MKSAP: 62-year-old man is evaluated for declining exercise capacity

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

A 62-year-old man is evaluated for declining exercise capacity over the past year. He was diagnosed with moderate COPD 3 years ago. His symptoms had previously been well controlled with tiotropium and as-needed albuterol. He has not had any hospitalizations. He is adherent to his medication regimen, and his inhaler technique is good. He quit smoking 2 years ago. All immunizations are up to date, including influenza and pneumococcal vaccination. A chest radiograph performed 3 months ago for increased cough and sputum production was normal. Pulmonary function testing performed 3 years ago showed an FEV1of 58% of predicted, an FEV1/FVC ratio of 60%, and a DLCO of 85% of predicted.

On physical examination, vital signs are normal. Oxygen saturation is 93% breathing ambient air. No jugular venous distention is noted. The lungs are clear. Cardiac examination reveals normal heart sounds. There are no murmurs. No edema is noted.

Which of the following is the most appropriate management?

A: Add roflumilast
B: Obtain complete pulmonary function tests
C: Perform chest CT
D: Repeat spirometry
E: Start oxygen therapy

MKSAP Answer and Critique

The correct answer is D: Repeat spirometry.

The most appropriate management is to repeat spirometry. Lung function can worsen over time in patients with COPD. During each visit, new or worsening symptoms (cough, sputum, dyspnea, fatigue), smoking status, adherence to and effectiveness of the medication regimen, adverse effects of treatment, and inhaler technique should be assessed. The frequency, severity, and causes of exacerbations should be evaluated. Comorbidities should be identified and managed. Spirometry is indicated when patients with COPD experience a change in symptoms. Annual spirometry can help determine which patients have rapid decline in lung function. Because this patient had pulmonary function testing done 3 years ago and has since had a decrease in his exercise capacity, spirometry is indicated. If spirometry shows worsening airflow obstruction in this patient, addition of a long-acting β2-agonist and an inhaled glucocorticoid may help with symptom control. If spirometry does not show significant worsening of airflow, other comorbidities such as cardiovascular disease should be considered.

Roflumilast is a phosphodiesterase-4 inhibitor that is indicated in patients with severe and very severe COPD with recurrent exacerbations. This patient does not meet these criteria for use of this medication.

Monitoring patients with COPD using complete pulmonary function testing (with lung volumes and diffusing capacity) rather than spirometry is not cost effective and does not change management. Complete pulmonary function testing is not required unless lung volume reduction surgery (LVRS) or lung transplantation is being considered.

CT of the chest is not routinely recommended in the monitoring of COPD. This patient had a recent chest radiograph, which was normal, and there are no symptoms or signs to suggest a tumor that would warrant a CT scan at this time. Chest CT would be useful if this patient was being evaluated for LVRS or lung transplantation.

Oxygen therapy is not indicated because an oxygen saturation greater than 88% is adequate. If oxygen saturation is less than 92%, arterial blood gas studies should be performed.

Key Point

  • Spirometry is indicated when patients with COPD experience a change in symptoms; annual spirometry can help determine which patients have rapid decline in lung function.

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 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.

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