A 65-year-old man comes to the physician to discuss chronic obstructive pulmonary disease. His medications include budesonide/formoterol, tiotropium, and as-needed albuterol. He has dyspnea on exertion after walking 100 yards or up a flight of stairs. The patient has never had an exacerbation requiring hospitalization. He quit smoking 7 years ago and has a 45-pack-year history. SaO₂ is 88% on room air at rest. He has a barrel chest, and the lung examination shows decreased air entry bilaterally but is otherwise clear to auscultation. Heart examination is significant for a holosystolic murmur at the left lower sternal border and a loud P2. There is 1+ bilateral pretibial edema. Pulmonary function results are as follows:

An echocardiogram demonstrates normal left ventricular function, normal right ventricular size and function, and moderate tricuspid regurgitation. Estimated pulmonary artery systolic pressure is 50 mm Hg, and mean pulmonary artery pressure is 29 mm Hg.
In addition to starting home oxygen, which of the following would be recommended in this patient?

Question

A 65-year-old man comes to the physician to discuss chronic obstructive pulmonary disease. His medications include budesonide/formoterol, tiotropium, and as-needed albuterol. He has dyspnea on exertion after walking 100 yards or up a flight of stairs. The patient has never had an exacerbation requiring hospitalization. He quit smoking 7 years ago and has a 45-pack-year history. SaO₂ is 88% on room air at rest. He has a barrel chest, and the lung examination shows decreased air entry bilaterally but is otherwise clear to auscultation. Heart examination is significant for a holosystolic murmur at the left lower sternal border and a loud P2. There is 1+ bilateral pretibial edema. Pulmonary function results are as follows:

An echocardiogram demonstrates normal left ventricular function, normal right ventricular size and function, and moderate tricuspid regurgitation. Estimated pulmonary artery systolic pressure is 50 mm Hg, and mean pulmonary artery pressure is 29 mm Hg.
In addition to starting home oxygen, which of the following would be recommended in this patient?

Quizplus · Accepted Answer

11ec193a_98e2_5552_853d_730979286dcb_MD0002_00 This patient with underlying chronic obstructive pulmonary disease (COPD) has the following signs suggesting significant pulmonary hypertension: HypoxemiaPeripheral edemaMurmur of tricuspid insufficiencyProminent pulmonic component of the second heart sound Hypoxemia Peripheral edema Murmur of tricuspid insufficiency Prominent pulmonic component of the second heart sound Many patients with COPD have associated pulmonary hypertension (PH). Right heart catheterization is definitive for diagnosis of PH, although the diagnosis can be confirmed with echocardiography in most patients. PH in COPD is usually mild-to-moderate in severity. However, patients with COPD may occasionally display more severe PH (mean pulmonary artery pressure >35-40 mm Hg) that is excessive for the (mild) degree of underlying COPD. These patients will have increased dyspnea, and it is speculated that this may represent concurrent idiopathic pulmonary arterial hypertension. Pulmonary vasoactive agents, including sildenafil, bosentan, and iloprost, have been considered for use in these patients, but studies to date have been limited. (Choices B, C, and D) This patient has "proportional" pulmonary hypertension (mean pulmonary artery pressure 29 mm Hg) and is not a candidate for additional treatment. The mainstays of treatment for patients with mild-to-moderate PH associated with COPD remain long-term oxygen therapy, smoking cessation, inhaled bronchodilators, and inhaled corticosteroids. (Choice E) Warfarin is recommended in patients with idiopathic pulmonary artery hypertension. Patients with COPD and PH are at increased risk for atrial fibrillation, but anticoagulation is not otherwise indicated for PH associated with COPD. Educational objective: Mild-to-moderate pulmonary hypertension (PH) is commonly associated with chronic obstructive pulmonary disease (COPD) and confers a worse prognosis. Specific pulmonary vasoactive medications have not been proven to relieve PH associated with COPD, and treatment should focus on corticosteroids, bronchodilators, and supplemental oxygen. __________ References: Pulmonary hypertension in COPD. (http://www.ncbi.nlm.nih.gov/pubmed/18978137) Pulmonary hypertension secondary to chronic obstructive pulmonary disease. (http://www.ncbi.nlm.nih.gov/pubmed/23610973)

A 65-Year-Old Man Comes to the Physician to Discuss Chronic