Analysing factors associated with successful treatment.

Case Study Overview

This case study involves a patient named R.W, a 64-year-old Caucasian postal clerk who has smoked a pack of cigarettes a day for the past 35 years. He reports to his CNP in his family practice clinic. He presents with progressive difficulty getting his breath while doing simple tasks. He is having difficulty doing any manual work, but he has no symptoms when working behind his desk. He also reports a cough, fatigue, and weight loss. He has been treated for three respiratory infections a year for the past 3 years and feels like another one is developing now. On physical examination, you notice clubbing of his fingers, use of accessory muscles for respiration, wheezing in the lungs, and hyper resonance on percussion of the lungs. Pulmonary function studies show an FEV1 of 58%. Analysing factors associated with successful treatment.

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Discussion

Diagnosis

The most likely diagnosis for R.W is Chronic Obstructive Pulmonary Disease (COPD). COPD is primarily characterized by a continuous limitation in the flow of air, and destruction of lung tissues. It is also associated with structural changes in the lungs that are a result of chronic inflammation from prolonged exposure to toxic gases and particles most specifically, cigarette smoking. The inflammation causes narrowing of the airways and a decrease in the lung recoil.Analysing factors associated with successful treatment.

Stage of Disease

Newsome et al., (2018) refer to the GOLD guidelines on the diagnosis and staging of COPD based on the level of obstruction in the flow of air as measured by spirometry, breathlessness, and symptoms. According to these guidelines, the stages of COPD are based on how decreased an individual’s FEV1 spirometry score. The CNP grades the COPD from grade I to grade IV. Grade I is mild COPD where the FEV1 value is 80% or more. Grade II is moderate COPD where the FEV1 value ranges between 50%-79% (O’Reilly, 2016). In stage III, the FEV 1 value ranges between 30%-49% and is deemed to be severe COPD. In the last stage, stage IV, the FEV1 value is less than 30% and deemed very severe. Therefore, since R.W has an FEV1 of 58% alongside his signs and symptoms, he has moderate COPD. Analysing factors associated with successful treatment.

Pharmacotherapeutics Treatment Goals

The pharmacological management of COPD is one of the most integral foundations of COPD management. The overall goal of COPD management is improving an individual’s quality of life (QoL) and functional status by improving symptoms, optimal lung function, and preventing the occurrence of exacerbations. This requires that a CNP should be able to recognize the impact that symptoms have on the life of a patient as part of patient-centered management (Patel et al., 2019). Therefore, for this patient, the main pharmacotherapeutics treatment goals are; relief and resolve of respiratory symptoms of cough, wheezing, and fatigue. He will also be able to perform manual work, simple tasks, and Activities of Daily Life (ADL) normally. His FEV1 will also increase from 58% to 80% and more. Analysing factors associated with successful treatment.

Prescription Drug Therapy

GOLD guidelines recommend that the pharmacological intervention of patients in GOLD group A (mild) should be managed with a short-acting beta2 agonist or a short-acting anticholinergic. Patients in GOLD group B should be managed with either a long-acting beta 2 (LABA) agonist or a long-acting anticholinergic (LAMA) as the first-line (Lee et al., 2013). Those in GOLD group C or D should be managed with combined therapy of an inhaled corticosteroid and a long-acting beta 2 agonist or a long acting anticholinergic. The guidelines further recommend that to increase the effectiveness of pharmacotherapy, CNPs should recommend smoking cessation for all patients with COPD who smoke (Patel et al., 2019). Analysing factors associated with successful treatment.

In comparison, guidelines by the American Thoracic Society (ATS) and the American College of Chest Physicians (ACCP) recommend that patients with an FEV1 of 60% to 80% should be managed with inhaled bronchodilators. Management for those with an FEV₁ < 60% should include a long-acting beta2 agonist or a long-acting anticholinergic (Fernandes et al., 2017). Since R.W has an FEV1 of 58%, he should be managed with a long-acting beta2 agonist or a long-acting anticholinergic based on the ATS/ACCP guidelines (FEV₁ < 60%). IN the GOLD guidelines, he falls in category B (moderate COPD) which also recommends management with either a long-acting beta 2 agonist or a long-acting anticholinergic. Analysing factors associated with successful treatment.

A preferred long-acting anticholinergic is tiotropium 18DPI 18 μg 24 hourly. The mode of action of tiotropium is by blocking acetylcholine action on M₃ receptors. It is licensed for   COPD management and is selective for M₃ and M₁ receptors. Current existing evidence reveals that management with tiotropium increases the efficacy and effectiveness of pulmonary rehabilitation and decreases the frequency of exacerbations.

Parameters for Monitoring Therapy Success

One of the most significant parameters that can be used to monitor RW’s therapy success is his HRQL (Health-related Quality Of Life). This includes RW’s social, physical, and psychological health domains. To determine the measure of each of these domains, a CNP can use instruments such as the Seattle Obstructive Lung Disease Questionnaire (SOLQ) which incorporates RW’s emotional and physical function, coping skills, and treatment satisfaction (Duarte-de-Araújo et al., 2020). This instrument is sensitive in detecting change (worsening or improvement of symptoms) in response to therapy.Analysing factors associated with successful treatment.

Another parameter is assessing dyspnea and breathlessness which are common manifestations of COPD that RW also presents with. The CNP can assess for dyspnea using either evaluative or discriminative instruments. The best instrument is the Baseline and Transition Dyspnea Index (BDI/TDI). BDI assesses a patient’s dyspnea and breathlessness about her magnitude of task and effort, and functional impairment (Duarte-de-Araújo et al., 2020). Exercise tolerance is also an important parameter since limitation in physical activity is a major problem for COPD patients which can best be assessed using the 6-minute walk distance (6MWD). Improvement intolerance for activity is a significant parameter outcome that predicts survival and correlates directly with QoL. According to Duarte-de-Araújo et al. (2020), the most important parameters to monitor for COPD severity and lung function are FEV1 changes and oxygen levels. Analysing factors associated with successful treatment.

Patient Education Based On The prescribed Therapy

Patient education should emphasize the fact that tiotropium does not cure COPD   but only controls the symptoms. For good outcomes, the patient should not swallow the capsule but inhale the powder in the capsules using the inhaler it comes with. It is also important to teach RW the appropriate technique of using the inhaler (Delgado & Bajaj, 2020). To assess his understanding of using the inhaler, the CNP can use the teach-back method. The patient should not use the tiotropium for sudden shortness of breath or a wheezing attack. Incase RW misses a dose; he should take it as soon as he remembers it. However, if the time to take the next dose is almost, he should skip the missed dose and continue with his dosing schedule as usual (Delgado & Bajaj, 2020). The patient should be aware of some of the side effects of tiotropium such as vomiting, dry mouth, and runny nose that disappear with time. Analysing factors associated with successful treatment.

Adverse Reactions of the Selected Agent That Can Cause Change Of Therapy

The most significant adverse effects of tiotropium are dry mouth, sinusitis, cough, and headaches. Since is it is an anticholinergic, another significant adverse effect that can cause a change in therapy is that of tachyarrhythmias (Delgado & Bajaj, 2020). In the systemic circulation, it has the potential of causing narrow-angle glaucoma and urinary retention which can lead to permanent damage of vision and dysuria.Analysing factors associated with successful treatment.

The choice for Second-Line Therapy

A preferred second-line drug for RW would be a LABA such as formoterol 12DPI 12 μg 12 hourly.  LABA has been demonstrated to decrease the need for rescue drugs, improve patient-associated outcomes and symptoms (Patel et al., 2019). Besides, they also have a good safety profile. Formoterol is a good choice in this case since it has a faster onset of action when compared to salmeterol.

Recommended Health Promotion Activities

The most appropriate health promotion activities for RW are education, ensuring up to date immunization, smoking cessation, and dietary medication to promote weight gain. RW should ensure that he gets annual pneumococcal and influenza vaccination. Evidence suggests that the aforementioned immunizations decrease pneumococcal and influenza-associated exacerbations in patients with COPD. He should also enroll in a smoking cessation program. The study by Ambrosino & Bertella (2018) reveals that smoking cessation decreases COPD-related morbidity, mortality and improves overall outcomes. With regards to dietary modification, the CNP should liaise with the dietician to improve his nutrition supplementation for increased muscle mass and weight gain. His diet should be rich in fruits, and vegetables.Analysing factors associated with successful treatment.

Recommended Change of Pharmacotherapy with Metoprolol

Metoprolol is a cardioselective beta-blocker that has demonstrated greater efficacy in managing patients with cardiovascular disease. Traditionally, the use of such agents in patients with COPD was contraindicated due to anecdotal evidence that it caused acute bronchospasms and increased hyperresponsiveness of the airways which is a major issue since that increases mortality in patients with COPD (Lipworth et al., 2016). However, the latest evidence reveals that COPD patients taking beta-blockers and a beta-agonist are less likely to experience exacerbations due to the cardio selectivity of beta-blockers. Therefore, as long as the dose of metoprolol for RW would be administered in doses that maintain cardio selectivity, there would be no need for change with pharmacotherapy. Analysing factors associated with successful treatment.