A 62-year-old man comes to the physician with weight loss, fatigue, and dyspnea at rest. He has no increased cough or sputum production. His medical problems include hypothyroidism and chronic obstructive pulmonary disease (forced expiratory volume in 1 second 18% predicted) requiring home oxygen. He has had 2 emergency department visits and 1 hospital admission in the last 6 months for chronic obstructive pulmonary disease exacerbations. He has a 50-pack-year smoking history and does not want to quit. He spends most of his free time sitting on the couch because he is limited by dyspnea. His medications include inhaled albuterol, tiotropium, inhaled mometasone and formoterol, montelukast, megestrol, low-dose oral prednisone, and levothyroxine.
His temperature is 37.2° C (99° F) , blood pressure is 150/80 mm Hg, pulse is 114/min, and respirations are 23/min. His BMI is 18 kg/m². The patient's pulse oximetry shows 94% on 4 L O₂. Physical examination shows pursed lip breathing, decreased breath sounds throughout, loud second heart sound, and 2+ pretibial edema bilaterally.
Laboratory results from his last admission are as follows:

Which of the following is the most appropriate next step in management?

Question

A 62-year-old man comes to the physician with weight loss, fatigue, and dyspnea at rest. He has no increased cough or sputum production. His medical problems include hypothyroidism and chronic obstructive pulmonary disease (forced expiratory volume in 1 second 18% predicted) requiring home oxygen. He has had 2 emergency department visits and 1 hospital admission in the last 6 months for chronic obstructive pulmonary disease exacerbations. He has a 50-pack-year smoking history and does not want to quit. He spends most of his free time sitting on the couch because he is limited by dyspnea. His medications include inhaled albuterol, tiotropium, inhaled mometasone and formoterol, montelukast, megestrol, low-dose oral prednisone, and levothyroxine.
His temperature is 37.2° C (99° F) , blood pressure is 150/80 mm Hg, pulse is 114/min, and respirations are 23/min. His BMI is 18 kg/m². The patient's pulse oximetry shows 94% on 4 L O₂. Physical examination shows pursed lip breathing, decreased breath sounds throughout, loud second heart sound, and 2+ pretibial edema bilaterally.
Laboratory results from his last admission are as follows:

Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

11ec193a_98dd_c169_853d_cb69190fadd4_MD0002_00 This patient with end-stage chronic obstructive pulmonary disease (COPD) should be referred for hospice care. Hospice involves supportive care that allows patients to die with dignity during the last phases of incurable conditions. Criteria for hospice eligibility in advanced lung disease patients include severe, irreversible chronic lung disease; hypoxemia or hypercapnia; right heart failure from pulmonary disease; unintentional weight loss > 10% body weight over 6 months; and resting tachycardia (> 100/min). (Choice A) Most COPD patients have elevated erythropoietin levels as an appropriate response to hypoxia. This patient's hematocrit is within normal limits and does not require erythropoietin therapy. (Choice B) Intravenous corticosteroids are usually indicated for acute COPD exacerbation, which this patient currently does not have. Adding intravenous steroids to this end-stage COPD patient's oral prednisone is not likely to be of much help. (Choice D) Pulmonary transplantation referral is indicated for COPD patients with BODE index (Body mass index, Obstruction, Dyspnea, Exercise) > 5, FEV₁ < 25% predicted, resting hypoxemia (PaO₂ < 55-60 mm Hg), hypercapnia, secondary pulmonary hypertension, or accelerated decline in FEV₁. Patients must be free of tobacco for at least 6 months before being considered for pulmonary transplantation. (Choice E) Lung volume reduction surgery may reduce mortality in patients with upper lobe emphysema and low exercise tolerance. However, it is not recommended in high-risk patients with FEV₁ < 20% predicted, diffusing capacity of the lung for carbon monoxide < 20% predicted, or homogenous emphysema due to increased mortality. Educational objective: Patients with severe chronic obstructive pulmonary disease may be considered for hospice care when they have disabling dyspnea at rest, progression to end-stage disease, hypoxemia, or hypercapnia. __________ References: An official American Thoracic Society clinical policy statement: palliative care for patients with respiratory diseases and critical illnesses. (http://www.ncbi.nlm.nih.gov/pubmed/18390964) Palliative and end-of-life care for patients with cardiopulmonary diseases: American College of Chest Physicians position statement. (http://www.ncbi.nlm.nih.gov/pubmed/16304319) BODE index and quality of life in advanced chronic obstructive pulmonary disease before and after lung transplantation. (http://www.ncbi.nlm.nih.gov/pubmed/21782467)

A 62-Year-Old Man Comes to the Physician with Weight Loss