"My Breathing Is Getting Worse Over
the Last Month."
CiCi is a 60-year-old female with a history of advanced, home oxygen (O2)–dependent COPD and heart failure who presents to the ED with a month of progressively worsening shortness of breath (SOB), nausea, vomiting, and productive cough with thick yellow sputum. She also reports having a fever of 102oF at home and occasional palpitations but denies any chest pain. CiCi smoked 2 ppd of cigarettes for 40 years, which she finally quit 2 years ago. In the last year, she has been hospitalized four times for similar symptoms.
CiCi's past medical history includes: COPD for 15 years on home oxygen, heart failure, allergic rhinitis, benign essential hypertension, and chronic respiratory failure. Her vital signs are as follows: T 98.4oF, BP 120/73, HR 95, RR 22.
Medication prior to admission: prednisone 5 mg qd, bumetanide 2 mg bid, montelukast 10 mg every evening, carvedilol 3.125 mg bid, potassium chloride 20 mEq tablet ER bid, tiotropium bromide 18-mcq capsule one inhalation every morning, albuterol/ipratropium hand-held nebulizer q4h prn SOB, fluticasone-salmeterol 500-50 mcg/dose disk with device 2 puffs bid, and albuterol-ipratropium MDI 2 puffs q4h prn SOB.
Upon arrival at the ED, CiCi received one dose of 125-mg IV methylprednisolone and q8h x 24h, ceftriaxone 1 g IV q24h and azithromycin 500 mg po q24h, levalbuterol 0.63 mg/3mL nebulizer and ipratropium 0.5-mg nebulizer x1 dose, and promethazine 25 mg IV x1.
With the initial treatment, CiCi's symptoms improved with 98% O2 saturation on 8 liters. During the course of hospitalization, she continued to receive taper IV steroids to oral prednisone, levalbuterol/ipratropium nebulizer, and guaifenesin ER 600 mg po bid. CiCi continues to improve with the current treatment regimen, and now her O2 saturation is 96% on 2 liters.
Prior to discharge, the doctor asked for your recommendations to help CiCi with her recurrent COPD exacerbation and frequent hospitalizations.
Amne Borghol, PharmD
Associate Professor of Clinical Pharmacy
Xavier University of Louisiana
New Orleans, Louisiana