From the Guidelines
Scott should take his controller medications as prescribed: Symbicort 2 puffs twice daily and Spiriva 1 capsule daily, rather than using them inconsistently, to improve his respiratory condition and reduce symptoms of emphysema. His concerns about "inhaling dust" with Spiriva should be addressed by explaining that the medication is a fine powder designed to reach deep into the lungs and improve breathing 1.
Key Points to Consider
- His symptoms of dyspnea with minimal exertion, difficulty with activities of daily living, orthopnea (sleeping sitting up), and yellow sputum production suggest poorly controlled emphysema and possible respiratory infection.
- He should be evaluated for a potential respiratory infection given the yellow sputum.
- While he quit cigarette smoking 7 years ago, he should also discontinue marijuana use as it can further irritate his lungs.
- His albuterol use (20 times weekly) indicates poor disease control, and proper use of controller medications would likely reduce his need for rescue inhalers.
- His methadone treatment (130 mg daily) for opioid use disorder should continue under Dr. Zuckerman's supervision, but respiratory depression from methadone should be monitored given his compromised lung function 1.
Recommendations for Management
- Continue methadone treatment for opioid use disorder under supervision.
- Monitor for respiratory depression due to methadone.
- Evaluate for potential respiratory infection.
- Discontinue marijuana use to avoid further lung irritation.
- Proper use of controller medications to reduce need for rescue inhalers.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Patient Profile
- Scott is a 54-year-old male with a history of emphysema and opiate use disorder.
- He presents with symptoms of shortness of breath, increased sputum production, and difficulty performing daily activities.
- He has a history of smoking, but quit 7 years ago.
Medication Adherence
- Scott is prescribed Symbicort (budesonide/formoterol) 2 puffs BID daily, but reports occasional use.
- He is also prescribed Spiriva (tiotropium) 1 capsule daily, but is not adherent due to concerns about inhaling dust into his lungs.
- He uses albuterol daily, approximately 20 times per week.
Treatment Options
- Studies have shown that triple therapy with budesonide/formoterol/tiotropium can improve lung function and reduce exacerbation rates in patients with COPD 2, 3.
- The combination of budesonide/formoterol has been shown to be effective in reducing COPD exacerbations and improving health outcomes compared to tiotropium alone 4.
- A systematic literature review and network meta-analysis found that budesonide/glycopyrronium/formoterol fumarate had comparable efficacy to other triple combination therapies in reducing exacerbation rates and improving lung function in patients with moderate-to-very-severe COPD 5.
Respiratory Assessment
- A physical examination of the chest should be conducted as part of a comprehensive respiratory assessment, including inspection, palpation, percussion, and auscultation 6.
- Nurses should have adequate knowledge and practical skills to undertake these assessments and provide appropriate care for patients with respiratory conditions.