1. History Taking Zinc code: UKACL1878ea Date of preparation May 2015 AstraZeneca provided funding & reviewed for technical accuracy

2. Natalia

3. Case study 1 - Natalia Natalia age 53yrs Occupation –manager of a Deli Very light smoking history stopped 30yrs ago Asthma & rhinitis since childhood FH of asthma (mother & brother) Current treatment – Short-acting inhaled beta 2 agonist (SABA) via a metered dose inhaler (MDI) 4-5 times/day

4. Natalia Previous management of her asthma : Frequent exacerbations Has been nebulised and given oral steroids on many occasions Hospitalised with acute asthma in pregnancy Has been prescribed preventative therapy but didn’t take it regularly- didn’t think it worked Symptoms have become progressively worse over time, little variability

5. Natalia A full medical & social history was taken Pre & post bronchodilator spirometry was performed by the Practice Nurse Results indicated some reversibility but not to normal, indicating that although Natalia still had asthma she now had some irreversible airways disease due to the chronicity and poor management of her asthma

6. Natalia Needs both asthma and fixed airways disease treated Commenced on a Long-acting beta 2 agonist (LABA) + Inhaled corticosteroid (ICS) combination product Options?

7. George

8. Case study 2- George George is 50yrs old Married Occupation – retired plumber Smoking history - Smoked since he was 16, has reduced from 40 to 25 cigarettes/day quite recently Patient’s Medical History - Nothing of note Current medical history/co-morbidities such as hypertension & hypercholesterolaemia

9. George The Practice Nurse performs George’s hypertension review In view of George’s significant smoking history and symptoms she arranges for him to come back for spirometry testing In the meantime she suggests that George make an appointment with the GP to arrange referral for a chest Xray

10. George Post-bronchodilator spirometry has confirmed the diagnosis of moderate airflow obstruction which along with his symptoms confirms a diagnosis of COPD. His COPD assessment test (CAT) score is 15 indicating his symptoms are having a moderate impact on his life Medical Research Council (MRC) score of 1 He needs to have appropriate therapy including smoking cessation

11. George At the very least George will need a SABA Discuss device options In view of his moderate impairment in lung function and his CAT score indicating disability What other treatment options may he benefit from? Possibly Long-acting Muscarinic Antagonist (LAMA) or LABA? Discuss device options

12. Bert

13. Case study 3 - Bert Bert is 64yrs old Retired at 59yrs from the shipyards where he had been a fitter Lives with wife in a 3 rd floor flat Ex-smoker - stopped recently, significant smoking pack history Family History – nothing of note Patient’s Medical History - nothing of note

14. Case study 3 - Bert Full medical & social history taken –discuss what this should entail Post bronchodilator spirometry indicates basically normal lung function What does this mean? How would you proceed?

15. Maggie

16. Case study 4 - Maggie Maggie age 60yrs Retired 4 yrs ago Gave up smoking when she retired as she couldn’t afford them any more Divorced, lives alone Says she was diagnosed with COPD 5yrs ago Attends the surgery for her annual COPD review

17. Maggie Current history indicates that Maggie is having an acute exacerbation of her COPD What questions would you ask to ascertain this? What features would she present with? What would be your next steps and why?

18. Maggie Maggie is treated with antibiotics & steroids She is advised to increase her use of SABA to the maximum number of puffs via her spacer Eat little and often Increase her fluid intake Keep warm & stay indoors until she feels better Contact the surgery if there is no improvement in her symptoms

19. Maggie When she has recovered her post bronchodilator spirometry shows she has severe disease as indicated by a Forced Expiratory Volume in one second (FEV 1 ) 32% predicted She still has a bit of ankle swelling She is currently taking LABA + ICS combination via a DPI and SABA at least 4 times a day, usually more She is still feeling down What would be your next steps & why?

20. Maggie Maggie needs to be formally assessed for depression and treated accordingly She also needs her treatment optimised Currently she is taking a combination LABA + ICS and a SABA Addition of a LAMA is recommended If sputum is an issue an anti-mucolytic may be useful Non-pharmacological interventions such as referral to pulmonary rehab

21. Thank you for your attention