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Persistent Dyspnea Despite Maximal Medical Therapy in COPD

Case Editor - Kamyar Afshar

Reviewed By Allergy, Immunology & Inflammation Assembly

Submitted by

Brian P. Mieczkowski, DO

Fellow

Division of Pulmonary, Allergy, Critical Care and Sleep Medicine

The Ohio State University Medical Center

Columbus, Ohio

Michael E. Ezzie, MD

Assistant Professor of Internal Medicine

Division of Pulmonary, Allergy, Critical Care and Sleep Medicine

The Ohio State University Medical Center

Columbus, Ohio

Submit your comments to the author(s).

History

A 64-year-old woman with a history of smoking presented with progressive shortness of breath with exertion. The patient smoked one to two packs of cigarettes per day for forty-two years and quit smoking one year ago. She had increasing dyspnea on exertion over the past few years that accelerated over the last year. She reported she could now only walk short distances before sitting down to catch her breath. Her family doctor started her on bronchodilators a few years ago. She had improvement at the time, but now feels very limited. She had several episodes of increased dyspnea, wheezing, and productive cough over the past two years. These exacerbations were treated as an outpatient with oral corticosteroids and antibiotics. Two years ago, she participated in a four week course of pulmonary rehab which resulted in improvement in her dyspnea. She denied chest pain or palpitations with breathing symptoms. She reported no shortness of breath at rest, except when talking for more than a few minutes. She had no emergency department visits and had not required mechanical ventilator support for breathing. She had no nocturnal symptoms of wheezing or shortness of breath, but did have occasional wheezing during the day along with a dry cough. The patient was interested in discussing additional therapies for her lung disease.

Her past medical history was significant for smoking, depression, arthritis, hypertension, hyperlipidemia, and squamous cell carcinoma of the skin on the leg that was removed.

Her current medications included amlodipine, sertraline, aspirin, tiotropium, albuterol, salmeterol/fluticasone, and simvastatin.

The patient reported that her father had chronic obstructive pulmonary disease (COPD). There was no other family history of lung disease.

The patient had been married for forty-five years and had two children. She was a former smoker of one to two packs per day for forty-two years. She denied alcohol or drug use. She reported no significant occupational exposures.

A review of systems was pertinent for fatigue and occasional heartburn.

Physical Exam

On examination, the patient’s weight was 118 pounds with a body mass index (BMI) of 20.3. Her blood pressure was 120/70 mmHg with a pulse of 96 beats per minute. Her oxygen saturation was 91% breathing ambient air. Her general appearance was thin, and notable for a pleasant female who was alert and oriented in no acute distress.Her oropharynx was clear without exudate and neck exam revealed no lymphadenopathy. Her lung exam had diminished breath sounds bilaterally with comfortable respirations and an appreciably long expiratory phase. No wheezes, rhonchi or rales were noted. Cardiac exam was normal rate with a regular rhythm. Abdomen was thin, soft and nontender and extremities showed no evidence of clubbing or edema.

Diagnostic studies

Pulmonary Function Tests:

Forced Expiratory Volume in one second (FEV1): 0.84 L (34% predicted)
Forced Vital Capacity (FVC): 2.46 L (56% predicted)
FEV1/FVC: 0.34
Total lung capacity (TLC): 138% of predicted
Residual volume (RV): 227% of predicted
Diffusing Capacity of Carbon Monoxide (DLCO): 31% of predicted

6-minute walk distance: She walked 900 feet and desaturated to 91%.            

Cardiopulmonary exercise testing: Her power output was 20 watts.

Arterial blood gas: Baseline measurement of pCO2 was 37 and pO2 was 72. The carboxyhemoglobin level was 0.

Figures


Figure 1.1: Posterior-Anterior and Lateral Chest Radiograph - Demonstrating hyperinflated lungs with emphysema

Figure 1.2: High Resolution Computed Tomography (CT) of the Chest - Demonstrating severe changes of upper lobe predominant pulmonary emphysema.

Figure 1.3: Lung Perfusion Scan – Demonstrating her right upper lobe with 3.6% of total perfusion, her left upper lobe with 5% of total perfusion, her right middle lobe 13.6% of the total, her right lower lobe 26.3% of the total, and her left lower lobe 25.8% with left middle area 25.7%.

Question 1

Based on our current understanding of gender differences in COPD, which of the following might be expected in this female patient compared to a male with an equivalent degree of airflow obstruction?


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