80
! Assessment write a two-page paper summarizing the available published
29 yo woman with moderate to severe exacerbation of asthma;
SECTION 3
uncontrolled chronic asthma
! Clinical Course
The patient is admitted overnight for treatment with oxygen, inhaled
bronchodilators, and oral prednisone 60 mg daily. She is discharged
home with her previous regimen plus nebulized albuterol 2.5 mg
every 8 hours for 5 days and prednisone 60 mg orally once daily to
complete a 10-day burst. She was also given nystatin swish and
Respiratory Disorders
swallow for treatment of her oral thrush infection. On follow-up at
day 4 in the clinic, her lungs are clear without wheezing; her respira-
tory rate is 16 breaths per minute; and her pulse oximetry is 97% on
room air. Her peak flow readings have improved to 300 L/min.
QUESTIONS
Problem Identification
1.a. Create a list of the patient’s drug therapy problems.
1.b. What information indicates the presence of uncontrolled
chronic asthma and an acute asthma exacerbation?
1.c. What factors may have contributed to this patient’s poorly
controlled asthma and acute exacerbation?
1.d. How would you classify this patient’s level of asthma control
(well controlled, not well controlled, or very poorly con-
trolled), according to NIH guidelines?
Desired Outcome
2. What are the goals of pharmacotherapy in this case?
Therapeutic Alternatives
3.a. What nonpharmacologic therapies might be useful for this
patient?
3.b. What feasible pharmacotherapeutic alternatives are available
for treatment of this patient’s chronic asthma?
Optimal Plan
4.a. Outline an optimal plan of treatment for this patient’s chronic
asthma.
4.b. What alternatives would be appropriate if the initial therapy fails?
Outcome Evaluation
5. What clinical parameters are necessary to evaluate the therapy for
achievement of the desired therapeutic effect and to detect or
prevent adverse effects?
Patient Education
6. What information should be provided to the patient regarding
the use of her asthma medications and how she can use her peak-
flow readings to better manage her disease?
■ SELF-STUDY ASSIGNMENTS
1. Review the NIH guidelines on the management of asthma during
pregnancy, and develop a pharmacotherapeutic treatment plan
for this patient’s asthma if she were to become pregnant.
2. Review the literature on the impact of chronic inhaled cortico-
steroid use on the risk for development of osteoporosis, and
literature on this topic.
CLINICAL PEARL
Patients with asthma who report that taking aspirin makes their
asthma symptoms worse may respond well to leukotriene modifiers.
Aspirin inhibits prostaglandin synthesis from arachidonic acid
through inhibition of cyclooxygenase. The leukotriene pathway may
play a role in the development of asthma symptoms in such patients,
as inhibition of cyclooxygenase by aspirin may shunt the arachidonic
acid pathway away from prostaglandin synthesis and toward leuko-
triene production. Although inhaled corticosteroids are still the pre-
ferred anti-inflammatory medications for patients with asthma and
known aspirin sensitivity, leukotriene modifiers may also be useful in
such patients based on this theoretical mechanism.
REFERENCES
1. National Asthma Education and Prevention Program. Executive sum-
mary of the NAEPP expert panel report 3: guidelines for the diagnosis
and management of asthma. Bethesda, MD: U.S. Department of
Health and Human Services, Public Health Service, National Institutes
of Health, National Heart, Lung, and Blood Institute, Full Report 2007.
Available at http://www.nhlbi.nih.gov/guidelines/asthma/index.htm.
2. Global Initiative for Asthma (GINA). Global strategy for asthma man-
agement and prevention (updated 2006). Available at http://www.
ginasthma.org; 2006.
3. Greening AP, Ind PW, Northfield M, et al. Added salmeterol versus
high-dose corticosteroid in asthma patients with symptoms on existing
inhaled corticosteroid. Lancet 1994;344:219–224.
4. Busse W, Raphael GD, Galant S, et al. Fluticasone Propionate Clinical
Research Study Group. Low-dose fluticasone propionate compared
with montelukast for first-line treatment of persistent asthma: a
randomized clinical trial. J Allergy Clin Immunol 2001;107:461–468.
5. Busse W, Nelson H, Wolfe J, et al. Comparison of inhaled salmeterol
and oral zafirlukast in patients with asthma. J Allergy Clin Immunol
1999;103:1075–1080.
6. Humbert M, Beasley R, Ayres J, et al. Benefits of omalizumab as add-
on therapy in patients with severe persistent asthma who are inade-
quately controlled despite best available therapy (GINA 2002 step 4
treatment): INNOVATE. Allergy 2005;60:309–316.
7. Food and Drug Administration (FDA) 2007. FDA alert: Omalizumab
(marketed as Xolair) information 2/2007. Available at: http://
www.fda.gov/cder/drug/infopage/omalizumab/default.htm.
25
CHRONIC OBSTRUCTIVE
PULMONARY DISEASE
Quick Fix, Lifetime Risk . . . . . . . . . . . . . . . . . . . Level II
Joel C. Marrs, PharmD, BCPS
LEARNING OBJECTIVES
After completing this case study, the reader should be able to:
• Recognize modifiable and nonmodifiable risk factors for the
development of COPD.
 81
• Interpret spirometry readings to evaluate and appropriately ! Meds
stage the severity of COPD for an individual patient.

CHAPTER 25
Metoprolol tartrate 50 mg po BID
• Identify the importance of nonpharmacologic therapy in pa- Salmeterol (Serevent Diskus) 1 inhalation (50 mcg) BID
tients with COPD. Tiotropium (Spiriva) 1 capsule (18 mcg) inhaled once daily
Lisinopril 20 mg po once daily
• Develop an appropriate medication regimen for a patient with Esomeprazole (Nexium) 20 mg po once daily
COPD based on disease severity. Albuterol MDI 1–2 puffs Q 6 h PRN
• Evaluate the role of inhaled and/or oral corticosteroids in the Aspirin 81 mg po once daily
management of COPD.
! All
• Educate patients on the proper use of inhaled medications and

Chronic Obstructive Pulmonary Disease

NKDA
determine which patients may benefit from spacers and/or
holding chambers. ! ROS
• Describe the relationship between α1-antitrypsin deficiency (+) Shortness of breath with chronic nonproductive cough; (+)
and the development of emphysema. fatigue; (+) exercise intolerance

! Physical Examination
PATIENT PRESENTATION Gen
WDWN man appearing in mild respiratory distress after walking to
! Chief Complaint the end of the hall to reach the exam room
“Why can’t I just take prednisone every day? It always works when
I get admitted to the hospital.” VS
BP 138/88, P 85, RR 26, T 37.5°C; Wt 95 kg, Ht 5'11''
! HPI
Skin
Thomas Jones is a 66-year-old man with COPD who is presenting
to the family medicine clinic today to have a 1-month follow-up Warm, dry; no rashes
appointment from his last hospital admission for an acute exacerba-
HEENT
tion of COPD. This last COPD exacerbation is the second hospital
admission in the last 6 months related to TJ’s COPD instability. Normocephalic; PERRLA, EOMI; normal sclerae; mucous mem-
After TJ’s hospitalization, his discharge COPD regimen was branes are moist; TMs intact; oropharynx clear
changed to include tiotropium, 1 inhalation daily in addition to
Neck/Lymph Nodes
salmeterol 50 mcg, 1 inhalation Q 12 h, and an albuterol MDI as
needed. TJ had pulmonary function tests (PFTs) while he was in the Supple without lymphadenopathy
hospital 1 month ago but has yet to have them reassessed after the
Lungs
change in his COPD regimen. He wants to start taking prednisone
every day because he believes this would prevent him from being Tachypnea with prolonged expiration; decreased breath sounds; no
readmitted to the hospital. The patient states that his respiratory rales, rhonchi, or crackles
symptoms are better than when he was admitted 1 month ago, but
CV
he still has shortness of breath every day and a decreased exercise
capacity (e.g., he becomes very short of breath after walking a RRR without murmur; normal S1 and S2
couple of blocks). He states that he is adherent to the new medica-
Abd
tion regimen that was changed on discharge from the hospital. No
other medications were changed at that time that he can recall. His Soft, NT/ND; (+) bowel sounds; no organomegaly
daughter, who is at the appointment today, states that she makes
Genit/Rect
sure he uses his inhalers but often wonders if he is using them
correctly because he still has daily symptoms. No back or flank tenderness; normal male genitalia

! PMH MS/Ext
COPD × 12 years No clubbing, cyanosis, or edema; pulses 2+ throughout
GERD × 5 years
Neuro
HTN × 20 years
CAD (MI 5 years ago) A & O × 3; CN II–XII intact; DTRs 2+; normal mood and affect

! FH ! Labs

Mother died from emphysema 4 years ago at the age of 82. Father Na 135 mEq/L Hgb 12.1 g/dL AST 40 IU/L Ca 8.9 mg/L
K 4.2 mEq/L Hct 38.5% ALT 19 IU/L Mg 3.6 mg/L
has a history of coronary artery disease.
Cl 108 mEq/L Plt 195 × 103/mm3 T. bili 1.1 mg/dL Phos 2.9 mg/dL
CO2 26 mEq/L WBC 6.4 × 103/mm3 Alb 3.1 g/dL
! SH BUN 19 mg/dL Pulse Ox 93% (RA)
He lives with his daughter and her family. His wife died 10 years ago SCr 1.1 mg/dL
Glu 109 mg/dL
from breast cancer. He has a 35 pack-year history of smoking. He
quit smoking approximately 3 months ago but has had occasional
relapses. He states he has not smoked for approximately a week. He ! Pulmonary Function Tests (during Hospital Admission 1 Month Ago)
drinks one to two beers every evening. Prebronchodilator FEV1 = 1.1 L (predicted is 3.1 L)
 82
Prebronchodilator FVC = 3.2 L
Postbronchodilator FEV1 = 1.6 L
SECTION 3
! Pulmonary Function Tests (during Clinic Visit Today)
Prebronchodilator FEV1 = 1.3 L (predicted is 3.1 L)
Prebronchodilator FVC = 3.2 L
Postbronchodilator FEV1 = 1.47 L
! Assessment
This is a normal-appearing 66 yo man presenting to the clinic with
Respiratory Disorders
mild respiratory distress for follow-up on his COPD medication
regimen that was changed 1 month ago on hospital discharge. He
also has a history of GERD, HTN, CAD, and a chronic cough.
QUESTIONS
Problem Identification
1.a. Create a list of this patient’s drug-related problems.
1.b. What signs, symptoms, and laboratory data provide evidence
that this patient is not yet optimally managed to reach a stable
COPD status? Based on the evidence, is his history more
consistent with emphysema or chronic bronchitis?
Desired Outcome
2. What are the desired goals for the treatment of COPD?
Therapeutic Alternatives
3.a. What nonpharmacologic therapies would be useful to improve
this patient’s COPD symptoms?
3.b. What feasible pharmacotherapeutic alternatives are available
for the treatment of COPD in this patient based on his response
to the current medication regimen and the most recent GOLD
guideline recommendations?
3.c. Should home oxygen therapy be considered for the patient at
this time?
3.d. Is this patient a candidate for α1-antitrypsin (Prolastin) therapy?
Optimal Plan
4. Evaluate the patient’s current COPD regimen and develop rec-
ommendations to continue or change the current COPD medica-
tions at his clinic visit today. Make sure to include specific doses,
route, frequency, and duration of therapy.
Outcome Evaluation
5.a. What clinical parameters will you monitor to assess the
COPD pharmacotherapy regimen in this patient?
5.b. What will need to be monitored to assess any possible
medication side effects?
5.c. What laboratory tests can be performed and how often
should they be performed to assess the efficacy of the current
COPD regimen as well as progression of the patient’s lung
disease?
Patient Education
6. What information should be provided to the patient to enhance
adherence, ensure successful therapy, and minimize adverse
effects?
■ SELF-STUDY ASSIGNMENTS
1. Describe and compare the expectations for deterioration in pul-
monary function in normal healthy adults and smokers with em-
physema. In particular, emphasis should be placed on expected
patterns of change in DLco, FEV1, and FVC, and general health
over time in years.
2. Why would additional phenotyping be necessary if this patient
were to have an abnormally low serum α1-antitrypsin level?
What are the implications of the results if the patient were
designated as homozygous ZZ, heterozygous MZ, or heterozy-
gous SZ at the α1-antitrypsin allele?
3. Research and describe the evidence-based medicine approach to
the management of an acute exacerbation of COPD and discuss
the process of how to transition a COPD patient back to his or
her chronic COPD regimen and/or adjust this regimen after an
acute exacerbation of COPD.
CLINICAL PEARL
A pulmonary rehabilitation program including mandatory exercise
training of the muscles used in respiration is recommended for
patients with COPD because of the established benefit related to
improvements seen in dyspnea symptoms, health-related quality of
life, and reduced number of hospital days secondary to exacerbations.
REFERENCES
1. Global Initiative for Chronic Obstructive Lung Disease. Global strategy
for the diagnosis, management, and prevention of chronic obstructive
pulmonary disease: executive summary. Updated 2006. Available at
http://www.goldcopd.com. Accessed March 28, 2007.
2. American Thoracic Society/European Respiratory Society Task Force.
Standards for the diagnosis and management of patients with COPD
[Internet]. Version 1.2. New York, American Thoracic Society, 2004.
Updated Sept. 8, 2005. Available at http://www.thoracic.org/go/copd.
3. Callahan CM, Dittus RS, Katz BP. Oral corticosteroid therapy for
patients with stable chronic obstructive pulmonary disease: a meta-
analysis. Ann Intern Med 1991;114:216–223.
4. Anzueto A. Clinical course of chronic obstructive pulmonary disease:
review of therapeutic interventions. Am J Med 2006;119:546–553.
5. MacDonald JL, Johnson CE. Pathophysiology and treatment of alpha
1-anti-trypsin deficiency. Am J Health Syst Pharm 1995;52:481–489.
6. Nichols J. Combination inhaled bronchodilator therapy in the man-
agement of chronic obstructive pulmonary disease. Pharmacotherapy
2007;27:447–454.
7. Toogood JH. Helping your patients make better use of MDIs and
spacers. J Respir Dis 1994;15:151–166.
8. Package insert. Spiriva (tiotropium bromide). New York, Boehringer
Ingelheim Pharmaceuticals Inc., October 2006.
9. Package insert. Advair (fluticasone propionate/salmeterol). Research
Triangle Park, NC, GlaxoSmithKline, February 2007.
10. Ries AL, Bauldoff GS, Carlin BW, et al. Pulmonary rehabilitation: joint
ACCP/AACVPR evidence-based clinical practice guidelines. Chest
2007;131:4S–42S.
Kasus 2
Keluhan Utama :
Tenggorokan saya sakit, dan saya tidak ingin bangun dari tempat tidur. Saya juga merasakan
demam, sesak nafas dan peningkatan batuk cokelat yang berlendir serta mengi sudah 5 hari
belakangan.
Riwayat kondisi dahulu :
James Hershey adalah laki-laki berusia 50 tahun datang ke bagian gawat darurat mengeluh
sakit tenggorokan, sakit kepala, demam, dan malaise sekitar 5 hari sebelumnya, dia menolak
makan sesuatu yang padat karena dia mengeluh itu terlalu menyakitkan.
Pasien memiliki riwayat PPOK 10 tahun yang lalu dan belakangan ini juga mengeluhkan sesak
nafas nya bertambah parah, mulai mengalami nyeri dada dan batuk produktif selama 5 hari
terakhir, dan merasa bahwa dia demam dengan menggigil, meskipun dia tidak mengukur suhu
tubuhnya. Dia menyatakan bahwa gejala awal sesak nafasnya dimulai sekitar 1 minggu yang
lalu setelah pada awal hari musim dingin. 1 minggu yang lalu dia pergi ke klinik dan menerima
resep levofloxacin 750 mg po selama 5 hari, yang tidak pernah dia tebus karena alasan
keuangan. Dia mengonsumsi acetaminophen dan obat batuk dan pilek yang dijual bebas untuk
mengurangi gejala. Pasien juga memiliki riwayat hipertensi sudah sejak 15 tahun yang lalu dan
alergi terhadap penisilin.
Riwayat Sosial :
Tinggal bersama istri dan empat anak. Pasien merokok aktif 2 bungkus/hari selama 30 tahun
terakhir. Pasien tidak mengkonsumsi alkohol dan narkotika.
Tanda Vital :
Tekanan darah 150/90 mmHg, RR 31 x, T 39,1 derajat celcius, BB : 65 kg, TB : 170 cm
Hasil laboratorium :
BUN = 31 mg/dl HCt = 35% SrCr = 1,4 mg/dl
Hb = 12,1 mg/dl Na = 141 mEq Ca = 2 mEq
K = 3,8 mEq Glukosa puasa= 101 mg/dl MCV = 91 mikro meter pangkat 3
Sel darah merah = 3,8 x 10 pangkat 6 / mm pangkat 3 MCHC = 35 g/dL
Sel darah putih = 17,2 x 10 pangkat 3 / mm pangkat (normal 4500-10000 sel/mm)
Tes fungsi paru (dengan spirometri) :
FEV1 = 1,39 L (normal 3.1 L) (45%)

Strain gram dahak :
25 WBC / hpf, <10 sel epitel / hpf, banyak Gram (+) streptococci berpasangan
Obat yang sekarang digunakan :
Lisinopril 10 mg po 1 x sehari; Hidroklortiazid 12,5 mg po 1 x sehari; Ipratropium/Albuterol MDI
2 semprot 4 x sehari; Albuterol MDI 2 semprot jika diperlukan pada saat sesak nafas;
Asetaminofen 650 mg po setiap 6 jam jika demam; Guaiafenesin/dekstrometorfan (100 mg/10
mg per 5 mL) 2 sendoh teh setiap 4 jam jika batuk; Amoksisilin 500 mg 3 x sehari 10 tablet