Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 72-year-old woman is evaluated for fatigue and decreased exercise capacity. The patient has severe chronic obstructive pulmonary disease, which was first diagnosed 10 years ago, and was hospitalized for her second exacerbation 1 month ago. She is a former smoker, having stopped smoking 5 years ago. She has no other significant medical problems, and her medications are albuterol as needed, an inhaled corticosteroid, a long-acting bronchodilator, and oxygen, 2 L/min by nasal cannula.

On physical examination, vital signs are normal. Breath sounds are decreased, and there is 1+ bilateral pitting edema. Spirometry done 1 month ago showed an FEV₁ of 28% of predicted, and blood gases measured at that time (on supplemental oxygen) showed pH 7.41, Pco₂ 43 mm Hg, and Po₂ 64 mm Hg; DLco is 30% of predicted. There is no nocturnal oxygen desaturation. Chest radiograph at this time shows hyperinflation. CT scan of the chest shows homogeneous distribution of emphysema.

Which of the following would be the most appropriate management for this patient?

A) Lung transplantation
B) Lung volume reduction surgery
C) Nocturnal assisted ventilation
D) Pulmonary rehabilitation

MKSAP Answer and Critique

The correct answer is D) Pulmonary rehabilitation. This item is available to MKSAP 15 subscribers as item 10 in the Pulmonary and Critical Care Medicine section. More information about MKSAP 15 is available online.

This patient who is on maximum medical treatment for chronic obstructive pulmonary disease (COPD) and is still symptomatic would benefit from pulmonary rehabilitation. Comprehensive pulmonary rehabilitation includes patient education, exercise training, psychosocial support, and nutritional intervention as well as the evaluation for oxygen supplementation. Referral should be considered for any patient with chronic respiratory disease who remains symptomatic or has decreased functional status despite otherwise optimal medical therapy.

Pulmonary rehabilitation increases exercise capacity, reduces dyspnea, improves quality of life, and decreases health care utilization. Reimbursement for pulmonary rehabilitation treatment remains an impediment to its widespread use.

The effect of lung volume reduction surgery is larger in patients with predominantly nonhomogeneous upper-lobe disease and limited exercise performance after rehabilitation. The ideal candidate should have an FEV₁ between 20% and 35% of predicted, the DLco no lower than 20% of predicted, hyperinflation, and limited comorbidities. There is no indication for nocturnal assisted ventilation because she does not have daytime hypercapnia and worsening oxygen desaturation during sleep.

Lung transplantation should be considered in patients hospitalized with COPD exacerbation complicated by hypercapnia (Pco₂ greater than 50 mm Hg) and patients with FEV₁ not exceeding 20% of predicted and either homogeneous disease on high-resolution CT scan or DLco less than 20% of predicted who are at high risk of death after lung volume reduction surgery. Lung transplantation is, therefore, not an option for this patient.

Key Point

• Pulmonary rehabilitation in patients with advanced lung disease can increase exercise capacity, decrease dyspnea, improve quality of life, and decrease health care utilization.

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