1

COPDforum is a
Takeda initiative
Case Study in COPD:
Comorbidity in the Patient with COPD
Differential Diagnosis and Treatment Selection
2
Patient History and Presentation
The patient is a 51-year-old obese Hispanic construction
worker who has smoked regularly since age 17
A few days after Christmas, he developed a sore throat,
a cough, a fever, and increasing breathing difficulties
Over 24 hours, he became so short of breath that he went
to the emergency department. He was febrile and had
labored breathing with expiratory wheezing
The patient has had no previous complaints or treatment
for chronic respiratory symptoms

Not actual patient photo
3
Initial Evaluation and Management
Evaluation:
Vital signs:
Blood pressure: 162/97 mm Hg
Heart rate: 102 bpm
Temperature: 39.5C
Chest x-ray had no indication of infiltrates
suggestive of pneumonia
Laboratory findings: rapid diagnostic test of a
nasal swab was positive for influenza
Management:
The patient was given antiviral therapy and his
condition stabilized after 48 hours
He was discharged from the hospital with advice
to see a physician for the treatment of his hypertension

Chest X-ray
4
Questions
What additional evaluations would you have carried out?
Was the treatment for this patient appropriate?
5
Further Assessment by Primary Care
Physician: Presentation and Physical Examination
Several months later, the patient visits a primary care practitioner. He
complains that he is having trouble keeping up with his co-workers as he
becomes short of breath at work. He is also bothered by a persistent cough
Physical Examination Findings:
Neck: mildly distended neck vein; carotids without bruits
Chest: scattered rhonchi throughout; coarse crackles; productive cough
Heart: tachycardia and regular rhythm; increased intensity of pulmonic component of
second heart sound; Grade 2/6 systolic murmur at LSB; no gallop rhythm is heard
Extremities: pitting oedema of ankles; mucus membranes and nail beds minimally
cyanotic, no clubbing; pulses intact
Abdomen: distended with mild tenderness of right upper quadrant
6
Chest Radiograph
Findings:
Increase in heart diameter
Prominent pulmonary arteries
Decreased retrosternal airspace
Clear lung fields
7
Findings: upper lobe emphysema, enlarged central pulmonary arteries,
no evidence of thromboembolic disease
CT Scan of the Chest (Contrast Study)
8
Vital Signs, Laboratory Evaluations, Imaging
Height: 169 cm
Weight: 88 kg
BMI: 30.2 kg/m
2
Blood pressure: 157/96 mm Hg
Pulse: 102 bpm
Respiration rate: 19 breaths/minute
Temperature: 37.3C
ECG: Right axis deviation;
R ventricular hypertrophy
Lipids:
Total cholesterol: 5.84 mmol/L (226 mg/dL)
LDL-C: 3.5 mmol/L (137 mg/dL)
HDL-C: 1.0 mmolL (37 mg/dL)
Triglycerides: 1.91 mmol/L (169 mg/dL)

A1C: 8.4%
Haematology:
Haemoglobin: 7.2 mmol/L (11.6 g/dL)
White blood cell count: 7800/mm
3
Platelet count: 322,000/mm
2
Chemistry
Sodium: 142 mmol/L (142 mEq/L)
Potassium: 4.0 mmol/L (4.0 mEq/L)
Chloride: 102 mmol/L (102 mEq/L)
Bicarbonate: 32 mmol/L (32 mEq/L)
Urea nitrogen: 6.4 mmol/L (18 mg/dL)
Glucose: 8.7 mmol/L (156 mg/dL)
Creatinine: 88.4 mol/L (1.0 mg/dL)
Urinalysis: within normal limits


9
Questions
Based on the available information, what is your provisional diagnosis
for this patient?
What additional evaluations would you have carried out?
10
Primary Care Physician Conclusions and
Actions
The primary care practitioner suspects cardiovascular disease, possibly mild
heart failure, and probably also type 2 diabetes
He asks the patient to return in 4 weeks for another evaluation of blood glucose
and also refers him to a cardiologist
11
Further Assessment and Management by
Primary Care Physician
Assessment of FPG after 4 weeks indicates a value of 7.9 mmol/L (143 mg/dL).
This is sufficient for a diagnosis of type 2 diabetes
Actions:
The patient is counseled regarding diet and lifestyle
Treatment is initiated with 1000 mg/day metformin with planned titration to
2000 mg/day
He is given hydrochlorothiazide 50 mg/day for his persistent pedal oedema
12
Assessment by Cardiologist: ECG
Sinus rhythm with evidence of right axis deviation P pulmonale and right
ventricular hypertrophy
13
Echocardiogram
The right ventricle (RV) is
markedly dilated
Normal left ventricular volume
A 55 mm Hg peak systolic
pressure gradient between the
right ventricle and right atrium (RA)
was calculated
14
Question
What is your diagnosis for this patient given the results of these
additional evaluations?
15
Cardiologist Actions
Patient is diagnosed as having New York Heart Association class II heart
failure: ordinary physical activity somewhat limited by dyspnoea
(e.g., long-distance walking, climbing two flights of stairs)
Initial treatment is advice to stop smoking continue the diuretic and
administration of a -blocker, and an angiotensin converting enzyme (ACE)
inhibitor
Consultation with a pulmonary specialist is suggested because of suspicion
of asthma or COPD
16
Patient Progress
The patients blood pressure declines to 141/83 mm Hg, but both the cough
and dyspnoea worsen
The cardiologist stops the ACE inhibitor and replaces it with an angiotensin
receptor blocker (ARB). This decreases the patients cough somewhat, but
there is no improvement in dyspnoea

17
Assessment and Treatment by Pulmonologist
Spirometry results:





Arterial blood gas results:
PaO
2
= 55 mm Hg (7.31 kPa)
PaCO
2
= 50 mm Hg (6.65 kPa)
pH = 7.43
HCO
3
= 32 mmol/L
Measure L %
FEV
1
1.46 57.9
FVC 2.64 83.0
FEV
1
/FVC - 67.6
Change from pre- to post-bronchodilator FEV
1
0.23 15.7
18
Questions
What do these pulmonary function results indicate?
How would you alter your management of this patient?
19
Diagnosis and Treatment
Differential diagnosis for this patient is COPD based on smoking history,
breathlessness, and partially reversible impairment in lung function. The patient
has moderate COPD, complicated by right heart failure and hypertension
The -blocker, ARB, and diuretic are continued in consultation with the
cardiologist. Treatment for COPD is initiated with tiotropium and pulmonary
rehabilitation
Hypercarbia in a patient with moderate COPD prompts evaluation of other
potential reasons for respiratory failure:
All night, polysomnography shows severe obstructive sleep apnoea and the
patient is begun on CPAP therapy

20
COPDforum is a
Takeda initiative
Case Study in COPD:
Distinguishing COPD
from Adult Asthma
21
Patient History
The patient is a 47-year-old overweight woman who currently going through
menopause
She complains of wheezing while walking rapidly or climbing stairs, and has
bouts of very rapid breathing and inability to catch her breath:
Over the last few years, she has had difficulty taking care of the house
She does not have the energy to take walks or work in her garden
The patient also complains of insomnia and feelings of low self worth
She recently fell and fractured her forearm
The patient had asthma as a child which she outgrew as a teenager. She is a
former smoker who smoked one pack of cigarettes a day from age 17 to 37
(20 pack-years).
She also has a history of recurrent respiratory infections and reports at least
one bad chest cold every winter:
Several required visits to her physician and a course of antibiotic treatment
22
Patient Presentation
The patient is overweight and appears anxious
She is not very communicative and does not
demonstrate much affect in describing her
condition
She is concerned about her relationships with
her husband and children, but believes that her
condition is a normal part of the aging process
She states that she come to her doctors office
to make sure nothing is really wrong and she
apologizes for probably wasting his time
Not actual patient photo
23
Initial Evaluation by Primary Care Physician
Vital Signs
Height: 161 cm
Weight: 79 kg
BMI: 30.5 kg/m
2
Blood pressure: 139/87 mm Hg
Pulse: 79 bpm
Respiration rate: 14 breaths/minute
Temperature: 37.4C
Physical Examination Findings
Heart: regular rate and rhythm
Extremities: 1+ bilateral pitting oedema.
No cyanosis or clubbing
Neurologic: alert, oriented; cranial nerves
intact
Skin: warm, dry
Chest/lungs: decreased breath sounds;
prolonged expiration with wheezing;
ronchi throughout
Abdomen: non-distended, non-tender,
normal bowel sounds
24
Questions
Given the patients history, symptoms, and physical examination results,
what are your preliminary diagnoses?
What additional tests would you carry out prior to initiating a course of
treatment for this patient?
25
Primary Care Physician Conclusions and
Actions
The primary care practitioner suspects a mood disorder (anxiety and/or
depression) and possibly osteoporosis
He orders a DEXA scan for determination of bone mineral density (BMD)
and refers the patient to a psychiatrist
26
Questions
Was the clinical approach to this patient appropriate?
27
Results from DEXA Scan and Psychiatric
Evaluation
DEXA Scan results (hip):





Results are consistent with a diagnosis of osteopenia
Psychiatric evaluation:
Patient does not meet criteria for major depressive disorder
Prescription of Xanax (0.5 mg TID) is recommended for temporary treatment
of the patients anxiety
Region BMD T-score
Neck 0.541 -2.78
Trochanter 0.483 -2.18
Intertrochanteric 0.837 -1.78
Total 0.678 -2.23
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Primary Care Physician Actions
The primary care practitioner prescribes Fosamax (70 mg, once weekly), and
recommends that the patient take a supplement that contains both calcium
(1500 mg/day) and vitamin D (800 IU/day)
He also prescribes Xanax as suggested by the psychiatrist
The patient is scheduled for a follow-up visit in 6 weeks
29
Follow-up
6 weeks after initiation of treatment with Fosamax and Xanax, the patient is
less anxious
However, treatment did not alter the patients breathlessness and wheezing
The primary care practitioner now suspects that the patient may be having a
recurrence of her childhood asthma and provides a short-acting bronchodilator
(Ventolin) for rescue when breathlessness or wheezing are severe


30
Questions
Is there sufficient evidence to support a diagnosis of asthma in this patient?
What additional evaluations, if any, should be carried out?
If this patient does have asthma, is provision of a short-acting bronchodilator
appropriate therapy?
31
Follow-up
After 2 weeks, the patient telephones the physicians office and states that she
needs a refill of her bronchodilator because she is using it 5-6 times per day
This use is clearly excessive, and the physician refers the patient to a
pulmonologist for more extensive evaluation


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Assessment by Pulmonologist
The pulmonologist evaluates the patients symptoms and also carries out
spirometry and orders a chest x-ray
Measure L %
FEV
1
1.53 60.0
FVC 2.50 80%
FEV
1
/FVC - 60%
Change from pre- to post-bronchodilator FEV
1
0.03 1.9%
33
Chest Radiograph: PA
Findings:
Paucity of lung markings in the upper
lung zones
No evidence of pulmonary infiltrative
disease
Increased markings in the lower lung
zones are soft tissue shadows
(breast densities)
34
Chest Radiograph: Lateral
Findings:
Flattening of the diaphragm (arrow), a sign of
lung hyperinflation associated with COPD
35
Questions
What do the pulmonary function results suggest?
What diagnoses are consistent with the chest x-ray results?
What is your diagnosis for this patient?
Are any additional tests needed to increase the certainty for this diagnosis?
36
Diagnosis and Treatment
The diagnosis in this patient is more likely COPD, based on smoking history,
breathlessness, and findings of non-reversible airflow obstruction. Recurrence
of her asthma is also possible, but considering her smoking history, COPD is
the major diagnosis.
The patient has moderate COPD (Stage II) according to the GOLD guidelines
Treatment for COPD is initiated with a long-acting bronchodilator and because
of the possibility of concomitant asthma an inhaled corticosteroid is added.
Pulmonary rehabilitation is also offered.
Treatment for osteopenia is continued as prescribed by the primary care
physician
The Xanax dose ins decreased by 0.5 mg every 5 days and the patient is
monitored closely for signs of withdrawal
37
COPDforum is a
Takeda initiative
Case Study: Biomass Fuel Exposure
NYC/COPD/10/022 Rev 01/2011
38 38
Case History
A 48-year-old Hispanic man presented at the
emergency department of an urban general
hospital with chronic cough and
breathlessness
He noted that the cough had begun about 4
years ago and gradually progressed and was
associated with some breathlessness when
walking rapidly or climbing stairs
The patient denied current fever, chills,
sweats, weight loss, eye pain, arthralgias,
rash, or sinusitis
He stated that he had a pet cat and dog at
home, but denied any past or present
tobacco use, alcohol, or illicit drug use

Purchased from istockphoto.com
39 39
Initial Evaluation
Evaluation:
Vital signs:
Blood pressure: 147/91 mm Hg
Heart rate: 78 bpm
Temperature: 37.8C
The patient appeared healthy without any signs of distress and had normal vital
signs and an oxygen saturation of 97%
The remainder of the examination was normal except for bilateral forced
expiratory wheezes
There were no signs of:
Pulmonary hypertension
Right heart failure
Clubbing
40 40
Laboratory Evaluation
Routine laboratory tests revealed
a complete blood count and blood
chemistry panel that were normal
Chest x-ray had no indication of
infiltrates suggestive of
pneumonia or interstitial lung
disease

Used with permission from S. Braman
41
Initial Treatment
The physician suggested that the patient take an over-the-
counter cough medicine dextromethorphan as well as
cough lozenges
No additional treatment was recommended and no referral
for further evaluation was made
42
Questions
What additional evaluations would you have carried out?
Was the appropriate treatment for this patient?
43 43
Further Follow-up
1 year later the mans cough had not resolved and his dyspnoea upon exertion
had worsened
He presented at a community health clinic with cough that produced yellow
sputum
At this visit, the examining physician took a more extensive personal history
and the patient revealed that he had emigrated from Honduras to the United
Kingdom in 1998 at the age of 36 to work as a landscaper
He noted that prior to leaving Honduras, he worked at a small plant that
produced charcoal from the age of 16-29. No protective respiratory masks
were worn by the employees of this plant
During the 1-year period since his initial presentation, he has had to miss work
on three occasions (3-5 days each) due to worsening cough and
breathlessness
44
Vital Signs, Laboratory Evaluations, Imaging
Height: 161 cm
Weight: 64 kg
Blood pressure: 143/92 mm Hg
Pulse: 79 bpm
Respiration rate: 21 breaths/minute
Temperature: 37.3C
ECG: normal
Lipids: normal
Haematology: normal
Chemistry: normal
Urinalysis: within normal limits



45
Questions
Based on the available information, what is your provisional
diagnosis for this patient?
What additional evaluations (e.g., electrocardiogram, CT,
pulmonary function testing) would you carry out?
46
Further Evaluation
Based on the additional information, the physician carries out pulmonary
function testing with the following results:
Measure Value %
FEV
1
(L)

1.53 49
FVC (L) 2.85 75
FEV
1
/FVC (L) - 53
Total Lung Capacity (L)

4.87 111
Residual Volume (L) 1.87 104
Diffusion Capacity for CO (mL/mm Hg/minute) 23.1 75.5
Arterial blood gasses Normal -
47
Questions
Based on spirometry results, symptoms, and history, what
is your diagnosis for this patient?
Are there any additional tests that would increase your
confidence in this diagnosis?
48
Diagnosis and Treatment

Differential diagnosis for this patient is COPD based on
history of exposure to biomass fuel, breathlessness,
cough, and sputum
According to GOLD criteria, this patient has severe (Stage
III) COPD
Treatment is initiated with tiotropium (18 g, twice daily)
49
Follow-up and Further Treatment
Treatment with tiotropium results in an increase in FEV
1

from 1.53 to 1.70 L
This treatment reduces severity of cough and
breathlessness, but these symptoms are not completely
resolved
The physician decides to add oral roflumilast (500 g,
once daily) to treatment:
This therapy is indicated for patients with severe COPD
(FEV
1
<50%) , cough and sputum production, and a history of
frequent exacerbations and is thus appropriate for this patient
50
Follow-up
Addition of roflumilast to tiotropium results in an increase
in FEV
1
from 1.70 to 1.79 L
Severity of cough and breathlessness reduced but the
patient still experiences some breathlessness on climbing
stairs and when walking rapidly. Ordered pulmonary
rehabilitation.

51
COPDforum is a
Takeda initiative
Case Study: COPD in a Patient with
Difficulty in Stopping Smoking
NYC/COPD/10/026 Rev 01/2011
52 52
Case History
A 57-year-old white woman was diagnosed with
COPD 9 years ago
She presented at the emergency department
with worsening dyspnoea, cough, and increasing
purulent sputum production over the past 3 days
The patient smoked 30-40 cigarettes per day for
30 years, but decreased to 15-20 per day over
the period since her diagnosis
She has attempted to quit smoking on several
occasions without any success
Current medications are:
Tiotropium (18 g, once daily) and
Salbutamol (200 g, every 4-6 hours when
required)
Pravastatin (40 mg, once daily) for
hypercholesterolemia
Losartan (100 mg, once daily) for hypertension


Purchased from istockphoto.com
53
Examination in the Hospital
Vital signs:
BP: 130/84 mm Hg
Pulse: 102 bpm
Respiration: 26 breaths per minute
Temperature 38.7 C
Examination: auscultation of the chest revealed widespread expiratory wheeze
and inspiratory coarse crackles in the left lung base
The patient has dyspnoea, but able to speak in whole sentences
No cyanosis is present
Most recent spirometry results (2 months ago, after last COPD exacerbation)
were:
FEV
1
39% predicted
FEV
1
/FVC ratio 62%
54
Chest x-ray
Used with permission from S. Braman
55
CT Scan
Used with permission from S. Braman
56 56
In-hospital Treatment and Discharge
Antimicrobial therapy:
Levofloxacin (500 mg, once daily for 7 days)
Non-invasive mechanical ventilation (NIV) for 3 days
Patients condition stabilises over 3 days:
Salbutamol is required only once or twice per day
Patient is ambulatory and can walk across the room
Arterial blood gasses have been stable for 36 hours
The patient is able to eat and sleep
The patient is discharged to with an appointment scheduled with her primary
care physician the following week
Discharge spirometry:
FEV
1
is 42% predicted
FEV
1
/FVC is 58% predicted
GOLD Stage III, severe COPD
57
Questions
Did the patient meet the criteria for administration of an antibiotic?
Was NIV warranted for this patient?
Were any additional in-hospital treatments indicated for this patient?
In your opinion, did this patient meet the criteria for hospital discharge?
58
Primary Care Physician Visit: Examination
Symptoms:
Dyspnoea on exertion
Cough with sputum
Vital signs:
BP: 134/86 mm Hg
Pulse: 81 bpm
Respiration: 19 breaths per minute
Temperature 37.5 C
Examination: auscultation of the chest revealed widespread expiratory wheeze
and inspiratory coarse crackles
Spirometry results:
FEV
1
is 43% predicted
FEV
1
/FVC is 58% predicted

59
Primary Care Physician Visit: Treatment
COPD:
Tiotropium (18 g, once daily)
Salbutamol (200 g, every 4-6 hours when required)
Smoking cessation:
ASK: systematically determine if patient is still smoking
ADVISE: strongly urge the patient to quit
ASSESS: determine willingness of the patient to make a quit attempt
ASSIST: aid the patient in quitting
ARRANGE: schedule follow-up contact
Treatment to assist smoking cessation:
Varenicline treatment is initiated (0.5 mg once daily on days 1-3, 0.5 mg twice daily on
days 4-7, 1 mg twice daily for 12 weeks)
Group counseling for smoking cessation
A follow-up visit is scheduled for 3 months
60
Questions
Are any other changes in the patients treatment for COPD
warranted?
What alternative treatments for smoking cessation might be
suitable for this patient?
61
Primary Care Physician Visit: 3-month Follow-
up
The patient states that she has not smoked since her last visit
Physical examination and vital signs are unchanged from previous visit
The patients cough and breathlessness are improved, but are still
present
Spirometry:
FEV
1
is 45% predicted
FEV
1
/FVC is 65% predicted
The physician decides to add an inhaled corticosteroid (fluticasone,
500 g, twice daily) in order to:
Provide increased symptom relief
Increase FEV
1

A follow-up visit is scheduled for 3 months

62
Questions
Is it reasonable to expect that addition of inhaled corticosteroid (ICS) to
a bronchodilator will improve symptoms or pulmonary function in a
long-term smoker?
What are potential concerns regarding addition of ICS to treatment:
Infection (pneumonia, Candida)?
Osteoporosis?
Elevation in intraocular pressure/glaucoma?
Cataracts?
63
Primary Care Physician Visit: 6-month Follow-
up
The patient states that smoking cessation continues to be successful
Physical examination shows evidence of thrush; vital signs are unchanged from
previous visit
The addition of fluticasone has not resulted in any reduction in the patients
cough or breathlessness, and the patient is now also complaining of throat
irritation
Spirometry results are slightly improved with the addition of ICS:
FEV
1
is 45% predicted
FEV
1
/FVC is 69% predicted
Treatment:
Group counseling is continued
The physician decides to discontinue fluticasone and add roflumilast (500 g, once-
daily) to treatment
A follow-up visit is scheduled for 3 months
64
Questions
Would you discontinue ICS in this patient?
Is it reasonable to substitute roflumilast for ICS?
Would it be reasonable to continue ICS and also add
roflumilast to treatment?

65
Physician Visit: 9-month Follow-up
The patient states that she has not smoked since her last visit. She
believes that she can maintain smoking cessation as long as she
continues the group counseling
Physical examination shows thrush is resolved and vital signs are
unchanged from previous visit
The patients cough and breathlessness are improved, but have not
completely resolved. The throat irritation has resolved
Spirometry:
FEV
1
is 46% predicted
FEV
1
/FVC is 73% predicted
There is no change in therapy and a follow-up visit is scheduled for 3
months

66
COPDforum is a
Takeda initiative
COPDforum is a Takeda initiative
For more information please see the
Terms & Conditions on the Takeda
website: www.COPDforum.org