A 68-year-old man comes to the office with a 2-year history of increasing shortness of breath and daily cough with sputum for the past several months. The patient now becomes dyspneic walking 2 blocks or up 1 flight of stairs. He has had no fever or chest pain. The patient has not seen a physician for many years and takes no regular medication, but on several occasions, he has used his wife's albuterol inhaler, which provides some symptom relief. He has a 40-pack-year history and is trying to stop smoking.
Blood pressure is 140/80 mm Hg, pulse is 90/min, and respirations are 18/min. Pulse oximetry is 88% at rest on ambient air. Examination shows jugular venous distension, increased anteroposterior chest diameter, an accentuated S2, and a holosystolic murmur at the left sternal border, the intensity of which increases with inspiration. Lung auscultation reveals a prolonged expiration phase with decreased breath sounds throughout. There is mild bilateral pitting edema of the lower extremities.
Pulmonary function testing results are as follows:
Chest radiograph shows hyperinflated lungs with a flattened diaphragm but no parenchymal opacities.
In addition to smoking cessation, which of the following is most likely to prolong survival in this patient?

Question

A 68-year-old man comes to the office with a 2-year history of increasing shortness of breath and daily cough with sputum for the past several months.  The patient now becomes dyspneic walking 2 blocks or up 1 flight of stairs.  He has had no fever or chest pain.  The patient has not seen a physician for many years and takes no regular medication, but on several occasions, he has used his wife's albuterol inhaler, which provides some symptom relief.  He has a 40-pack-year history and is trying to stop smoking.
Blood pressure is 140/80 mm Hg, pulse is 90/min, and respirations are 18/min.  Pulse oximetry is 88% at rest on ambient air.  Examination shows jugular venous distension, increased anteroposterior chest diameter, an accentuated S2, and a holosystolic murmur at the left sternal border, the intensity of which increases with inspiration.  Lung auscultation reveals a prolonged expiration phase with decreased breath sounds throughout.  There is mild bilateral pitting edema of the lower extremities.
Pulmonary function testing results are as follows:
 Chest radiograph shows hyperinflated lungs with a flattened diaphragm but no parenchymal opacities.
In addition to smoking cessation, which of the following is most likely to prolong survival in this patient?

Quizplus · Accepted Answer

This patient's clinical presentation and pulmonary function testing (FEV1/FVC <70%) are diagnostic of chronic obstructive pulmonary disease (COPD). Smoking cessation can slow the progression of COPD and improve survival. In addition, long-term home oxygen therapy (LTOT) has been shown to improve quality of life and prolong survival in patients with COPD and significant chronic hypoxemia. LTOT is indicated in patients who meet 1 of the following criteria: Resting PaO₂ ≤55 mm Hg or oxygen saturation (SaO₂) ≤88%Resting PaO₂ ≤59 mm Hg or SaO₂ ≤89% plus cor pulmonale (right-sided heart failure) or erythrocytosis (hematocrit >55%) Resting PaO₂ ≤55 mm Hg or oxygen saturation (SaO₂) ≤88% Resting PaO₂ ≤59 mm Hg or SaO₂ ≤89% plus cor pulmonale (right-sided heart failure) or erythrocytosis (hematocrit >55%) LTOT should be titrated to maintain SaO₂ 90%-92% and should be used for >15 hours per day. In addition to the above criteria, patients with COPD and PaO₂ ≤55 mm Hg or SaO₂ ≤88% during exercise or sleep may benefit from supplemental oxygen therapy during those times. Lung-reduction surgery has also demonstrated prolonged survival in select patients with advanced COPD and symptoms that are refractory to other therapy. (Choices A and B) Combination inhaled long-acting beta agonist/corticosteroid therapy (eg, salmeterol/fluticasone) and inhaled long-acting muscarinic antagonist therapy (eg, tiotropium) improve lung function and decrease the frequency of COPD exacerbation and hospitalization. However, these agents have not been shown to prolong survival. (Choice D) Noninvasive ventilation in the form of bilevel positive airway pressure is used for temporary ventilatory support in patients with severe exacerbations of COPD, but long-term nocturnal use does not prolong survival. (Choice E) The oral phosphodiesterase-4 inhibitor roflumilast reduces the frequency of COPD exacerbation and is often reserved for patients with COPD that is uncontrolled on maximum inhaled therapy. However, it has not been shown to prolong survival. Educational objective: Long-term home oxygen therapy (LTOT) improves quality of life and prolongs survival in patients with chronic obstructive pulmonary disease and significant chronic hypoxemia. LTOT is indicated in those with resting PaO₂ ≤55 mm Hg or oxygen saturation ≤88%, and in those with resting PaO₂ ≤59 mm Hg or oxygen saturation ≤89% and comorbid cor pulmonale (right-sided heart failure) or erythrocytosis. __________ References: TORCH and UPLIFT: what has been learned from the COPD "mega-trials"? (http://www.ncbi.nlm.nih.gov/pubmed/19229702) Changing the burden of COPD mortality. (http://www.ncbi.nlm.nih.gov/pubmed/18046859) A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema. (http://www.ncbi.nlm.nih.gov/pubmed/12759479)

A 68-Year-Old Man Comes to the Office with a 2-Year