Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

MKSAP: 75-year-old man with very severe COPD

mksap
Conditions
February 3, 2018
Share
Tweet
Share

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

A 75-year-old man is seen for routine follow-up for very severe COPD. He has constant dyspnea and air hunger and spends most of the day in a chair. He has had no change in baseline cough and sputum production. He has had multiple COPD exacerbations that required ICU admission and intubation. He has not benefited from pulmonary rehabilitation in the past. He quit smoking 3 years ago. His medical history is also notable for hypertension, type 2 diabetes mellitus, and a myocardial infarction 3 years ago. His medications are lisinopril, insulin glargine, budesonide/formoterol, tiotropium, roflumilast, as-needed albuterol, and 2 L of oxygen by nasal cannula. Spirometry performed 1 year ago showed an FEV1 of 21% of predicted and a DLCO of 35% of predicted. Residual volume/total lung capacity is 105% of predicted.

On physical examination, the patient is very thin and demonstrates a significantly increased work of breathing. He is afebrile, blood pressure is 125/80 mm Hg, pulse rate is normal, and respiration rate is 32/min; BMI is 17. Oxygen saturation is 90% breathing 2 L of oxygen. Pulmonary examination reveals significantly decreased breath sounds, with no crackles or wheezing, and the remainder of the examination is unremarkable.

Laboratory studies reveal a serum albumin level of 2.3 g/dL (23 g/L). Arterial blood gas studies reveal a PCO2 of 55 mm Hg (7.3 kPa). Chest radiograph shows no acute changes. Echocardiogram shows normal left ventricular function; the estimated pulmonary artery pressure is elevated, suggesting cor pulmonale. CT scan shows diffuse emphysema.

Which of the following is the most appropriate management?

A. Hospice referral
B. Lung transplantation
C. Lung volume reduction surgery
D. Repeat pulmonary rehabilitation

MKSAP Answer and Critique

The correct answer is A. Hospice referral.

The most appropriate management is to refer this patient for hospice care. Hospice is considered appropriate for patients in whom attempted curative therapy is not likely to be beneficial, and specifically in those who are predicted to have less than 6 months to live. In hospice care, treatment goals are refocused from cure and life-prolonging therapy toward maintaining the highest possible quality of life. In patients with COPD, parameters that portend a poor prognosis and trigger more extensive discussions regarding end-of-life care include an FEV1 of less than 30% of predicted, oxygen dependence, multiple hospital admissions for COPD exacerbations, significant comorbidities, weight loss and cachexia, decreased functional status, and increasing dependence on others. This patient has very severe COPD, cor pulmonale, decreased functional capacity, constant dyspnea and air hunger, poor nutritional status, and a history of multiple COPD exacerbations on maximal medical therapy and home oxygen. Given these factors and an overall poor prognosis, discussion of a hospice approach to care would be an appropriate next step in management.

In any patient with advancing COPD, it is important to have ongoing discussions regarding the goals of care as the disease progresses so that appropriate management decisions may be made based on anticipated outcomes and patient values and preferences. Involvement of clinicians trained in palliative care may be helpful in these discussions. Palliative care focuses on the many implications of any significant illness with an emphasis on establishing patient-centered goals of care and symptom management. Palliative care does not preclude active treatment of disease and is appropriate regardless of estimated survival time.

Although this patient might meet several of the criteria for possible lung transplantation, most transplant centers use 65 years of age as an arbitrary cutoff, and the presence of other comorbidities such as diabetes mellitus, coronary artery disease, and osteoporosis should also be considered. This patient’s age and comorbid conditions likely would preclude lung transplantation.

Lung volume reduction surgery (LVRS) is indicated for patients with severe COPD with predominant upper lobe emphysema who are symptomatic despite optimal medications. Because this patient has diffuse emphysema, he is not a candidate for LVRS.

This patient has completed pulmonary rehabilitation in the past without improvement, and chair-bound patients may not benefit from it; therefore, pulmonary rehabilitation is not an appropriate option for this patient.

Key Point

ADVERTISEMENT

  • In patients with COPD, parameters that portend a poor prognosis and trigger more extensive discussions regarding end-of-life care include an FEV1 of less than 30% of predicted, oxygen dependence, multiple hospital admissions for COPD exacerbations, significant comorbidities, weight loss and cachexia, decreased functional status, and increasing dependence on others.

This content is excerpted from MKSAP 17 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 16 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to KevinMD.com on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

Prev

Immigrant health care workers serve a vital function within the American health care system

February 2, 2018 Kevin 47
…
Next

One house, one spouse, one job. How did this physician do?

February 3, 2018 Kevin 1
…

Tagged as: Palliative Care, Pulmonology

Post navigation

< Previous Post
Immigrant health care workers serve a vital function within the American health care system
Next Post >
One house, one spouse, one job. How did this physician do?

ADVERTISEMENT

More by mksap

  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 26-year-old man with back pain

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 36-year-old man with abdominal cramping, diarrhea, malaise, and nausea

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 52-year-old woman with osteoarthritis of the right hip

    mksap

Related Posts

  • How this student took care of his severe depression in medical school

    Anonymous
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 35-year-old woman with constipation

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 60-year-old woman with persistent constipation

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 45-year-old woman with type 2 diabetes mellitus

    mksap
  • How social media can help or hurt your health care career

    Health eCareers
  • Why health care replaced physician care

    Michael Weiss, MD

More in Conditions

  • Why psychotherapy works and why psychotherapy fails

    Peggy A. Rothbaum, PhD
  • How oral health silently affects your heart, brain, and body

    Charles Reinertsen, DMD
  • How President Biden’s cognitive health shapes political and legal trust

    Muhamad Aly Rifai, MD
  • The emotional first responders of aesthetic medicine

    Sarah White, APRN
  • Why testosterone matters more than you think in women’s health

    Andrea Caamano, MD
  • How veteran health care is being transformed by tech and teamwork

    Deborah Lafer Scher
  • Most Popular

  • Past Week

    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • The hidden health risks in the One Big Beautiful Bill Act

      Trevor Lyford, MPH | Policy
    • How New Mexico became a malpractice lawsuit hotspot

      Patrick Hudson, MD | Physician
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy
    • Why health care leaders fail at execution—and how to fix it

      Dave Cummings, RN | Policy
    • How digital tools are reshaping the doctor-patient relationship

      Vineet Vishwanath | Tech
  • Past 6 Months

    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • The hidden health risks in the One Big Beautiful Bill Act

      Trevor Lyford, MPH | Policy
  • Recent Posts

    • How regulatory overreach is destroying innovation in U.S. health care

      Kayvan Haddadan, MD | Physician
    • Why the U.S. mental health care system is failing and how to fix it [PODCAST]

      The Podcast by KevinMD | Podcast
    • The unseen cost of detachment in radiology

      Dr. Yesu Raju | Physician
    • I thought success was a destination. Then I became a doctor.

      Ryan Nadelson, MD | Physician
    • Why psychotherapy works and why psychotherapy fails

      Peggy A. Rothbaum, PhD | Conditions
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

Leave a Comment

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

  • Most Popular

  • Past Week

    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • The hidden health risks in the One Big Beautiful Bill Act

      Trevor Lyford, MPH | Policy
    • How New Mexico became a malpractice lawsuit hotspot

      Patrick Hudson, MD | Physician
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy
    • Why health care leaders fail at execution—and how to fix it

      Dave Cummings, RN | Policy
    • How digital tools are reshaping the doctor-patient relationship

      Vineet Vishwanath | Tech
  • Past 6 Months

    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • The hidden health risks in the One Big Beautiful Bill Act

      Trevor Lyford, MPH | Policy
  • Recent Posts

    • How regulatory overreach is destroying innovation in U.S. health care

      Kayvan Haddadan, MD | Physician
    • Why the U.S. mental health care system is failing and how to fix it [PODCAST]

      The Podcast by KevinMD | Podcast
    • The unseen cost of detachment in radiology

      Dr. Yesu Raju | Physician
    • I thought success was a destination. Then I became a doctor.

      Ryan Nadelson, MD | Physician
    • Why psychotherapy works and why psychotherapy fails

      Peggy A. Rothbaum, PhD | Conditions
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Leave a Comment

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...