Respiratory Clinic

Respiratory Problems

• Chronic obstructive pulmonary disease (COPD) - GOLD stage 2
• Bronchiectasis
• Ex-smoker (40 pack-year history, quit in 2019)

Other Medical Problems

• Myasthenia gravis (diagnosed 2021, stable on maintenance therapy)
• Hypertension
• Laparoscopic cholecystectomy (2015)
• BMI 28.4 kg/m²

Medications

• Beclometasone dipropionate/formoterol fumarate/glycopyrronium bromide (Trimbow®) 100/6/10 mcg 2 puffs INH BID, salbutamol (Ventolin®) 100 mcg 2 puffs INH PRN, pyridostigmine (Mestinon®) 60 mg PO TID, amlodipine 5 mg PO OD, colecalciferol 800 IU PO OD
• Allergies: Penicillin (widespread maculopapular rash), doxycycline (severe GI upset)

Investigations

• CT Thorax 12/01/2025: Moderate centrilobular emphysema and mild cylindrical bronchiectasis in the right lower lobe; no suspicious pulmonary nodules or thymic mass.
• Lung Function Tests 18/02/2025: FEV1 1.65 L (58% predicted), FVC 2.95 L (82% predicted), FEV1/FVC ratio 0.56, DLCO 62% predicted, KCO 75% predicted, RV 135% predicted.
• STANDARD SPUTUM
  • 02/02/2025: Moderate growth of Haemophilus influenzae (resistant to amoxicillin, sensitive to clarithromycin).
  • 15/11/2024: Normal respiratory flora.
• MYCOBACTERIAL SPUTUM
  • 02/02/2025: AFB smear negative, culture negative at 6 weeks.
• Venous Bloods 18/02/2025: FBC normal, eosinophils 0.4 x 10^9/L, CRP 8 mg/L, alpha-1 antitrypsin level normal.

Discussion Today

• Recap of background
  • Reviewed ongoing exertional dyspnoea and recent infective exacerbations following the initial respiratory assessment six months ago, ensuring respiratory management remains safe alongside concurrent myasthenia gravis.
• Progressive SOB over the past 4 months, currently MRC dyspnoea scale grade 3. Three infective exacerbations over the past year requiring oral steroids and antibiotics. Daily productive cough yielding 1 tablespoon of mucopurulent sputum, predominantly in the mornings.
• Symptoms worsen in cold weather and on incline walking. Relieved partially by rest and salbutamol (Ventolin®) use. Attempted OTC steam inhalation with minimal benefit.
• Struggling with heavy gardening and carrying shopping upstairs; retired, lives in a two-storey house with spouse.
• Intermittent wheeze. Denies haemoptysis, chest pain, weight loss, night sweats, bulbar weakness, or ptosis.
• Ex-smoker, consumes 4 units of alcohol per week, retired carpenter with historical wood dust exposure, maternal father had emphysema, no pets at home.
• HR 76 bpm, BP 132/78 mmHg, SpO2 94% on room air, Temp 36.6 °C.
• Respiratory: Chest clear to auscultation bilaterally with prolonged expiratory phase, no coarse crackles or focal wheeze. Cardiovascular: HS I+II+0, JVP not elevated, no peripheral oedema. Neurological: Normal speech volume, no fatigable ptosis or proximal limb weakness today.
• Discussed inhaler technique and airway clearance strategies. Advised to rinse the mouth after steroid inhaler use to prevent thrush, obtain necessary vaccines (annual influenza and pneumococcal) from the GP to prevent respiratory disease, use a rescue pack appropriately (noting to avoid fluoroquinolones and macrolides where possible due to myasthenia gravis risk, though short-course clarithromycin was tolerated previously, co-trimoxazole is preferred), and undertake pulmonary rehabilitation.

Impression

• Suboptimally controlled COPD and mild right lower lobe bronchiectasis with frequent exacerbations
• Stable myasthenia gravis with no evidence of neuromuscular respiratory weakness on recent spirometry

Management Plan

• Repeat spirometry with maximal inspiratory/expiratory pressures (MIP/MEP) in 6 months
• Commence carbocisteine 375 mg 2 capsules PO TID to aid sputum clearance
• Referral to respiratory physiotherapy for Acapella device training and pulmonary rehabilitation; follow-up in Respiratory Clinic in 6 months

Actions for GP

• Please issue a prescription for carbocisteine 375 mg 2 capsules PO TID.
• Please provide a COPD rescue pack consisting of prednisolone 30 mg PO OD for 5 days and co-trimoxazole 960 mg PO BID for 5 days (avoiding ciprofloxacin and aminoglycosides due to myasthenia gravis).
• Please ensure annual influenza and pneumococcal vaccinations are up to date.

Patient Summary, Key Takeaways, Next Steps

• Start your new mucus-thinning medication (carbocisteine) as prescribed by your GP, attend your upcoming respiratory physiotherapy and pulmonary rehabilitation appointments, and return to this clinic in 6 months after completing your repeat breathing tests.
• Continue complete smoking cessation, practice daily chest clearance exercises, and pace your physical activities at home.
• Rinse your mouth with water and spit it out after using your Trimbow inhaler to prevent mouth infections. If your breathing suddenly worsens, your sputum becomes darker or increases in volume, or you develop a fever, start your rescue pack and contact your GP. Seek urgent medical attention if you experience severe difficulty breathing, chest pain, or any new muscle weakness or swallowing difficulties.