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

A 55-year-old man is evaluated in follow-up for severe COPD, which was diagnosed 2 years ago. He has had two exacerbations in the past year requiring hospitalization, and his baseline exercise tolerance is low. He completed pulmonary rehabilitation 3 months ago without much improvement in exercise capacity. He quit smoking 1 year ago. His medications are tiotropium, fluticasone/salmeterol, daily roflumilast, and albuterol as needed.

On physical examination, vital signs are normal; BMI is 22. Oxygen saturation is 92% breathing ambient air. Scattered wheezing is noted bilaterally.

Chest radiograph and CT scan both show emphysematous changes in the upper lobes. Spirometry shows an FEV₁ of 40% of predicted and a DLCO of 25% of predicted. His 6-minute walking distance is 240 meters (787 feet), consistent with decreased exercise tolerance.

Which of the following is most likely to benefit this patient?

A. Change fluticasone/salmeterol to fluticasone/vilanterol
B. Daily prednisone
C. Lung transplantation
D. Lung volume reduction surgery

MKSAP Answer and Critique

The correct answer is D. Lung volume reduction surgery.

The most appropriate next step in management is to evaluate for lung volume reduction surgery (LVRS). To be eligible for LVRS, patients must meet the following criteria: (1) severe COPD; (2) symptomatic despite maximal pharmacologic therapy; (3) completed pulmonary rehabilitation; (4) evidence of bilateral predominant upper-lobe emphysema on CT; (5) postbronchodilator total lung capacity greater than 100% and residual lung volume greater than 150% of predicted; (6) maximum FEV₁ greater than 20% and less than or equal to 45% of predicted and DLCO greater than or equal to 20% of predicted; and (7) ambient air arterial PCO₂ less than or equal to 60 mm Hg (8.0 kPa) and arterial PO₂ greater than or equal to 45 mm Hg (6.0 kPa). In patients with severe COPD and predominantly upper-lobe emphysema and low post-rehabilitation exercise capacity, LVRS results in improved survival compared with medical treatment. However, higher mortality is seen in patients with severe emphysema with an FEV₁of less than or equal to 20% of predicted and a DLCO less than or equal to 20% of predicted or homogeneous emphysema on high-resolution CT scan. Because of this patient’s severe disability associated with his COPD and available parameters suggesting he may be a candidate for LVRS, further evaluation of this option would be appropriate.

This patient is on appropriate medical treatment, and switching from one combination medication to another medication in the same class is not likely to be helpful. Vilanterol is a newer ultra–long-acting β₂-agonist that may be used once daily. Although a once-daily inhaler regimen may be more convenient for some patients than a twice-daily regimen, these formulations tend to be of significantly higher cost, and there are no evidence-based clinical benefits for these newer ultra–long-acting agents. Therefore, making this change in medication would not be expected to have a significant effect in this patient.

Systemic glucocorticoids are recommended for the short-term treatment of acute exacerbations of COPD. However, continuous therapy with systemic glucocorticoids is associated with significant side effects and is not recommended for the chronic management of COPD.

Criteria for referral for lung transplant evaluation include one of the following: pulmonary hypertension, cor pulmonale, or both despite oxygen therapy; history of exacerbation associated with acute hypercapnia; and FEV₁ less than 20% of predicted with DLCO less than 20% of predicted or homogeneous distribution of emphysema. This patient has an FEV₁greater than 20% of predicted, a DLCO greater than 20% of predicted, and emphysema in the upper lobes; therefore, he is not a candidate for lung transplantation.

Key Point

• In patients with severe COPD and predominantly upper-lobe emphysema and low post-rehabilitation exercise capacity, lung volume reduction surgery results in improved survival compared with medical treatment.

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