ANSWER 90
The most likely diagnosis is chronic obstructive pulmonary disease(COPD). The physical
signs and chest X-ray indicate overinflation. The early inspiratory crackles are typical of
COPD.
Treatment with bronchodilators should be pursued looking at the effect of $ 2 -agonists and
anticholinergic agents, judging the effect from the patient’s symptoms and exercise toler-
ance rather than spirometry. Theophylline may sometimes be useful as a third-line ther-
apy but has more side-effects.
With this degree of severity, inhaled corticosteroids and long-acting bronchodilators (sal-
meterol/formoterol or tiotropium) would be appropriate inhaled therapy. Careful attention
would need to be given to inhaler technique.
He is cyanosed and has signs of right-sided heart failure (cor pulmonale). Blood gases
should be checked to see if he might be a candidate for long-term home-oxygen therapy
(known to improve survival if the pressure of arterial oxygen (paO 2 ) in the steady-state
breathing air remains!7.2 kPa). Gentle diuresis might help the oedema although oxygen
would be a better approach if he is sufficiently hypoxic. Annual influenza vaccination
should be recommended and Streptococcus pneumoniaevaccination should be given.
Antibiotics might be kept at home for infective exacerbations.
Exercise tolerance will be reduced by his obesity and by lack of muscle use. A weight-
reducing diet should be started. If he has the motivation to continue exercising, then a
pulmonary rehabilitation programme has been shown to increase exercise tolerance by
around 20 per cent and to improve quality of life. Other more dramatic interventions such
as lung-reduction surgery or transplantation might be considered in a younger patient.
Depression is often associated with the poor exercise tolerance and social isolation, and
this should be considered.
COPD is often regarded as a condition where treatment has little to offer. However, a vig-
orous approach tailored to the need of the individual patient can provide a worthwhile
benefit.
- In COPD $ 2 -agonists and anticholinergic agents produce similar effects or a greater
response from anticholinergics. The combination may be helpful. In contrast, in asthma
$ 2 -agonists produce a greater effect. - Assessment for home oxygen should be made in a stable state on optimal inhaled therapy.
- Exercise and diet are important elements in the management of COPD.
- Depression is common in chronic conditions such as COPD.