A 64-year-old woman comes to the office for follow-up. She was diagnosed with chronic obstructive pulmonary disease (COPD) 4 years ago. She initially used albuterol as needed but was started on daily tiotropium a year ago. The patient reports a mild cough and shortness of breath with exertion, which somewhat limits her daily activities. She has no dyspnea or chest pain at rest. She had 3 COPD exacerbations last year but has never been hospitalized, and she has never undergone endotracheal intubation. The patient quit smoking when she was diagnosed with COPD. She received both pneumococcal and annual influenza vaccinations. Her other medical problems include osteoarthritis of the knees and hypertension.
Vital signs are normal. Oxygen saturation at rest is 95% on room air but 90% on room air after a 6-minute walk. BMI is 29 kg/m². Examination reveals decreased breath sounds bilaterally with no wheezing or crackles. There is no jugular venous distension or peripheral edema.
Pulmonary function testing reveals an FEV1/FVC ratio of 62% and an FEV1 55% of predicted. Chest x-ray shows mild hyperinflation but no infiltrates.
Which of the following is the most appropriate next step in management of this patient?

Question

Quizplus · Accepted Answer

11ec193a_98cf_6971_853d_07764665ec7d_MD0002_00 The Global Initiative for chronic obstructive pulmonary disease (COPD) provides disease categorization primarily based on symptom burden and risk of exacerbation. Airflow limitation, determined by FEV₁, is also considered but plays a smaller role due to poor correlation with symptoms and quality of life. Symptom burden can be calculated using questionnaires such as the COPD Assessment Test, and risk of exacerbation is determined based on the number and severity of exacerbations in the past year. Patients are categorized into groups A-D based on symptoms and risk of exacerbation and also graded 1-4 based on FEV1 values. Pulmonary rehabilitation is a key component of the management plan for patients in groups B-D (regardless of FEV1 grade). Based solely on this patient's increased risk of exacerbation (history of >2 exacerbations/year), she would be placed in group C or D and should be referred to a pulmonary rehabilitation program. ₁ FEV1 values Patients with COPD often limit their physical activity as exercise can worsen dyspnea. This leads to further deconditioning, creating a vicious cycle, with dyspnea occurring at even lower levels of physical activity. Pulmonary rehabilitation, consisting of conditioning, breathing training, psychological support, and disease education, helps to break the cycle and can improve symptoms, exercise capacity, and quality of life. (Choice A) Inhaled corticosteroids are not the preferred treatment for patients with COPD and are considered second-line options for patients in category C or D. The exception is patients with a history of concomitant asthma, which this patient lacks. (Choice B) Lung volume reduction surgery provides a survival benefit in patients with upper lobe emphysema and low exercise capacity, but it is usually reserved for selected patients with severe COPD who fail maximal therapy. (Choice C) Theophylline is occasionally given to patients with refractory disease on triple inhaler therapy (ie, beta agonists, antimuscarinics, and corticosteroids). However, it offers only modest bronchodilation and requires close monitoring of serum levels to prevent toxicity. (Choice E) Long-term oxygen use is associated with improved survival and quality of life in patients with chronic hypoxemia (PaO₂ <55 mm Hg or SpO₂ <88%). This patient's pulse oximetry is >88% and she does not meet the criteria for oxygen therapy. < < Educational objective: Chronic obstructive pulmonary disease categorization usually guides optimal therapy. Patients with category B-D disease should undergo pulmonary rehabilitation to improve symptoms, exercise capacity, and quality of life. __________ References: Global strategy for the diagnosis, management and prevention of chronic obstructive lung disease 2017 report: GOLD executive summary. (http://www.ncbi.nlm.nih.gov/pubmed/28150362) Pulmonary rehabilitation and COPD: providing patients a good environment for optimizing therapy. (http://www.ncbi.nlm.nih.gov/pubmed/24368884)

A 64-Year-Old Woman Comes to the Office for Follow-Up