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'It never hurts to take a step back and think objectively'

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One of the potential risks of practising in a very specialist field is the tendency to see everything through the narrow spectrum of that specialty, or even a small aspect of that specialty.

As a respiratory nurse specialist, working primarily with people with advanced disease, there have been many times that I have wanted to put the brakes on a bit when assumptions are being made about a change in symptoms or a sudden deterioration in the status of a patient.

It may well be that all is related to the underlying lung complaint but it never hurts to just take a step back and think objectively before making that conclusion.

”it never hurts to just take a step back and think objectively before making conclusions”

I was reminded of this again recently when a lady attended my clinic for review six weeks after discharge from an acute hospital admission.

In her late 50s, she was a smoker who had presented to the A&E with worsening breathlessness and cough.

She gave a history of progressive breathlessness on exertion, persistent productive cough and frequent courses of antibiotics. She had no formal respiratory diagnosis prior to admission and had never had any inhaled therapy.

On admission, she was wheezy, hypoxic breathing room air and in compensated hypercapnic respiratory failure, with raised paCO2 and bicarbonate on arterial blood gas analysis.

She was treated with antibiotics, steroids, controlled oxygen therapy and nebulised bronchodilators.

After four days she was sufficiently recovered to be discharged home. Spirometry on discharge showed marked airflow obstruction with FEV1/FVC ratio of 60% and FEV1 of 37% predicted.

She was given a diagnosis of COPD and commenced on regular inhaled therapy of long acting muscarinic (LAMA), combination long-acting beta-agonist/inhaled corticosteroid (LABA/ICS) plus a short acting beta-agonist as required.

At her follow-up appointment her lung function tests were near normal with FEV1/FVC ratio of 75% and FEV1 of 85% predicted.

Detailed history revealed a long history of intermittent wheeze and breathlessness, often associated with exercise, change of temperature and seasons. She described a cough productive of white sticky sputum and reported frequently waking at night over the months leading up to the hospital admission.

She had a 40 pack a year smoking history and a BMI of 30. She was a housewife with a fairly sedentary lifestyle. She had no other medical history of note.

”After treatment she demonstrated a degree of reversibility that was surprising”

This patient certainly had a significant smoking history and at initial presentation described a picture not untypical for COPD/emphysema.

However, after treatment she demonstrated a degree of reversibility that was surprising. With no evidence of irreversible airflow obstruction it seemed likely that the primary diagnosis was in fact asthma, which had responded well to corticosteroids and regular inhaled therapy.

She probably also had an element of chronic bronchitis and her smoking habit put her at significant risk of developing fixed airflow obstruction in the future but the initial discharge working diagnosis was not proven.

”Breathlessness is multi factorial and diagnosis is not always clear initially”

Along with many people presenting as inpatients or in outpatient clinics, this lady had a number of factors which could have been responsible for her symptoms; breathlessness is multi factorial and diagnosis is not always clear initially.

We need to be sure to undertake careful clinical assessment and a comprehensive history to ensure we tease out the primary significant problem so that treatment and advice can be directed appropriately.

Sandra Olive, Respiratory Nurse Specialist


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