A 68-year-old woman comes to the office due to gradually worsening shortness of breath. Over the past several months, she has bothersome dyspnea on exertion, now developing with even light housework. She also reports cough in the mornings that is productive of minimal white sputum. The patient has had no chest pain or fever. She smoked approximately 10 cigarettes daily from age 18 to 50. Blood pressure is 128/76 mm Hg, pulse is 80/min, and respirations are 14/min. Oxygen saturation is 94% on room air. On physical examination, the patient is breathing comfortably without using accessory muscles of respiration. The trachea is central, and jugular venous pressure is normal. Lung auscultation reveals bilateral vesicular breath sounds with occasional rhonchi that clears after the patient is asked to cough. Heart sounds are normal. Chest x-ray reveals no abnormalities. Pulmonary function testing shows that FEV₁ is 65% of predicted, and the FEV₁/FVC ratio is 50%. These values are unchanged after administration of albuterol. Which of the following is the best next step in management of this patient?

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Explanation: 11ec25c8_d106_9927_bc81_17a13fea6d33_MD0003_00 This patient has a significant smoking history, chronic respiratory symptoms (eg, dyspnea, productive cough), and fixed airflow limitation (ie, FEV₁/FVC ratio <70%, unchanged after albuterol), consistent with chronic obstructive pulmonary disease (COPD). ₁ Selection of initial bronchodilator therapy for stable COPD depends on 2 parameters: Symptom severity is graded using validated instruments such as the COPD Assessment Test. These scales measure the impact of respiratory symptoms on daily life (higher severity: dyspnea during light housework). Disease risk is assessed by the frequency of COPD acute exacerbations and/or hospitalizations (higher risk: ≥1 hospitalization or ≥2 exacerbations [requiring oral corticosteroids] annually). Although pulmonary function tests are crucial for COPD diagnosis, FEV₁ is not a primary consideration when deciding initial therapy because it correlates poorly with severity and risk. The 2-by-2 strata of severity and risk partitions patients into 4 groups (groups A to D). This patient has higher symptom severity with lower disease risk (group B). ₁ Except for low risk/low severity patients (ie, group A), the preferred initial therapy for patients with COPD includes a daily long-acting muscarinic antagonist (LAMA). LAMAs (eg, tiotropium) block airway M₃ receptors to stabilize against bronchoconstriction and reduce mucus hypersecretion. LAMAs are superior to long-acting beta agonists (LABAs) in COPD. ₃ In addition to bronchodilators, patients should be assessed for smoking cessation, supplemental oxygen, and influenza and pneumococcal vaccination. (Choice B) Inhaled corticosteroids (ICSs), such as budesonide, are preferred for asthma (reversible obstruction) or as part of triple therapy (LABA + LAMA + ICS) for refractory COPD. ICSs are not first line for COPD because LAMAs are more effective and have fewer adverse effects. ICSs increase pneumonia risk in COPD due to local pulmonary immunosuppression. (Choice C) Leukotriene antagonists (eg, montelukast) are an adjuvant therapy for asthma (reversible obstruction with albuterol administration), rather than COPD. They are especially helpful for aspirin-exacerbated respiratory disease (triad of asthma, nonsteroidal anti-inflammatory drug sensitivity, and nasal polyposis) due to the central role of leukotrienes in this condition. (Choice D) All patients with COPD should be screened for pulmonary rehabilitation, a supervised exercise program that improves aerobic tolerance. It is indicated for patients with deconditioning and life-limiting dyspnea (eg, light housework or at rest) despite optimal medical therapy. (Choice E) Oral corticosteroids are indicated for acute exacerbations of COPD (increased wheezing, sputum, and dyspnea) but not as initial therapy for stable disease. Educational objective: Daily long-acting muscarinic antagonists are the best initial therapy for stable chronic obstructive pulmonary disease with higher symptom burden (ie, dyspnea on light exertion) and/or disease risk (history of exacerbations and hospitalizations).

A 68-Year-Old Woman Comes to the Office Due to Gradually