A 66-year-old man comes to the office due to shortness of breath and cough. Three years ago, he was diagnosed with chronic obstructive pulmonary disease and as needed inhaled albuterol was started. Over the past few months, he has been having worsening shortness of breath and has been using his inhaler more frequently. The patient is an avid golfer and says he has had to stop to catch his breath when walking on the golf course. He has had no chest pain, orthopnea, or leg swelling. The patient has never required urgent medical care for his breathing. His other medical problems include hypertension and hyperlipidemia. The patient has smoked for 50 years and says he has now cut down to 5 cigarettes daily.
Blood pressure is 140/83 mm Hg, pulse is 77/min, and respirations are 16/min. Oxygen saturation on room air is 95% at rest and 90% after walking for several minutes. Lung auscultation reveals good air entry with occasional expiratory wheezes.
Pulmonary function testing shows FEV1 is 54% of predicted, FVC is 68% of predicted, and FEV1/FVC is 61%. Chest radiography reveals no lung infiltrates or masses.
In addition to recommending complete smoking cessation, which of the following is the most appropriate next step in management of this patient?

Question

A 66-year-old man comes to the office due to shortness of breath and cough.  Three years ago, he was diagnosed with chronic obstructive pulmonary disease and as needed inhaled albuterol was started.  Over the past few months, he has been having worsening shortness of breath and has been using his inhaler more frequently.  The patient is an avid golfer and says he has had to stop to catch his breath when walking on the golf course.  He has had no chest pain, orthopnea, or leg swelling.  The patient has never required urgent medical care for his breathing.  His other medical problems include hypertension and hyperlipidemia.  The patient has smoked for 50 years and says he has now cut down to 5 cigarettes daily.
Blood pressure is 140/83 mm Hg, pulse is 77/min, and respirations are 16/min.  Oxygen saturation on room air is 95% at rest and 90% after walking for several minutes.  Lung auscultation reveals good air entry with occasional expiratory wheezes.
Pulmonary function testing shows FEV1 is 54% of predicted, FVC is 68% of predicted, and FEV1/FVC is 61%.  Chest radiography reveals no lung infiltrates or masses.
In addition to recommending complete smoking cessation, which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_98d6_474e_853d_7d4514109168_MD0002_00 The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines categorize disease and determine appropriate management based primarily on symptom burden and risk of exacerbation. Airflow limitation, graded based on FEV1, plays a minimal role in determining therapy. FEV1 Based on his dyspnea while ambulating on the golf course (moderate-severe symptoms) and no prior disease exacerbations (<1 exacerbation a year), this patient has GOLD category B chronic obstructive pulmonary disease (COPD) and should be started on a daily long-acting muscarinic antagonist (eg, tiotropium) in addition to his as-needed short-acting beta agonist (albuterol). < (Choice A) Inhaled corticosteroid (eg, mometasone) monotherapy is not recommended in COPD as long-acting bronchodilators are more effective and have fewer adverse effects. (Choice B) The combination of an inhaled corticosteroid and long-acting beta agonist (eg, budesonide/formoterol) is appropriate in patients with GOLD category C or D COPD and frequent disease exacerbations. However, it is not used in patients with GOLD category A or B COPD. (Choice D) Home oxygen therapy improves mortality and is indicated in patients with chronic hypoxemia (PaO₂ <55 mm Hg, oxygen saturation <88%). However, it is not indicated in patients with exertional shortness of breath in the absence of chronic hypoxemia. < < (Choice E) A short course of an oral glucocorticoid (eg, prednisone) is indicated for the treatment of an acute exacerbation of COPD. This patient's symptoms have been gradually progressive, without an acute worsening in dyspnea, cough, or sputum production to suggest COPD exacerbation. Educational objective: Based on the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, disease is categorized based on symptom burden and risk of exacerbation to determine appropriate management. Patients with GOLD category B disease (moderate-severe symptoms and <1 exacerbation a year) should be on a long-acting muscarinic antagonist (eg, tiotropium), in addition to an as-needed short-acting beta agonist (eg, albuterol). < __________ 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)

A 66-Year-Old Man Comes to the Office Due to Shortness