A 60-year-old man comes to the office due to shortness of breath over the last 5 months. He also has a chronic mild mucoid cough, especially in the morning. The shortness of breath initially occurred with heavy exertion or long-distance walking, but the patient now experiences it even if he walks only 2 or 3 blocks. He has no fever, chills, hemoptysis, chest pain, or difficulty breathing while lying on his back. His only other medical problem is hypertension. The patient has smoked a pack of cigarettes daily for the last 40 years. Temperature is 37.2 C (99 F), blood pressure is 130/86 mm Hg, pulse is 78/min, and respirations are 18/min. Pulse oximetry shows 95% oxygen saturation on room air and 92% after a short, brisk walk. Examination shows a thin man in no respiratory distress. Breath sounds are mildly decreased throughout. Spirometry results are as follows: No significant change is noted with bronchodilator therapy. Complete blood count is normal. Which of the following is the most effective measure to decrease mortality in this patient?

Question

A 60-year-old man comes to the office due to shortness of breath over the last 5 months.  He also has a chronic mild mucoid cough, especially in the morning.  The shortness of breath initially occurred with heavy exertion or long-distance walking, but the patient now experiences it even if he walks only 2 or 3 blocks.  He has no fever, chills, hemoptysis, chest pain, or difficulty breathing while lying on his back.  His only other medical problem is hypertension.  The patient has smoked a pack of cigarettes daily for the last 40 years.  Temperature is 37.2 C (99 F), blood pressure is 130/86 mm Hg, pulse is 78/min, and respirations are 18/min.  Pulse oximetry shows 95% oxygen saturation on room air and 92% after a short, brisk walk.  Examination shows a thin man in no respiratory distress.  Breath sounds are mildly decreased throughout.  Spirometry results are as follows:  No significant change is noted with bronchodilator therapy.  Complete blood count is normal.  Which of the following is the most effective measure to decrease mortality in this patient?

Quizplus · Accepted Answer

Progressive dyspnea and persistent mucoid cough in this patient with a significant smoking history are highly suggestive of chronic obstructive pulmonary disease (COPD). In patients with suspected COPD, the diagnosis can be confirmed with spirometry demonstrating an obstructive pattern with FEV1/FVC <70% with no improvement in FEV1 following bronchodilator therapy (as compared with asthma, in which there is reversibility in obstruction with bronchodilator therapy). Smoking is the most important risk factor for COPD. In those diagnosed with COPD, smoking cessation has been shown to decrease the rate of decline of FEV1 and decrease mortality. Long-term supplemental oxygen therapy (LTOT) and lung reduction surgery have shown mortality benefit in specific subpopulations of patients with COPD. (Choices A and C) Inhaled corticosteroids have been shown to decrease the number of COPD exacerbations and improve quality of life but have no mortality benefit. Oral corticosteroids are useful on a short-term basis during acute exacerbations of COPD (which this patient does not have). They have not demonstrated mortality benefit in acute exacerbation. (Choice B) LTOT is associated with decreased mortality in patients with COPD demonstrating significant hypoxemia (eg, SpO₂ <88%, SpO₂ <89% with right heart failure or erythrocytosis). There is no proven mortality benefit or indication for LTOT in this patient with only mild hypoxemia. (Choice D) Although antibiotics are sometimes used in patients with moderate or severe acute COPD exacerbations, prophylactic antibiotics are rarely used in chronic COPD management. They may decrease the frequency of exacerbation in select patients with frequent COPD exacerbations, but no mortality benefit has been demonstrated. (Choice E) Regular incentive spirometry has shown some improvement in pulmonary function tests and may improve quality of life in patients with COPD, but no mortality benefit has been demonstrated. (Choice F) Short-acting beta agonists such as albuterol have quick onset of action and improve symptoms as well as lung function in the short term in patients with COPD. However, they have not been shown to decrease mortality. Educational objective: Smoking cessation is associated with a mortality benefit and reduced progression of disease in patients with chronic obstructive pulmonary disease.

A 60-Year-Old Man Comes to the Office Due to Shortness