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‘Racism absolutely must not be tolerated’

STEVE FORD, EDITOR

• You are here: COPD

Diagnosis and management of COPD: a case study

04 May, 2020

This case study explains the symptoms, causes, pathophysiology, diagnosis and management of chronic obstructive pulmonary disease

This article uses a case study to discuss the symptoms, causes and management of chronic obstructive pulmonary disease, describing the patient’s associated pathophysiology. Diagnosis involves spirometry testing to measure the volume of air that can be exhaled; it is often performed after administering a short-acting beta-agonist. Management of chronic obstructive pulmonary disease involves lifestyle interventions – vaccinations, smoking cessation and pulmonary rehabilitation – pharmacological interventions and self-management.

Citation: Price D, Williams N (2020) Diagnosis and management of COPD: a case study. Nursing Times [online]; 116: 6, 36-38.

Authors: Debbie Price is lead practice nurse, Llandrindod Wells Medical Practice; Nikki Williams is associate professor of respiratory and sleep physiology, Swansea University.

• This article has been double-blind peer reviewed
• Scroll down to read the article or download a print-friendly PDF here (if the PDF fails to fully download please try again using a different browser)

Introduction

The term chronic obstructive pulmonary disease (COPD) is used to describe a number of conditions, including chronic bronchitis and emphysema. Although common, preventable and treatable, COPD was projected to become the third leading cause of death globally by 2020 (Lozano et al, 2012). In the UK in 2012, approximately 30,000 people died of COPD – 5.3% of the total number of deaths. By 2016, information published by the World Health Organization indicated that Lozano et al (2012)’s projection had already come true.

People with COPD experience persistent respiratory symptoms and airflow limitation that can be due to airway or alveolar abnormalities, caused by significant exposure to noxious particles or gases, commonly from tobacco smoking. The projected level of disease burden poses a major public-health challenge and primary care nurses can be pivotal in the early identification, assessment and management of COPD (Hooper et al, 2012).

Grace Parker (the patient’s name has been changed) attends a nurse-led COPD clinic for routine reviews. A widowed, 60-year-old, retired post office clerk, her main complaint is breathlessness after moderate exertion. She scored 3 on the modified Medical Research Council (mMRC) scale (Fletcher et al, 1959), indicating she is unable to walk more than 100 yards without stopping due to breathlessness. Ms Parker also has a cough that produces yellow sputum (particularly in the mornings) and an intermittent wheeze. Her symptoms have worsened over the last six months. She feels anxious leaving the house alone because of her breathlessness and reduced exercise tolerance, and scored 26 on the COPD Assessment Test (CAT, catestonline.org), indicating a high level of impact.

Ms Parker smokes 10 cigarettes a day and has a pack-year score of 29. She has not experienced any haemoptysis (coughing up blood) or chest pain, and her weight is stable; a body mass index of 40kg/m 2 means she is classified as obese. She has had three exacerbations of COPD in the previous 12 months, each managed in the community with antibiotics, steroids and salbutamol.

Ms Parker was diagnosed with COPD five years ago. Using Epstein et al’s (2008) guidelines, a nurse took a history from her, which provided 80% of the information needed for a COPD diagnosis; it was then confirmed following spirometry testing as per National Institute for Health and Care Excellence (2018) guidance.

The nurse used the Calgary-Cambridge consultation model, as it combines the pathological description of COPD with the patient’s subjective experience of the illness (Silverman et al, 2013). Effective communication skills are essential in building a trusting therapeutic relationship, as the quality of the relationship between Ms Parker and the nurse will have a direct impact on the effectiveness of clinical outcomes (Fawcett and Rhynas, 2012).

In a national clinical audit report, Baxter et al (2016) identified inaccurate history taking and inadequately performed spirometry as important factors in the inaccurate diagnosis of COPD on general practice COPD registers; only 52.1% of patients included in the report had received quality-assured spirometry.

Pathophysiology of COPD

Knowing the pathophysiology of COPD allowed the nurse to recognise and understand the physical symptoms and provide effective care (Mitchell, 2015). Continued exposure to tobacco smoke is the likely cause of the damage to Ms Parker’s small airways, causing her cough and increased sputum production. She could also have chronic inflammation, resulting in airway smooth-muscle contraction, sluggish ciliary movement, hypertrophy and hyperplasia of mucus-secreting goblet cells, as well as release of inflammatory mediators (Mitchell, 2015).

Ms Parker may also have emphysema, which leads to damaged parenchyma (alveoli and structures involved in gas exchange) and loss of alveolar attachments (elastic connective fibres). This causes gas trapping, dynamic hyperinflation, decreased expiratory flow rates and airway collapse, particularly during expiration (Kaufman, 2013). Ms Parker also displayed pursed-lip breathing; this is a technique used to lengthen the expiratory time and improve gaseous exchange, and is a sign of dynamic hyperinflation (Douglas et al, 2013).

In a healthy lung, the destruction and repair of alveolar tissue depends on proteases and antiproteases, mainly released by neutrophils and macrophages. Inhaling cigarette smoke disrupts the usually delicately balanced activity of these enzymes, resulting in the parenchymal damage and small airways (with a lumen of <2mm in diameter) airways disease that is characteristic of emphysema. The severity of parenchymal damage or small airways disease varies, with no pattern related to disease progression (Global Initiative for Chronic Obstructive Lung Disease, 2018).

Ms Parker also had a wheeze, heard through a stethoscope as a continuous whistling sound, which arises from turbulent airflow through constricted airway smooth muscle, a process noted by Mitchell (2015). The wheeze, her 29 pack-year score, exertional breathlessness, cough, sputum production and tiredness, and the findings from her physical examination, were consistent with a diagnosis of COPD (GOLD, 2018; NICE, 2018).

Spirometry is a tool used to identify airflow obstruction but does not identify the cause. Commonly measured parameters are:

• Forced expiratory volume – the volume of air that can be exhaled – in one second (FEV1), starting from a maximal inspiration (in litres);
• Forced vital capacity (FVC) – the total volume of air that can be forcibly exhaled – at timed intervals, starting from a maximal inspiration (in litres).

Calculating the FEV1 as a percentage of the FVC gives the forced expiratory ratio (FEV1/FVC). This provides an index of airflow obstruction; the lower the ratio, the greater the degree of obstruction. In the absence of respiratory disease, FEV1 should be ≥70% of FVC. An FEV1/FVC of <70% is commonly used to denote airflow obstruction (Moore, 2012).

As they are time dependent, FEV1 and FEV1/FVC are reduced in diseases that cause airways to narrow and expiration to slow. FVC, however, is not time dependent: with enough expiratory time, a person can usually exhale to their full FVC. Lung function parameters vary depending on age, height, gender and ethnicity, so the degree of FEV1 and FVC impairment is calculated by comparing a person’s recorded values with predicted values. A recorded value of >80% of the predicted value has been considered ‘normal’ for spirometry parameters but the lower limit of normal – equal to the fifth percentile of a healthy, non-smoking population – based on more robust statistical models is increasingly being used (Cooper et al, 2017).

A reversibility test involves performing spirometry before and after administering a short-acting beta-agonist (SABA) such as salbutamol; the test is used to distinguish between reversible and fixed airflow obstruction. For symptomatic asthma, airflow obstruction due to airway smooth-muscle contraction is reversible: administering a SABA results in smooth-muscle relaxation and improved airflow (Lumb, 2016). However, COPD is associated with fixed airflow obstruction, resulting from neutrophil-driven inflammatory changes, excess mucus secretion and disrupted alveolar attachments, as opposed to airway smooth-muscle contraction.

Administering a SABA for COPD does not usually produce bronchodilation to the extent seen in someone with asthma: a person with asthma may demonstrate significant improvement in FEV1 (of >400ml) after having a SABA, but this may not change in someone with COPD (NICE, 2018). However, a negative response does not rule out therapeutic benefit from long-term SABA use (Marín et al, 2014).

NICE (2018) and GOLD (2018) guidelines advocate performing spirometry after administering a bronchodilator to diagnose COPD. Both suggest a FEV1/FVC of <70% in a person with respiratory symptoms supports a diagnosis of COPD, and both grade the severity of the condition using the predicted FEV1. Ms Parker’s spirometry results showed an FEV1/FVC of 56% and a predicted FEV1 of 57%, with no significant improvement in these values with a reversibility test.

GOLD (2018) guidance is widely accepted and used internationally. However, it was developed by medical practitioners with a medicalised approach, so there is potential for a bias towards pharmacological management of COPD. NICE (2018) guidance may be more useful for practice nurses, as it was developed by a multidisciplinary team using evidence from systematic reviews or meta-analyses of randomised controlled trials, providing a holistic approach. NICE guidance may be outdated on publication, but regular reviews are performed and published online.

NHS England (2016) holds a national register of all health professionals certified in spirometry. It was set up to raise spirometry standards across the country.

Assessment and management

The goals of assessing and managing Ms Parker’s COPD are to:

• Review and determine the level of airflow obstruction;
• Assess the disease’s impact on her life;
• Risk assess future disease progression and exacerbations;
• Recommend pharmacological and therapeutic management.

GOLD’s (2018) ABCD assessment tool (Fig 1) grades COPD severity using spirometry results, number of exacerbations, CAT score and mMRC score, and can be used to support evidence-based pharmacological management of COPD.

When Ms Parker was diagnosed, her predicted FEV1 of 57% categorised her as GOLD grade 2, and her mMRC score, CAT score and exacerbation history placed her in group D. The mMRC scale only measures breathlessness, but the CAT also assesses the impact COPD has on her life, meaning consecutive CAT scores can be compared, providing valuable information for follow-up and management (Zhao, et al, 2014).

After assessing the level of disease burden,  Ms Parker was then provided with education for self-management and lifestyle interventions.

Lifestyle interventions

Smoking cessation.

Cessation of smoking alongside support and pharmacotherapy is the second-most cost-effective intervention for COPD, when compared with most other pharmacological interventions (BTS and PCRS UK, 2012). Smoking cessation:

• Slows the progression of COPD;
• Improves lung function;
• Improves survival rates;
• Reduces the risk of lung cancer;
• Reduces the risk of coronary heart disease risk (Qureshi et al, 2014).

Ms Parker accepted a referral to an All Wales Smoking Cessation Service adviser based at her GP surgery. The adviser used the internationally accepted ‘five As’ approach:

• Ask – record the number of cigarettes the individual smokes per day or week, and the year they started smoking;
• Advise – urge them to quit. Advice should be clear and personalised;
• Assess – determine their willingness and confidence to attempt to quit. Note the state of change;
• Assist – help them to quit. Provide behavioural support and recommend or prescribe pharmacological aids. If they are not ready to quit, promote motivation for a future attempt;
• Arrange – book a follow-up appointment within one week or, if appropriate, refer them to a specialist cessation service for intensive support. Document the intervention.

NICE (2013) guidance recommends that this be used at every opportunity. Stead et al (2016) suggested that a combination of counselling and pharmacotherapy have proven to be the most effective strategy.

Pulmonary rehabilitation

Ms Parker’s positive response to smoking cessation provided an ideal opportunity to offer her pulmonary rehabilitation (PR)  – as indicated by Johnson et al (2014), changing one behaviour significantly increases a person’s chance of changing another.

PR – a supervised programme including exercise training, health education and breathing techniques – is an evidence-based, comprehensive, multidisciplinary intervention that:

• Improves exercise tolerance;
• Reduces dyspnoea;
• Promotes weight loss (Bolton et al, 2013).

These improvements often lead to an improved quality of life (Sciriha et al, 2015).

Most relevant for Ms Parker, PR has been shown to reduce anxiety and depression, which are linked to an increased risk of exacerbations and poorer health status (Miller and Davenport, 2015). People most at risk of future exacerbations are those who already experience them (Agusti et al, 2010), as in Ms Parker’s case. Patients who have frequent exacerbations have a lower quality of life, quicker progression of disease, reduced mobility and more-rapid decline in lung function than those who do not (Donaldson et al, 2002).

“COPD is a major public-health challenge; nurses can be pivotal in early identification, assessment and management”

Pharmacological interventions

Ms Parker has been prescribed inhaled salbutamol as required; this is a SABA that mediates the increase of cyclic adenosine monophosphate in airway smooth-muscle cells, leading to muscle relaxation and bronchodilation. SABAs facilitate lung emptying by dilatating the small airways, reversing dynamic hyperinflation of the lungs (Thomas et al, 2013). Ms Parker also uses a long-acting muscarinic antagonist (LAMA) inhaler, which works by blocking the bronchoconstrictor effects of acetylcholine on M3 muscarinic receptors in airway smooth muscle; release of acetylcholine by the parasympathetic nerves in the airways results in increased airway tone with reduced diameter.

At a routine review, Ms Parker admitted to only using the SABA and LAMA inhalers, despite also being prescribed a combined inhaled corticosteroid and long-acting beta 2 -agonist (ICS/LABA) inhaler. She was unaware that ICS/LABA inhalers are preferred over SABA inhalers, as they:

• Last for 12 hours;
• Improve the symptoms of breathlessness;
• Increase exercise tolerance;
• Can reduce the frequency of exacerbations (Agusti et al, 2010).

However, moderate-quality evidence shows that ICS/LABA combinations, particularly fluticasone, cause an increased risk of pneumonia (Suissa et al, 2013; Nannini et al, 2007). Inhaler choice should, therefore, be individualised, based on symptoms, delivery technique, patient education and compliance.

It is essential to teach and assess inhaler technique at every review (NICE, 2011). Ms Parker uses both a metered-dose inhaler and a dry-powder inhaler; an in-check device is used to assess her inspiratory effort, as different inhaler types require different inhalation speeds. Braido et al (2016) estimated that 50% of patients have poor inhaler technique, which may be due to health professionals lacking the confidence and capability to teach and assess their use.

Patients may also not have the dexterity, capacity to learn or vision required to use the inhaler. Online resources are available from, for example, RightBreathe (rightbreathe.com), British Lung Foundation (blf.org.uk). Ms Parker’s adherence could be improved through once-daily inhalers, as indicated by results from a study by Lipson et al (2017). Any change in her inhaler would be monitored as per local policy.

Vaccinations

Ms Parker keeps up to date with her seasonal influenza and pneumococcus vaccinations. This is in line with the low-cost, highest-benefit strategy identified by the British Thoracic Society and Primary Care Respiratory Society UK’s (2012) study, which was conducted to inform interventions for patients with COPD and their relative quality-adjusted life years. Influenza vaccinations have been shown to decrease the risk of lower respiratory tract infections and concurrent COPD exacerbations (Walters et al, 2017; Department of Health, 2011; Poole et al, 2006).

Self-management

Ms Parker was given a self-management plan that included:

• Information on how to monitor her symptoms;
• A rescue pack of antibiotics, steroids and salbutamol;
• A traffic-light system demonstrating when, and how, to commence treatment or seek medical help.

Self-management plans and rescue packs have been shown to reduce symptoms of an exacerbation (Baxter et al, 2016), allowing patients to be cared for in the community rather than in a hospital setting and increasing patient satisfaction (Fletcher and Dahl, 2013).

Improving Ms Parker’s adherence to once-daily inhalers and supporting her to self-manage and make the necessary lifestyle changes, should improve her symptoms and result in fewer exacerbations.

The earlier a diagnosis of COPD is made, the greater the chances of reducing lung damage through interventions such as smoking cessation, lifestyle modifications and treatment, if required (Price et al, 2011).

• Chronic obstructive pulmonary disease is a progressive respiratory condition, projected to become the third leading cause of death globally
• Diagnosis involves taking a patient history and performing spirometry testing
• Spirometry identifies airflow obstruction by measuring the volume of air that can be exhaled
• Chronic obstructive pulmonary disease is managed with lifestyle and pharmacological interventions, as well as self-management

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Major Case Study: COPD

Mar 14, 2019

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Major Case Study: COPD. Emily Brantley Dietetic Intern Andrews University. Patient’s Initials: NM Primary Problem &amp; other medical conditions: COPD , DM, IBS, Pneumonia, IgA deficiency Height: 160.02 Weight: 107.2 Age: 62 years old Sex: Female. Introduction. Introduction.

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Major Case Study: COPD Emily Brantley Dietetic Intern Andrews University

Patient’s Initials: NM Primary Problem & other medical conditions: COPD, DM, IBS, Pneumonia, IgA deficiency Height: 160.02 Weight: 107.2 Age: 62 years old Sex: Female Introduction

Introduction • Reason patient was chosen for case study: • NM was chosen because of the multiple complications that she faces. • Date the study began and ended • December 5, 2013 – December 6, 2013 • Focus of this study: • Chronic Obstructive Pulmonary Disease (COPD) • NM has other comorbidities, however, NM is most often admitted to the hospital for exacerbation of COPD.

Social History • NM is a Christian woman who lives at home with her husband and pet parakeet. • She is currently on Medicare. • Retired RN. • Her three children are all adults and live within the region. • NM is a former smoker • Medical records indicate that she does not smoke or drink alcohol anymore.

Normal Anatomy and Physiology of Applicable Body Functions • COPD is characterized by slow, progressive obstruction of the airways. • There are two physical conditions that make up COPD. • Emphysema • Characterized by abnormal, permanent enlargement and destruction of the alveoli • Chronic Bronchitis • A progressive cough with inflammation of bronchi and other lung changes • Frequently, both illnesses coexist as part of this disorder. • In both cases, the disease limits the airflow 1&2

Past Medical History

Past Medical History • NM initially received the diagnosis of COPD in 1997. • American Thoracic Society states comorbidities such as cardiac disease, diabetes mellitus, hypertension, and psychological disorders are commonly reported in patients with COPD, but with great variability in reported prevalence.

Past Medical History • Pneumonia • NM has been hospitalized six times within the past year for episodes of pneumonia. • COPD is more frequently associated with pneumonia. • Corticosteroids are standard of care for acute exacerbations of COPD, but their role in the management of patients with COPD with pneumonia is less defined. 3 • Diabetes Mellitus. • The evidence for an interaction between diabetes and COPD is supported by studies that demonstrate reduced lung function as a risk factor for the development of diabetes. • Smoking has been established as a risk factor for both COPD and Diabetes Mellitus. 3 • Gastro-esophageal reflux disease (GERD). • An increased prevalence of GERD has been reported in patients with COPD. A study of 421 patients with severe COPD using 24-hour esophageal pH monitoring showed that 62% had pathological GERD, and 58% of the patients reported no symptoms of GERD.3

Past Medical History • Bronchial Asthma • Adrenal Insufficiency • Coronary Artery Disease • Trachaeomalacia • Addison’s disease • Hypothyroidism • Bipolar Disorder • Irritable Bowel syndrome • Vascular stent placement • Hyperlipidemia • Hyperthyroidism • Anemia

Present Medical Status and Treatment

Theoretical Discussion of Disease Condition • COPD is the fourth leading cause of death in America. COPD is also more prevalent in women.3&4 • The primary risk factor in the development of COPD is smoking. • Beyond the cessation of smoking, it has been shown that the inflammatory stress continues to damage the lung tissue. • Other risk factors include air pollution, secondhand smoke, history of childhood infections, and occupational exposure to certain industrial pollutants.

Theoretical Discussion of Disease Condition • Although normal lung function gradually declines with age, individuals who are smokers have a more rapid decline—twice the rate of nonsmokers. • Low body weight has also been shown to be a risk factor for the development of COPD even after adjusting for other potential risk factors including smoking and age.2 • Malnourished patients with COPD experience worsened respiratory muscle strength, decreased ventilator drive and response to hypoxia, and altered immune function.1,5&6

Usual Treatment of the Condition • An early and accurate diagnosis of COPD is the key to treatment. • Quitting smoking is the single most important thing that can be done to help treat COPD.7 • The usual treatment of COPD is composed of four main goals for effective management: • 1. Assess and monitor the disease • 2. Reduce risk factors • 3. Maintain stable COPD and respiratory status • 4. Manage any exacerbations • Once the disease progresses, rehabilitation programs along with oxygen therapy are used as treatment. • Medications include bronchodilators, glucocorticosteroids, mucolytic agents, and antibiotics to treat infections. • In cases where COPD may be advanced, there is an option for surgical intervention, such as a lung transplant.1

Patient’s Symptoms upon Admission Leading to Present Diagnosis • NM was admitted with shortness of breath, cough, diarrhea, hypokalemia and fever. • She revealed that one of the possible causes of her diarrhea may be the fact that she had “been around a couple of people with Clostridium Difficile.” • NM also showed symptoms of hyperlipidemia and hypertension • High blood pressure is a complication of COPD.6 • Hyperglycemia is a side effect of steroid therapy for COPD. • Steroids can increase the blood sugar making diabetes harder to control.8

Laboratory Findings and Interpretation

Current Medications • Depakote ER (Valproic Acid) • Lexapro (Escitaloprem) • Florinef (Fludrocortison Acitate) • Fluticasone- salmeterol • Metronidazole Flagyl • Insulin Lispro (Humalog) • Misoprostal (Cytotec) • Monelukast (Singulair) • Pantaprazole (Protonix oral) • Potassium Chloride • RisperiDONE (RisperDAL) • Rosuvastatin (Crestor) • NaCl • Tolterodine • Voriconazole

Observable Physical and Psychological Changes in Patient • NM physically looked well nourished. • She did not appear to have difficulty breathing until after she spoke for a long period of time. • She did have a severe cough that she tried to conceal. • NM was a very agreeable patient for both psychological interviews. • In spite of her COPD diagnosis and all of the multiple medical comorbidities that NM faced, she still presented a positive attitude and spoke openly about her faith.

Treatment • NM received a chest x ray that revealed consolidation in the left lung and midline lung level. • Once this was identified, she was admitted to the hospital from the Emergency room for treatment. • She was started on IV steroids, IV antibiotics, flagyl and nebulizers around the clock to see how she progressed.

Medical Nutrition Therapy

Nutrition History • Beginning in March 2012, NM began intentionally losing weight by following a PCP prescribed commercial diet known as Optifast. • Optifast offers shakes, protein bars and soups. • With this regimen, NM has lost 70 pounds since March 2012. • At home, NM usually sticks to her Optifast food items for breakfast, lunch and snacks between meals. • For dinner, she shares a meal with her husband. • He is a professional chef who is control of purchasing groceries and prepares dinner most nights.

Analysis of Previous Diet: 24 hour recall

Current Prescribed Diet • NM was on steroid therapy to treat her COPD. • Because of the steroid therapy, NM was admitted with consistently high blood glucose levels. • For this reason, doctor’s orders were given for an Average Diabetic Diet for the duration of her stay at Winter Park Memorial Hospital. • An Average Diabetic Diet provides a consistent 60-75 grams of carbohydrates for each meal. • NM’s diet order remained the same for her entire stay.

Objectives of Dietary Treatment • The objective of the Average Diabetic diet is to maintain NM’s blood sugars within normal limits or as close as possible to normal levels. • Steroid therapy that NM was undergoing to treat her COPD helps keep blood sugars high • Finger-stick blood sugar levels referred to as “Accuchecks” ranged inconsistently from 130 to 289 as seen on the lab values table above.

Patient’s Physical and Psychological Response to Diet • At home, NM followed an eating pattern similar to that of the Average Diabetic Diet but with the addition of snacks in between meals. • She denied facing vomiting or constipation while on this diet. • She did admit to experiencing diarrhea and nausea upon admission to the hospital. • As previously mentioned, NM believed she was exposed to Clostridium Difficile, to which she attributes to the cause of having diarrhea.

List nutrition-related problems with supporting evidence • COPD: Increased energy expenditure related to increased energy requirements during COPD exacerbation as evidenced by measured resting energy expenditure greater than predicted needs.

Evaluation of Present Nutritional Status • According to the diet analysis table, NM was meeting her increased caloric needs for COPD. • Her diarrhea subsided by day two of hospitalization. • Per lab values as those noted above in the table, there did not appear to be any indication of dehydration.

Calorie and Protein Guidelines • Nutritional needs are often increased in COPD due to the increased work of breathing. • Optimal nutritional status plays an important role in maintaining the integrity of the respiratory system and in allowing maximal participation in daily living.1 • Caloric requirements for COPD individually determined based on: • Patient age, weight and gender, the extent of protein energy malnutrition loss of lean body mass, current medications and other acute or chronic medical conditions. • The Mifflin St. Jeor equation may underestimate the caloric requirements of patient’s with COPD because of the caloric increase from metabolically active tissue. • To compensate for this underestimation, a stress activity factor may be added according to the degree of stress. • In most cases the total calorie intake of the COPD patient is more important than the source from calories.

Calorie and Protein Guidelines • For maintenance 1.33 x REE or 25/35 calories per kilogram is appropriate for the needs of the COPD patient. • Protein is recommended at 1.0-1.5 grams per kilogram of body weight for maintenance.1 • Below is a chart of how NM’s needs were clinically calculated during her hospital admission on December 5th through the 6th.

Need for Alternative Feeding Methods and the Patient’s Nutrition Education Process • NM was in fact meeting the additional needs required for COPD, I do not believe that there was any need for alternative feedings such as tube feeding. • Moreover, in explaining the prescribed diabetic diet to NM, no type of barrier to learning was identified.

Prognosis • NM expressed her motivation to continue to follow a diet similar to that of the Average Diabetic Diet upon her return home as long as her increased COPD needs were met. • She was aware of the effects of steroid therapy on her blood sugar levels. • NM clearly verbalized her understanding on the use of steroids, their effects on increasing blood sugar levels and the importance of meal planning especially around carbohydrates. • This was more of a motivating factor for her to continue monitoring her diet on discharge.

Summary • From this study, I learned how very serious COPD is. • It was once explained to me some time ago that COPD was like a gradual suffocating in a pillow. • Seeing NM experiencing shortness of breath during the interviews or when speaking to me during the interviews made me realize that even the slightest amount of energy requires oxygen. • Imagine not being able to breathe to conduct the simplest activities of daily living! • In addition to other medical issues as NM had, it made me realize how important nutrition energy is needed for healing.

Thank You!

References • Mahan LK, Escott-Stump S, Raymond JL. Krause’s Food, Nutrition and Diet Therapy, 13th Edition, Philadelphia, Pa: Elsevier; 2012 • Nelms M, Sucher KP, Lacey K, Roth SL. Nutrition Therapy and Pathophysiology, 2nd Edition. Cengage Learning, Inc: 2010. • Chatila WM, Thomashow BM, Make BJ. Comorbidities in Chronic Obstructive Pulmonary Disease. Journal of the American Thoracic Society. 2008 May 1; 5(4): 549-555 • Centers for Disease Control. Chronic Obstructive Pulmonary Disease (COPD) Data and Statistics. Available at: http://www.cdc.gov/copd/data.htm. Accessed December 29, 2013. • American Society for Parenteral and Enteral Nutrition. Disease-Related Malnutrition and Enteral Nutrition Therapy. Available at: http://www.nutritioncare.org/index.aspx?id=5696. Accessed January 5, 2014. • Mayo Clinic. Disease and Conditions: COPD. Available at: http://www.mayoclinic.org/diseases-conditions/seo/basics/symptoms/con-20032017. Accessed January 8, 2014. • National Institutes of Health: National Heart Lung and Blood Institute. How Is COPD Treated? Available at: http://www.nhlbi.nih.gov/health/health-topics/topics/copd/treatment.html. Accessed January 8, 2014. • British Lung Foundation. Steroids. Available at: http://www.blf.org.uk/Page/Steroids. Accessed December 29, 2013. • MedlinePlus: A service of the U.S. National Library of Medicine From the National Institutes of Health National Institutes of Health. Drugs and Supplements. Available at: http://www.nlm.nih.gov/medlineplus/druginfo/drug_Ca.html • U.S. National Library of Medicine. Drug Information from the National Library of Medicine. Available at: https://www.nlm.nih.gov/learn-about-drugs.html. Accessed January 8, 2014. • Optifast. Product Information. Available at: http://www.optifast.com/Pages/index.aspx. Accessed January 7, 2014

References: Images • http://sciencelife.uchospitals.edu/2013/05/07/qa-dr-christopher-wigfield-on-the-future-of-lung-transplantation/ • http://www.guidantwealth.com/Goal-early-retirement.html • http://www.recessionista.com • http://www.everydayhealth.com • https://www.spiriva.com/?sc=SPRACQWEBPGOGBS1105034&utm_source=google&utm_medium=cpc&utm_term=spiriva&utm_campaign=Branded&MTD=2&ENG=1 • http://www.nlm.nih.gov/medlineplus/ency/imagepages/19376.htm • http://www.cdc.gov/copd/data.htm • http://www.www.kingcounty.gov • http://www.www.anactivelife.com • http://www.optifast.com/Pages/index.aspx • www.fairmed.at • www. Eatright.org • http://www.alltheweigh.com

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