A 74-year-old man comes to the office with increasing shortness of breath, especially on exertion. He also has cough with mucoid expectoration, especially in the morning. He has no orthopnea, paroxysmal nocturnal dyspnea, or chest pain. The patient was hospitalized for community-acquired pneumonia 2 years ago. His other medical problems include glaucoma, benign prostatic hyperplasia, and hypertension. He smoked a pack of cigarettes daily for 40 years and quit 2 years ago. His temperature is 37.2 C (98.9 F), blood pressure is 144/96 mm Hg, pulse is 82/min, and respirations are 16/min. Pulse oximetry shows an oxygen saturation of 89% on room air at rest. His face appears plethoric. The chest is barrel shaped. Breath sounds are diminished throughout, and the expiratory phase is prolonged. Heart sounds are distant but regular, and there are no murmurs or gallops. There is no peripheral edema or jugular venous distension. Laboratory results are as follows: Which of the following interventions will have the maximum impact on this patient's survival?

Question

A 74-year-old man comes to the office with increasing shortness of breath, especially on exertion.  He also has cough with mucoid expectoration, especially in the morning.  He has no orthopnea, paroxysmal nocturnal dyspnea, or chest pain.  The patient was hospitalized for community-acquired pneumonia 2 years ago.  His other medical problems include glaucoma, benign prostatic hyperplasia, and hypertension.  He smoked a pack of cigarettes daily for 40 years and quit 2 years ago.  His temperature is 37.2 C (98.9 F), blood pressure is 144/96 mm Hg, pulse is 82/min, and respirations are 16/min.  Pulse oximetry shows an oxygen saturation of 89% on room air at rest.  His face appears plethoric.  The chest is barrel shaped.  Breath sounds are diminished throughout, and the expiratory phase is prolonged.  Heart sounds are distant but regular, and there are no murmurs or gallops.  There is no peripheral edema or jugular venous distension.  Laboratory results are as follows:  Which of the following interventions will have the maximum impact on this patient's survival?

Quizplus · Accepted Answer

Chronic obstructive pulmonary disease (COPD) is a progressive condition of limited airflow during expiration that is not entirely reversible. COPD encompasses chronic bronchitis and emphysema and is one of the leading causes of death worldwide. Smoking is the most important risk factor for COPD. Signs and symptoms include progressive dyspnea, cough with sputum production, decreased breath sounds, and a prolonged expiratory phase. Patients may have a barrel-shaped chest, which is due to air trapping and hyperinflation of the lungs. Chronic hypoxemia is often present in advanced disease, and consequent secondary polycythemia may occur. Long-term supplemental oxygen therapy (LTOT) has demonstrated prolonged survival and improved quality of life in patients with COPD with significant chronic hypoxemia. The criteria for initiating LTOT in such patients include: Resting arterial oxygen tension (PaO₂) <55 mm Hg or pulse oxygen saturation (SaO₂) <88% on room airPaO₂ <59 mm Hg or SaO₂ <89% in patients with cor pulmonale, evidence of right heart failure, or hematocrit >55% (as in this patient) Resting arterial oxygen tension (PaO₂) <55 mm Hg or pulse oxygen saturation (SaO₂) <88% on room air < PaO₂ <59 mm Hg or SaO₂ <89% in patients with cor pulmonale, evidence of right heart failure, or hematocrit >55% (as in this patient) < In addition to continued abstinence from smoking, initiation of LTOT will have the greatest benefit to this patient's survival. (Choice A) Although vaccinating against influenza and pneumococcus is important and may help decrease the rate of COPD exacerbations, a significant mortality benefit has not been clearly and consistently demonstrated in studies. (Choice B) Beta blockers are generally avoided in moderate/severe asthma and COPD due to their bronchoconstrictive properties. However, beta-2 agonists are central to COPD management. (Choice D) Temporary use of systemic corticosteroids is appropriate in the management of acute COPD exacerbations. However, maintenance systemic corticosteroids should not be used in COPD due to significant side effects and possibly increased mortality. (Choice E) Mucoactive agents (eg, N-acetylcysteine) may have some symptomatic benefit in patients with COPD who have bothersome sputum production, but there is no evidence of survival benefit with use of these agents. (Choice F) Periodic phlebotomy is sometimes performed in secondary polycythemia when symptoms (eg, fatigue, blurred vision, paresthesias) are present. This patient is plethoric but has no other polycythemia symptoms (which generally do not occur with a hematocrit <65%). (Choice G) Prophylactic antibiotics are rarely used in COPD management. There is some evidence of decreased frequency of exacerbations in select patients with frequent exacerbations, but no survival benefit has been demonstrated. Educational objective: Long-term supplemental oxygen therapy has been proven to prolong survival in patients with chronic obstructive pulmonary disease and significant chronic hypoxemia.

A 74-Year-Old Man Comes to the Office with Increasing Shortness