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Question 31#

A 62-year-old man seeks your advice for management of his COPD. He is a former 60-pack-year smoker, but stopped smoking 3 years ago. He uses inhaled albuterol when he feels particularly short of breath. He has noticed mild peripheral edema. He has diabetes mellitus, hypertension, and peripheral vascular disease. For these conditions he takes metformin, HCTZ, lisinopril, and cilostazol. Physical examination reveals a thin man who appears older than his stated age. His BP is 136/78, HR is 88, and RR 18. Room air O2 saturation is 85%. He has distant breath sounds, but no rales, rhonchi, or wheezes. What treatment is most important in his overall health status?

A) Long acting bronchodilator such as tiotropium or salmeterol
B) Inhaled corticosteroids
C) Oxygen to keep O2 saturation 90% or above
D) Pulmonary rehabilitation
E) Antibiotics promptly at time of purulent exacerbation

Correct Answer is C

Comment:

Oxygen treatment (as close to 24 hours a day as possible) is the one active treatment modality that has been shown to decrease mortality in COPD. Interestingly, it decreases the incidence of sudden death. This effect is presumably due to the beneficial effect of oxygen on cor pulmonale and right heart strain. It is important to emphasize to the patient that they should use the oxygen continuously, not just at times of increased dyspnea. Several treatments (inhaled corticosteroids, long-acting bronchodilators) are symptomatically useful and may slow progression of functional loss but have not been shown to prolong life. Pulmonary rehabilitation can increase functional status but does not improve parameters such as FEV1 or mortality. The number of exacerbations is an important determinant of functional decline in COPD, but preventing them is difficult. Prompt antibiotic treatment of purulent exacerbations decreases the rate of hospitalization but has not been proven to affect mortality. Methods to slow progression of COPD are important research topics, as COPD is approaching cerebrovascular disease as the third leading cause of death in the United States.