COPD Multidisciplinary Management Case Scenario
Original Editor - Ewa Jaraczewska based on the course by Rachael Moses
Abstract
This fictional case scenario analyses the multidisciplinary management of a patient with chronic obstructive pulmonary disease (COPD).
Client Characteristics
Mr Singh is a 62-year-old male. He was diagnosed with COPD five years ago after presenting to his family doctor with increasing shortness of breath (SOB) on exertion. He continued to work in his own restaurant until two years ago. Mr Singh's last spirometry showed a moderate airflow limitation, with a forced expiratory volume (FEV1) of 70% predicted and a Modified Medical Research Council Dyspnoea Scale score of 2.
When he was first diagnosed, Mr Singh was prescribed a short-acting bronchodilator inhaler. However, as his usage gradually increased, he was prescribed a long-acting beta-2 agonist inhaler two years ago. He uses this in the morning and evening. Mr Singh has a 35 pack year smoking history and still smokes five to ten cigarettes per day. He lives at home with his 61-year-old wife in a two-storey house and has three adult children who live nearby.
Over the last year, Mr Singh has become increasingly breathless and is now unable to walk more than 50 metres without stopping for breath. On some days, he experiences shortness of breath at rest. He has developed a productive morning cough, particularly in the morning, and an intermittent wheeze. His symptoms have worsened over the last six months and he has required two courses of antibiotics at home for chest infections.
Mr Singh is increasingly anxious about leaving the house alone because of his breathlessness and reduced exercise tolerance. He is also unsteady on his feet. Mr Singh's body mass index is 25. His weight has been stable, but he has not been eating as regularly due to his breathlessness.
Current Situation
Mr Singh was admitted to the hospital via the emergency department with a three-day history of worsening shortness of breath at rest, thick green sputum and a general feeling of being unwell.
Examination Findings
Upon hospital admission, Mr Singh was pyrexial, with a temperature of 38.2°C. He was hypotensive, with a blood pressure of 95/40 mmHg, tachycardic, with a heart rate of 104 beats per minute, and hypoxic, with an oxygen saturation (SpO2) of 86% on room air. His respiratory rate was elevated, at 28 breaths per minute.
A chest x-ray showed right lower lobe consolidation, consistent with infection. On auscultation, upper respiratory tract secretions could be heard with reduced air entry at the right lung base. Mr Singh was using his accessory muscles of breathing and could only speak in short sentences. An arterial blood gas was performed with the following results: pH 7.36, pCO2 45mmHg, pO2 75mmHg, HCO3 24, BE 0. He was unable to provide a sample of sputum for cultures and sensitivities due to increased work of breathing and an ineffective cough.
Intervention
Mr Singh was started on 4 litres of oxygen via nasal cannula, intravenous antibiotics, fluids, steroids and saline nebulisers.
He was transferred to a medical ward when his SpO2 stabilised to 88%, blood pressure improved to 110/65mmHg, heart rate dropped to 79 beats per minute and his respiratory rate came down to 22 breaths per minute.
The following sections describe the multidisciplinary input Mr Singh received.
Nursing
On the ward, the nursing staff sat Mr Singh upright in bed. They noticed his mouth was very dry due to dehydration, so they provided oral care and helped brush his teeth. They also spoke to the doctors about transferring him onto humidified oxygen to help provide additional humidification. At this point, he was started on 35% humidified oxygen via a face mask to keep his oxygen levels at around 92%.
Physiotherapy
The doctors requested a physiotherapy review for Mr Singh as he was struggling to cough and expectorate sputum despite audible secretions. After conducting an assessment, the physiotherapist explained breathing control exercises to Mr Singh, encouraging diaphragmatic breathing to help decrease his work of breathing and reduce his use of accessory muscles. A saline nebuliser was administered to help provide additional humidification and aid secretion clearance.
Next, the physiotherapist went through the active cycle of breathing technique (ACBT) with Mr Singh, aiming to encourage deep breathing to improve oxygenation and lung recruitment. As part of the ACBT, Mr Singh was taught a forced expiratory technique (FET). This technique helps to move secretions into the upper airways to aid expectoration. However, while this helped Mr Singh, it wasn’t totally effective. The physiotherapist then repositioned Mr Singh in left side lying to help improve ventilation and postural drainage to aid further secretion clearance. Gentle percussion was then used to help mobilise and loosen secretions and further ABCT cycles were performed. This technique was effective, and a sputum sample was obtained for culture and sensitivities.
The physiotherapist advised that Mr Singh should try to change position regularly in bed from high sitting to alternate side lying as comfortable until he was able to sit in the chair. They also provided him with an ACBT leaflet and asked him to carry out the exercises every hour he was awake. They planned to return later that day to repeat chest physiotherapy and review their plan.
Dietetics
A dietetic review was requested as Mr Singh had not been eating since he became unwell a few days ago. He had also lost his appetite and had not been drinking much. The dietitian started Mr Singh on a nutritional shake to help with his calorific intake and suggested a modified diet while he was unwell to help improve his appetite. Enteral feeding was discussed but it was decided it was not needed.
Occupational Therapy
An occupational therapy review was completed on day 3 of Mr Singh's hospital admission when he was feeling less unwell. This included assessing and practising his personal activities of daily living, transfers and mobility to ensure a safe discharge from hospital. Mr Singh required some equipment at home to help to assist with his activities of daily living so this was arranged prior to his discharge.
Because Mr Singh was becoming more limited by breathlessness and fatigue, the occupational therapist explained techniques that could help to conserve energy, such as planning and pacing activities. They also discussed fatigue management strategies to help Mr Singh complete his daily activities as efficiently as possible. In addition to this, the occupational therapist taught Mr Singh some anxiety management techniques to cope with the impact that his breathlessness was starting to have on his lifestyle.
Long-term Plan
Before discharge from hospital, a personalised care plan was produced with Mr Singh and his wife to support his self-management at home, reduce the incidence of further exacerbations and hospital admissions and improve his independence and quality of life.
Medication Optimisation
This was Mr Singh's first acute exacerbation of COPD requiring hospital admission. Thus, it was decided that he would need to be followed up post-discharge by a specialist respiratory team to optimise his management. He would also see a respiratory pharmacist or nurse to go through inhaler techniques, using a spacer, and checking he was up to date with his vaccinations.
Pulmonary Rehabilitation
While the hospital physiotherapist had commenced ward-based rehabilitation to get Mr Singh mobile again for home discharge, they felt he would benefit from additional rehabilitation. Pulmonary rehabilitation is a specialist exercise and education programme designed for people with lung disease who experience symptoms of breathlessness.[1] It is usually a 6-8 week programme, with two group sessions held each week. Pulmonary rehabilitation includes both physical exercise and information sessions. It is designed to help people better understand and manage their lung condition and symptoms, including feeling short of breath, managing fatigue, anxiety and pacing strategies. It also provides peer support and advice. Patients often feel huge benefits from attending pulmonary rehabilitation groups.
Supported Self-management
As part of discharge planning, a supported self-management plan was filled in with Mr Singh and his wife. This plan included information on his current management plan, medications, self-care, managing exacerbations and breathlessness, how to monitor symptoms, activity and mood as well as setting short-term goals to help optimise his condition. If you would like to see an example of a supported self-management plan, please see: COPD Self-management Plan.
As well as a self-management plan, Mr Singh was given a list of key contacts, he may need including his respiratory nurse. He was provided with contact information for peer support groups which are held online and in his local community so he could connect with other people living with COPD.
Mr Singh was given advice on smoking cessation and was referred to a team where he could discuss interventions that could help him give up smoking.
Family Advice and Support
Mr Singh's family were keen to be included in his care plan and were provided information about the exercises and interventions prescribed to help support him after discharge from hospital.
The nurse discussed the new self-management plan in detail and answered questions. They also went through good inhaler technique and a medication plan if symptoms worsened. Emergency planning was discussed in the event of future exacerbations and the concept of advanced care planning was mentioned - it was decided to discuss this at a later date.
The physiotherapist discussed strengthening exercises that Mr Singh could perform in a chair and standing to help improve his mobility and balance. They also provided information on the ACBT and breathing control, highlighting that this could be used daily to help improve breathing techniques and when Mr Singh was experiencing breathlessness or had an infection.
The occupational therapist discussed techniques that would help Mr Singh conserve energy to manage daily activities and increase confidence, as well as some of the aids they had supplied for home use to increase functional independence. They went through anxiety management techniques as Mr Singh had been reluctant to leave the house leading up to this hospital admission.
The dietitian discussed the importance of ensuring Mr Singh's nutritional requirements were met and encouraged a balanced diet with adequate calories, protein and micronutrient targets. This was particularly important to prevent any further deconditioning and ensure his BMI stayed above 25. They also stressed the importance of oral hygiene and staying adequately hydrated.
Discussion
A multidisciplinary approach for people living with respiratory conditions ensures that patients have a greater understanding of how their condition affects different aspects of their health and well-being. It allows healthcare professionals to share their expertise in teaching interventions that can help patients, families and carers manage the patient's condition as independently as possible with the relevant support mechanisms in place.
- ↑ Man W, Chaplin E, Daynes E, Drummond A, Evans RA, Greening NJ, et al. British Thoracic Society Clinical Statement on pulmonary rehabilitation. Thorax. 2023 Oct;78(Suppl 4):s2-s15.