Pulmonology Respiratory Follow-Up Note

I was pleased to see the patient in clinic on 15/10/2023. As you know, Robert is a pleasant 68-year-old male with chronic obstructive pulmonary disease (COPD) and obstructive sleep apnoea (OSA).

Respiratory Issues

Chronic Obstructive Pulmonary Disease (COPD) Presentation: Presented in 2019 with progressive exertional dyspnoea and a chronic productive morning cough over 2 years. Diagnosis: Confirmed via spirometry in 05/2019 showing post-bronchodilator FEV1/FVC of 0.58 and FEV1 62% predicted, alongside a 40-pack-year smoking history. Management:

• 05/2019: Initiated salbutamol (Ventolin®) 100 mcg INH PRN for acute symptom relief.
• 11/2020: Added tiotropium (Spiriva®) 18 mcg INH daily due to persistent exertional dyspnoea (mMRC 2).
• 02/2023: Transitioned to fluticasone furoate/umeclidinium/vilanterol (Trelegy Ellipta®) 100/62.5/25 mcg INH daily following two moderate acute exacerbations requiring oral corticosteroids within 12 months.

Obstructive Sleep Apnoea (OSA) Presentation: Presented in 2021 with daytime somnolence, non-restorative sleep, and witnessed apnoeas reported by his spouse. Diagnosis: Established via Level 1 polysomnography in 08/2021 demonstrating an Apnoea-Hypopnoea Index (AHI) of 28 events/hour with nadir SpO2 of 82%. Management:

• 09/2021: Initiated auto-titrating CPAP (6–14 cmH2O) to resolve nocturnal hypoxia and daytime fatigue.

Past Medical History

• Hypertension
• Type 2 diabetes mellitus (T2DM)
• Dyslipidaemia
• Laparoscopic cholecystectomy (2014)

Current Medications

• Fluticasone furoate/umeclidinium/vilanterol (Trelegy Ellipta®) 100/62.5/25 mcg INH daily
• Salbutamol (Ventolin®) 100 mcg INH 2 puffs q4h PRN
• Perindopril (Coversyl®) 8 mg PO daily
• Metformin (Glucophage®) 1,000 mg PO BID
• Rosuvastatin (Crestor®) 20 mg PO daily

Interval History

Robert attends today for routine follow-up of his COPD and OSA. Since switching to triple inhaler therapy in February, he reports no further acute exacerbations, emergency department visits, or antibiotic/steroid use. His baseline exertional dyspnoea occurs only when walking uphill or hurrying on level ground (mMRC 1). He notes a minimal morning cough productive of clear sputum. He denies chest pain, haemoptysis, orthopnoea, or paroxysmal nocturnal dyspnoea.

Regarding his OSA, he tolerates CPAP well, using it > 6 hours per night with good mask seal and resolution of daytime somnolence. Review of systems is otherwise negative for fevers, night sweats, or weight loss.

Social History

Ex-smoker, quit in 12/2020 (40-pack-year history); denies vaping or recreational drug use. Drinks 2–3 standard alcoholic beverages per week. Lives in a single-storey home with his supportive wife. Retired machinist.

Interval Investigation

• PFTs (10/10/2023): Post-bronchodilator FEV1 1.85 L (60% predicted), FVC 3.25 L (82% predicted), FEV1/FVC 0.57. TLC 115% predicted, RV 135% predicted, DLCO 55% predicted. Stable airflow obstruction and hyperinflation compared to 2022.
• Low-dose CT Thorax (01/10/2023): Moderate centrilobular emphysema. No pulmonary nodules, consolidations, or pleural effusions.
• Labs (01/10/2023): Hb 145 g/L, WBC 6.8 x 10^9/L, Eosinophils 0.3 x 10^9/L, Cr 82 µmol/L. CPAP download shows 92% usage > 4 hours/night, residual AHI 2.1 events/hour.

On Exam

• BP 128/76 mmHg, HR 74 bpm (regular), RR 16/min, SpO2 95% on room air, Temp 36.6 °C, BMI 28.4 kg/m2.
• Alert, NAD, speaking in full sentences. JVP not elevated, no peripheral oedema, no digital clubbing. Chest auscultation reveals diffusely decreased breath sounds bilaterally without wheezes, crackles, or rhonchi. Normal S1/S2, no murmurs.

Assessment

Robert is a pleasant 68-year-old gentleman whose severe COPD has stabilised significantly since escalating to single-inhaler triple therapy earlier this year. He has remained exacerbation-free with improved exercise tolerance, and his recent pulmonary function tests confirm stable lung mechanics. Furthermore, his severe OSA remains optimally controlled with excellent adherence to CPAP therapy, which is greatly benefiting his overall energy and quality of life. Given his positive clinical response and stability, no acute changes to his maintenance pharmacological regimen are required today.

Plan

• Continue fluticasone furoate/umeclidinium/vilanterol (Trelegy Ellipta®) 100/62.5/25 mcg INH daily and salbutamol (Ventolin®) 100 mcg INH PRN; continue CPAP at current settings.
• Refer to local pulmonary rehabilitation programme to optimise exercise capacity.
• Follow up in clinic in 6 months with repeat spirometry.
• Reviewed inhaler technique today (satisfactory) and reinforced his written COPD action plan for early recognition of exacerbations.
• Advised to receive annual influenza, updated COVID-19, and pneumococcal (Prevnar 20®) vaccinations via his primary care provider, and encouraged daily walking.