MKSAP Quiz: Follow-up examination for COPD
A 62-year-old man is evaluated in follow-up examination for COPD. Despite smoking cessation, adherence to his medical regimen, good inhaler technique, and participation in pulmonary rehabilitation, he continues to experience breathlessness with mild exertion and has diminished quality of life. Following a physical exam and other tests, what is the most appropriate treatment?
A 62-year-old man is evaluated in follow-up examination for COPD. Despite smoking cessation, adherence to his medical regimen, good inhaler technique, and participation in pulmonary rehabilitation, he continues to experience breathlessness with mild exertion and has diminished quality of life. He has a minimal dry cough, and he has never required treatment for an acute exacerbation of COPD. Medications are fluticasone-umeclidinium-vilanterol and albuterol inhalers as needed. Immunizations are up to date.
On physical examination, vital signs are normal. Oxygen saturation is 93% with the patient breathing ambient air. There are diminished breath sounds.
A 6-minute walk test shows a minimum oxygen saturation of 90% with the patient breathing ambient air. Spirometry shows an FEV1 of 35% of predicted and a DLCO of 42% of predicted.
Chest imaging shows upper-lobe-predominant emphysema.
Which of the following is the most appropriate treatment?
A. Long-term azithromycin therapy
B. Lung volume reduction surgery
C. Roflumilast
D. Supplemental oxygen
MKSAP Answer and Critique
The correct answer is B. Lung volume reduction surgery. This content is available to MKSAP subscribers as Question 44 in the Pulmonary and Critical Care Medicine section. More information about MKSAP is available online.
The most appropriate therapy for this patient is lung volume reduction surgery (Option B). Lung volume reduction surgery improves quality of life, exercise tolerance, pulmonary function, and survival in patients with emphysema. The National Emphysema Treatment Trial also found that success relied on ideal patient selection. Ideal patients are those with upper-lobe-predominant emphysema, FEV1 and DLCO of 20% of predicted or higher, and low exercise tolerance after completion of pulmonary rehabilitation. Patients with an FEV1 of less than 20% of predicted, a DLCO of less than 20% of predicted, or non-upper-lobe-predominant disease had high mortality rates. Bronchoscopic surgery is also a possible therapeutic option. Carefully selected patients who received endobronchial valve therapy have a greater likelihood of an increase in their FEV1 of 15% or greater, significant improvements in their 6-minute walk distances, and improvements in their dyspnea.
Macrolide antibiotics such as azithromycin (Option A) have anti-inflammatory and antimicrobial effects. Long-term macrolide therapy may reduce the frequency of exacerbations when prescribed to patients with severe COPD and a history of frequent exacerbations. Chronic antibiotic therapy is not indicated for most patients with COPD, and this patient has no indication for chronic antibiotic therapy.
Roflumilast (Option C) is a selective phosphodiesterase-4 inhibitor that is used to reduce chronic symptoms and the frequency of exacerbations in patients with severe COPD who have either primarily symptoms of chronic bronchitis or frequent exacerbations. This patient with symptoms and radiographic findings most consistent with emphysema and no history of frequent exacerbations does not have an indication for roflumilast therapy.
The patient had a minimum oxygen saturation of 90% during a 6-minute walk test. Supplemental oxygen therapy (Option D) improves quality of life and decreases mortality for patients with COPD and an arterial PO2 of 55 mm Hg (7.3 kPa) or less or an oxygen saturation of 88% or less. For patients with COPD and comorbidities such as erythrocytosis, heart failure, or cor pulmonale, supplemental oxygen is reasonable if the arterial PO2 is 59 mm Hg (7.8 kPa) or less or oxygen saturation is 89% or less. This patient does not meet the criteria for supplemental oxygen.
Key Points
- Lung volume reduction surgery improves quality of life, exercise tolerance, pulmonary function, and survival in selected patients with emphysema.
- Ideal patients for lung volume reduction therapy are those with upper-lobe-predominant emphysema, FEV1 and DLCO of 20% of predicted or higher, and low exercise tolerance after completion of pulmonary rehabilitation.