Question

"A 58-year-old man with a history of severe COPD is evaluated for his chronic exertional dyspnea. He is taking his inhalers and medications as prescribed with excellent technique and has completed a pulmonary rehabilitation program within the last 6 months and is continuing his exercise program. He is using supplemental oxygen but despite adequate oxygenation still has significant exertional dyspnea. Current medications are umeclidinium/vilanterol, mometasone, and albuterol. He feels that his current quality of life is poor and would like other treatment options. On physical examination, vital signs are normal. Oxygen saturation is 90% on 2 L/min of oxygen. BMI is normal. Pulmonary examination reveals decreased breath sounds throughout with a prolonged expiratory phase but no wheezing. Spirometry demonstrates severe airflow obstruction. A recent chest CT shows heterogeneous emphysema without any nodules. A recent echocardiogram shows diastolic dysfunction but no evidence of pulmonary hypertension. Which of the following is the most appropriate management? a. Add daily roflumilast b. Evaluation for lung volume reduction surgery c. Obtain a right heart catheterization d. Repeat pulmonary rehabilitation program"

Answer 1

Evaluation for lung volume reduction surgery is the most appropriate management for the patient with severe COPD who has optimized current therapy and persistent exertional dyspnea. The correct option is B.

Step-by-step explanation:

The most appropriate management for a 58-year-old man with severe COPD, currently on triple therapy (umeclidinium/vilanterol, mometasone, and albuterol), using supplemental oxygen, and who has completed pulmonary rehabilitation with persistent exertional dyspnea, is b. evaluation for lung volume reduction surgery.

His current therapy is optimized, and there's no evidence of pulmonary hypertension to suggest a need for right heart catheterization.

Roflumilast may be considered in cases of chronic bronchitis with frequent exacerbations, which is not described here. Repeating the pulmonary rehabilitation program is unlikely to offer additional benefit since he has recently completed it and is continuing with an exercise program.

Chronic obstructive pulmonary disease (COPD) includes conditions such as emphysema and chronic bronchitis, which lead to the destruction of alveolar walls, reducing the surface area for gas exchange. Spirometry shows a low FEV1/FVC ratio, indicative of obstructive lung disease. Treatment for severe COPD can include bronchodilators, corticosteroids, and supplemental oxygen. The correct option is B.