administration records, as well as her medication history, as this would make sure that the right medication was being given following her discharge from hospital.