A 66-year-old man complains of exertional dyspnea that has progressed over the last two years. As a result he has had to limit his physical activities to avoid becoming short of breath. He denies any significant chest pain, but does note having a recurrent cough productive of whitish sputum. His past medical history is significant for hypertension controlled with hydrochlorothiazide. He has a 40 pack-year smoking history. His family history is significant for a stroke in his mother. His blood pressure is 160/90 mmHg and his heart rate is 80/min. Physical examination reveals a mildly overweight patient in no acute distress. His anteroposterior chest diameter is markedly increased. Breath sounds are decreased bilaterally with scattered expiratory wheezes. Which of the following agents is most likely to reduce this patient's symptoms?

Question

A 66-year-old man complains of exertional dyspnea that has progressed over the last two years.  As a result he has had to limit his physical activities to avoid becoming short of breath.  He denies any significant chest pain, but does note having a recurrent cough productive of whitish sputum.  His past medical history is significant for hypertension controlled with hydrochlorothiazide.  He has a 40 pack-year smoking history.  His family history is significant for a stroke in his mother.  His blood pressure is 160/90 mmHg and his heart rate is 80/min.  Physical examination reveals a mildly overweight patient in no acute distress.  His anteroposterior chest diameter is markedly increased.  Breath sounds are decreased bilaterally with scattered expiratory wheezes.  Which of the following agents is most likely to reduce this patient's symptoms?

Quizplus · Accepted Answer

This patient's history and presentation are classic for chronic obstructive pulmonary disease (COPD). Typically due to cigarette smoking, COPD causes gradually decreasing expiratory flow rates, increased lung compliance, and increased lung volumes. The only therapies proven to prolong survival in patients with COPD are smoking cessation, supplemental oxygen, and lung reduction surgery in certain patients. The remainder of therapies are aimed at decreasing respiratory symptoms, improving quality of life, and decreasing hospitalizations. The mainstays of treatment are inhaled bronchodilators, especially anti-cholinergic medications like ipratropium and tiotropium. Anti-muscarinic agents may be combined with short-acting beta agonists like albuterol. Inhaled steroids and long-acting beta agonists may be used for patients with more severe COPD. (Choice A) Alpha-adrenergic blockers are used to treat benign prostatic hypertrophy and hypertension. They do not play a role in the treatment of COPD. (Choice B) Beta-adrenergic blockers may exacerbate pulmonary symptoms in patients with severe reactive airway disease. They are safe in most patients with mild to moderate COPD and asthma, however. (Choice D) Dopamine agonists are used to treat Parkinson's disease, prolactinomas, and restless leg syndrome. They are not used to treat COPD. (Choice E) Alpha 2-adrenergic agonists include clonidine, methyldopa, and dexmedetomidine. Clonidine and methyldopa are used to treat hypertension. Dexmedetomidine is used for sedation in the intensive care unit. These medications are not used to treat COPD. Educational objective: Inhaled anti-muscarinic agents such as ipratropium are the mainstay of symptom management in COPD. These anti-cholinergic medications may be combined with short-acting beta-adrenergic agonists for greater symptom relief.

A 66-Year-Old Man Complains of Exertional Dyspnea That Has Progressed