Case study 1

David is a 58-year-old male who smokes regularly and has been feeling progressively unwell for
about a week. He often feels short of breath and often stops to ‘catch up’ his breathing when
walking. He wheezes frequently. He has had a worsening cough and has been producing
yellow/green sputum. He also mentions that he coughs almost every morning and this has been
developing over the past 4 years. John also experiences tremors.

He is currently prescribed salbutamol (100 micrograms up to 4 times a day) and beclomethasone

(400 micrograms twice-daily).

1) What condition is David likely to be experiencing?

2) What issues can be identified with his current therapy?
3) Why might John be experiencing tremors?

John undergoes a spirometry test. His forced expiratory volume (1 second) (FEV1) is 1.95, forced vital
capacity (FVC) is 3.95 and FEV1/FVC is 49 %. FEV1 is 62 % of predicted.

4
Volume (L)

0
0 1 2 3 4 5 6 7
Time (s)

4) What does the FEV1/FVC measurement refer to?

5) How would the FEV1/FVC ratio differ between obstructive and restrictive respiratory
disease? What does David’s FEV1/FVC ratio indicate?
6) How does the pathophysiology of David’s disease explain his signs and symptoms?
7) How should David’s disease be managed?
Case study 1 answers

1) COPD – dyspnoea, must catch his breath when walking, wheezing, productive cough with
yellow/green sputum, cough in the morning, progressively worsening over 4 years.
MRC dyspnoea scale – Grade 3/5 Walks slower than contemporaries on level ground
because of breathlessness, or must stop for breath when walking at own pace
2) This is pharmacological treatment for asthma.
3) Salbutamol-induced tremor
4) The proportion of the vital capacity that can be expired within one breath.
5) In obstructive disease the FEV1/FVC ratio is decreased because of an obstruction to air
escaping the lungs.
In restrictive disease the FEV1/FVC ratio remains broadly similar.
NICE guidelines link to GLI 2012 reference values
6) Emphysema is a disease of the alveoli. The fibers that make up the walls of the alveoli
become damaged. The damage makes them less elastic and unable to recoil when you
exhale, making it hard to exhale carbon dioxide out of the lungs.

If the lung airways become inflamed, this results in bronchitis with subsequent mucus
production.

One of the reasons breathing becomes more challenging is because the lungs produce more
mucus and the bronchioles become inflamed and narrower as a result.

With more mucus in your airways, less oxygen is being inhaled. This means less oxygen
reaches the capillaries for gas exchange in your lungs. Less carbon dioxide is also being
exhaled. Coughing to try to help release the mucus from the lungs is a common sign of
COPD.

7) Encouragement to stop smoking and offering help to do so.

Long-acting-