Clinical scenario
A 55 year-old cleaner attends for the third time this year with an exacerbation of her COPD. She has an increased cough, productive of clear sputum and breathlessness, with scattered rhonchi in the chest and an oxygen saturation level of 96%. She knows from experience that it will be at least 10 days before she is back to normal, and requests a medical certificate to be absent from work. She normally recovers well, and although she is always breathless on more strenuous exercise, she is not otherwise troubled by her symptoms which are eased sufficiently by her short-acting β2-agonist. She therefore stopped the inhaled corticosteroid/long-acting β2-agonist (ICS/LABA) prescribed after a previous exacerbation. Spirometry last year showed an FEV1/FVC ratio of 0.58 and a post-bronchodilator FEV1 of 47% predicted. She still smokes about 15 cigarettes a day.