COPD — frequent exacerbator on the wrong inhaler — CCE clinical encounter

CCE-style clinical encounter: a 66-year-old ex-smoker with GOLD grade 3 COPD on ICS-LABA alone, two exacerbations this year, still smoking, never offered cessation pharmacotherapy or rehabilitation. The candidate must restructure inhaled therapy with trial evidence, deliver cessation pharmacotherapy, and safety-net the next exacerbation.

clinical encounter with role-player (CCE format)2 min readVerification in progress

Prompt

A 66-year-old retired plumber attends for a repeat script of his fluticasone-salmeterol inhaler. He stopped smoking 18 months ago but restarted after his wife died. He has had two chest infections treated with prednisolone this year and wakes breathless twice most nights. Spirometry last year: post-bronchodilator FEV1/FVC 0.55, FEV1 44% predicted. Blood eosinophils 180 cells/µL. He has never been offered pulmonary rehabilitation and keeps a 'spare pack of steroids' in the cupboard without instructions. He says the inhaler 'doesn't really work' and asks for something stronger.

Objectives

Rebuild the assessment: confirm control status, exacerbation count and current regimen fit. ^[1]
Restructure inhaled therapy using the eosinophil count and exacerbation history with FLAME/IMPACT/WISDOM logic. ^[12] ^[13] ^[14]
Relaunch smoking cessation with pharmacotherapy and evidence framing. ^[6] ^[7]
Convert the 'spare pack' into a proper written action plan. ^[23]
Refer to pulmonary rehabilitation and set review cadence. ^[20]

References13Show

[1]Agustí A, Celli BR, Criner GJ, Halpin D, Anzueto A, et al. Global Initiative for Chronic Obstructive Lung Disease 2023 Report: GOLD Executive Summary. Eur Respir J, 2023.PMID 36858443
[3]Fletcher C, Peto R The natural history of chronic airflow obstruction. Br Med J, 1977.PMID 871704
[6]Cahill K, Lindson-Hawley N, Thomas KH, Fanshawe TR, Lancaster T Nicotine receptor partial agonists for smoking cessation. Cochrane Database Syst Rev, 2016.PMID 27158893
[7]Anthenelli RM, Benowitz NL, West R, St Aubin L, McRae T, et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, placebo-controlled clinical trial. Lancet, 2016.PMID 27116918
[10]Lipson DA, Barnhart F, Brealey N, Brooks J, Criner GJ, et al. Once-Daily Single-Inhaler Triple versus Dual Therapy in Patients with COPD. N Engl J Med, 2018.PMID 29668352
[11]Rabe KF, Martinez FJ, Ferguson GT, Wang C, Singh D, et al. Triple Inhaled Therapy at Two Glucocorticoid Doses in Moderate-to-Very-Severe COPD. N Engl J Med, 2020.PMID 32579807
[12]Wedzicha JA, Banerji D, Chapman KR, Vestbo J, Roche N, et al. Indacaterol-Glycopyrronium versus Salmeterol-Fluticasone for COPD. N Engl J Med, 2016.PMID 27181606
[13]Magnussen H, Disse B, Rodriguez-Roisin R, Kirsten A, Watz H, et al. Withdrawal of inhaled glucocorticoids and exacerbations of COPD. N Engl J Med, 2014.PMID 25196117
[14]Watz H, Tetzlaff K, Wouters EF, Kirsten A, Magnussen H, et al. Blood eosinophil count and exacerbations in severe chronic obstructive pulmonary disease after withdrawal of inhaled corticosteroids: a post-hoc analysis of the WISDOM trial. Lancet Respir Med, 2016.PMID 27066739
[16]Anthonisen NR, Manfreda J, Warren CP, Hershfield ES, Harding GK, Nelson NA Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease. Ann Intern Med, 1987.PMID 3492164
[17]Leuppi JD, Schuetz P, Bingisser R, Bodmer M, Briel M, et al. Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE randomized clinical trial. JAMA, 2013.PMID 23695200
[20]McCarthy B, Casey D, Devane D, Murphy K, Murphy E, Lacasse Y Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev, 2015.PMID 25705944
[23]Schrijver J, Lenferink A, Brusse-Keizer M, Zwerink M, van der Valk PD, et al. Self-management interventions for people with chronic obstructive pulmonary disease. Cochrane Database Syst Rev, 2022.PMID 35001366

COPD — frequent exacerbator on the wrong inhaler — CCE clinical encounter

clinical encounter with role-player (CCE format)2 min readVerification in progress

Objectives

Rebuild the assessment: confirm control status, exacerbation count and current regimen fit. ^[1]

Restructure inhaled therapy using the eosinophil count and exacerbation history with FLAME/IMPACT/WISDOM logic. ^[12] ^[13] ^[14]

Relaunch smoking cessation with pharmacotherapy and evidence framing. ^[6] ^[7]

Convert the 'spare pack' into a proper written action plan. ^[23]

Refer to pulmonary rehabilitation and set review cadence. ^[20]

References13Show

[1]Agustí A, Celli BR, Criner GJ, Halpin D, Anzueto A, et al. Global Initiative for Chronic Obstructive Lung Disease 2023 Report: GOLD Executive Summary. Eur Respir J, 2023.PMID 36858443
[3]Fletcher C, Peto R The natural history of chronic airflow obstruction. Br Med J, 1977.PMID 871704
[6]Cahill K, Lindson-Hawley N, Thomas KH, Fanshawe TR, Lancaster T Nicotine receptor partial agonists for smoking cessation. Cochrane Database Syst Rev, 2016.PMID 27158893
[7]Anthenelli RM, Benowitz NL, West R, St Aubin L, McRae T, et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, placebo-controlled clinical trial. Lancet, 2016.PMID 27116918
[10]Lipson DA, Barnhart F, Brealey N, Brooks J, Criner GJ, et al. Once-Daily Single-Inhaler Triple versus Dual Therapy in Patients with COPD. N Engl J Med, 2018.PMID 29668352
[11]Rabe KF, Martinez FJ, Ferguson GT, Wang C, Singh D, et al. Triple Inhaled Therapy at Two Glucocorticoid Doses in Moderate-to-Very-Severe COPD. N Engl J Med, 2020.PMID 32579807
[12]Wedzicha JA, Banerji D, Chapman KR, Vestbo J, Roche N, et al. Indacaterol-Glycopyrronium versus Salmeterol-Fluticasone for COPD. N Engl J Med, 2016.PMID 27181606
[13]Magnussen H, Disse B, Rodriguez-Roisin R, Kirsten A, Watz H, et al. Withdrawal of inhaled glucocorticoids and exacerbations of COPD. N Engl J Med, 2014.PMID 25196117
[14]Watz H, Tetzlaff K, Wouters EF, Kirsten A, Magnussen H, et al. Blood eosinophil count and exacerbations in severe chronic obstructive pulmonary disease after withdrawal of inhaled corticosteroids: a post-hoc analysis of the WISDOM trial. Lancet Respir Med, 2016.PMID 27066739
[16]Anthonisen NR, Manfreda J, Warren CP, Hershfield ES, Harding GK, Nelson NA Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease. Ann Intern Med, 1987.PMID 3492164
[17]Leuppi JD, Schuetz P, Bingisser R, Bodmer M, Briel M, et al. Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE randomized clinical trial. JAMA, 2013.PMID 23695200
[20]McCarthy B, Casey D, Devane D, Murphy K, Murphy E, Lacasse Y Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev, 2015.PMID 25705944
[23]Schrijver J, Lenferink A, Brusse-Keizer M, Zwerink M, van der Valk PD, et al. Self-management interventions for people with chronic obstructive pulmonary disease. Cochrane Database Syst Rev, 2022.PMID 35001366