Family Medicine · Year 3 · from Family Medicine

Case 2: COPD Exacerbation in Primary Care

Patient Demographics

  • Age: 67 years old
  • Sex: Male
  • Occupation: Retired construction worker

Chief Complaint

"My breathing has gotten worse over the past 4 days, and I'm coughing up more mucus than usual."

History of Present Illness

Mr. William Foster is a 67-year-old man with known COPD who presents with worsening dyspnea, increased cough, and change in sputum production over 4 days. His sputum has changed from white to yellow-green and increased in volume. He has been using his rescue inhaler every 2-3 hours instead of his usual 1-2 times daily. He slept sitting up last night due to breathlessness. He denies fever, but his wife notes he "feels warm." No chest pain, leg swelling, or hemoptysis.

He has not had a COPD exacerbation requiring steroids or antibiotics in 8 months. He continues to smoke, though he has cut down to 5 cigarettes daily.

Past Medical History

  • COPD, moderate (GOLD stage 2), diagnosed 5 years ago
  • Former smoker: 45 pack-years, currently smoking 5 cigarettes/day
  • Coronary artery disease, prior stent 3 years ago
  • Hypertension
  • Osteoporosis

Current Medications

  • Tiotropium 18 mcg inhaled daily
  • Fluticasone/salmeterol 250/50 mcg 1 puff twice daily
  • Albuterol MDI PRN
  • Aspirin 81 mg daily
  • Atorvastatin 40 mg daily
  • Lisinopril 10 mg daily
  • Alendronate 70 mg weekly

Family History

  • Father: COPD, lung cancer
  • Mother: Heart disease

Social History

  • Current smoker (reduced from 1 pack/day to 5 cigarettes/day)
  • No alcohol
  • Widowed, lives with daughter
  • Uses home oxygen at night (2L NC) for nocturnal hypoxemia

Physical Examination

  • Vital Signs: BP 142/88 mmHg, HR 98, RR 24, Temp 99.6F, SpO2 89% on room air (baseline 92-94%)
  • General: Appears uncomfortable, using accessory muscles, speaking in short phrases
  • HEENT: Normal
  • Neck: Elevated JVP to 8 cm
  • Lungs: Diffuse expiratory wheezes, decreased breath sounds at bases, prolonged expiratory phase, no crackles
  • Cardiovascular: Tachycardic, regular rhythm, no murmurs
  • Extremities: No edema, warm

Assessment and Diagnosis

  1. COPD exacerbation, moderate severity - Increased dyspnea, sputum volume, and sputum purulence (Anthonisen Type 1 - all 3 cardinal symptoms)
  2. Likely bacterial trigger - Purulent sputum, low-grade fever
  3. COPD, GOLD stage 2 - Moderate, Group E (exacerbation history)
  4. Active tobacco use - Ongoing harm

Management Plan

Acute Exacerbation Treatment:

Bronchodilators:

  • Increase albuterol: Nebulizer 2.5 mg every 4 hours or MDI with spacer 4-8 puffs every 4 hours
  • Continue tiotropium

Systemic Corticosteroids:

  • Prednisone 40 mg daily for 5 days
  • Short course adequate for most exacerbations

Antibiotics:

  • Indicated given purulent sputum and all 3 Anthonisen criteria
  • Azithromycin 500 mg day 1, then 250 mg days 2-5 (5-day Z-pack)
  • Alternative: Amoxicillin-clavulanate or doxycycline

Oxygen:

  • Maintain SpO2 88-92%
  • Increase home oxygen if needed during exacerbation

Decision: Outpatient vs. Inpatient:

  • Patient has moderate exacerbation but is stable
  • No severe respiratory distress, confusion, or hemodynamic instability
  • Has support at home (daughter)
  • Can manage outpatient with close follow-up
  • Discuss warning signs requiring ED visit

Smoking Cessation:

  • Reinforce importance, even during exacerbation
  • Offer varenicline when acute illness resolves
  • Provide quitline referral: 1-800-QUIT-NOW

Preventive Measures:

  • Ensure influenza and pneumococcal vaccinations up to date
  • Discuss pulmonary rehabilitation when stable

Follow-Up

  • Phone check in 24-48 hours to assess response
  • Return visit in 5-7 days or sooner if worsening
  • Indications to go to ED: Worsening dyspnea, confusion, unable to speak, SpO2 <88% on supplemental O2

Teaching Points

  1. COPD exacerbation definition: Acute worsening of respiratory symptoms beyond normal day-to-day variation requiring change in therapy. Anthonisen criteria: increased dyspnea, increased sputum volume, sputum purulence.
  1. Treatment of exacerbations:
  • Bronchodilators: Increase SABA frequency
  • Systemic corticosteroids: Prednisone 40 mg x 5 days (shorter courses as effective as longer)
  • Antibiotics: Indicated if purulent sputum present or need for mechanical ventilation
  1. Disposition decision: Consider hospitalization for severe dyspnea, failure to respond to initial treatment, serious comorbidities, inadequate home support, or altered mental status.
  1. GOLD classification:
  • Based on FEV1 and symptoms/exacerbation history
  • Group A: Low symptoms, low exacerbation risk
  • Group B: High symptoms, low exacerbation risk
  • Group E: Any exacerbation leading to hospitalization or ≥2 moderate exacerbations/year
  1. Smoking cessation: Most important intervention to slow COPD progression. Address at every visit, even during exacerbations.

All cases for this lecture as Markdown