68 year old man

Introduction

• A 68 year old man with a history of coronary artery disease, type 2 diabetes & COPD presents for initial evaluation of COPD
• He has a 60 pack-year history of cigarette smoking & currently smokes 1 pack per day
• Four months ago, he was hospitalized for COPD exacerbation (increased cough & sputum production with severe shortness of breath) found to have acute hypercapneic respiratory failure necessitating non-invasive positive pressure ventilation (NPPV) for 1 day.
• He was treated with a Z-pak & 5 days of prednisone 40 mg/day & discharged on day 3.
• He had been previously hospitalized for an earlier COPD exacerbation ~6 months prior to today's visit, but did not require NPPV.

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• Today he reports mild dyspnea & occasional non-productive cough
• He is able to walk comfortably on level ground but becomes short-of-breath walking uphill.
• He can perform all of his activities of daily living without limitation.
• His current medications include carvedilol 6.25 mg BID, atorvastatin 40 mg QHS, chlorthalidone 12.5 mg QD, KCl 20 meq QD & albuterol MDI PRN.

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• An electrocardiogram shows normal sinus rhythm with left axis deviation, a left anterior fascicular block & QTc of 507 sec.
• A transthoracic echocardiogram reveals regional anterolateral wall motion abnormality, LVEF of 55-60% & normal right ventricular function without evidence of pulmonary hypertension
• There is no evidence of valvular dysfunction.

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• Pulmonary function testing shows FEV1/FVC if 58%, FEV1 of 44% predicted without bronchodilator response, total lung capacity of 120%, DLCO 79% of predicted.
• A CBC shows an eosinophil count of 99/uL.

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• In addition to recommending smoking cessation, providing appropriate vaccinations, & referring to pulmonary rehabilitation, what pharmaceutical intervention should be prescribed?

More general terms

• case presentation