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

• 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.

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