What is the next step for an 89-year-old male patient with a history of hypertension and severe aortic stenosis, status post Transcatheter Aortic Valve Replacement (TAVR), presenting with exertional dyspnea and a chest x-ray showing Chronic Obstructive Pulmonary Disease (COPD) with colonic changes?

From the Guidelines

The next step for this 89-year-old male with new radiographic findings of COPD with colonic changes should be a comprehensive pulmonary evaluation including pulmonary function tests (PFTs) with bronchodilator response testing and a CT scan of the chest, as well as a colonoscopy to evaluate the unexpected colonic changes. Given the patient's shortness of breath with exertion, these tests will help confirm the COPD diagnosis and assess its severity 1. Additionally, a colonoscopy should be scheduled to evaluate the unexpected colonic changes noted on chest X-ray, as these could represent an incidental finding requiring further investigation. While managing the patient's symptoms, consider initiating a short-acting bronchodilator such as albuterol 90 mcg, 2 puffs every 4-6 hours as needed for breathlessness. Some key points to consider in the management of this patient include:

• The importance of a multidisciplinary approach involving cardiology, pulmonology, and gastroenterology to manage this complex patient with multiple conditions 1
• The need for shared decision-making and education of the patient and their family about treatment alternatives, including the risks and benefits of different treatment strategies 1
• The potential benefits of pulmonary rehabilitation, including improved health status, reduced health service use, and improved quality of life 1
• The importance of addressing end-of-life decision making and advance care planning, particularly in patients with severe COPD and other comorbidities 1. It's also important to determine whether the patient's symptoms are primarily due to his known severe aortic stenosis status post TAVR or the newly identified COPD. The unexpected finding of colonic changes on chest X-ray without prior history raises concern for possible malignancy or other pathology that requires prompt evaluation. A comprehensive approach to this patient's care will require careful consideration of these factors and close collaboration between multiple specialties.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Patient Assessment and Diagnosis

• The patient is an 89-year-old male with a history of hypertension and severe aortic stenosis, status post TAVR, presenting with shortness of breath on exertion.
• A chest x-ray revealed COPD with colon changes, but the patient has no history of COPD.

Next Steps in Management

• According to the study 2, pulmonary function testing is essential for the diagnosis and treatment of COPD, and should include spirometry, full-body plethysmography, and determination of diffusion capacity.
• The study 3 also highlights the importance of lung function testing in the comprehensive assessment and individualized management of COPD.
• Given the patient's symptoms and chest x-ray results, lung function testing should be performed to confirm the diagnosis of COPD and assess the severity of the disease.
• The study 4 suggests that tiotropium, a once-daily inhaled anticholinergic bronchodilator, can improve exercise tolerance and reduce symptoms in patients with COPD, and may be considered as part of the treatment plan.

Considerations for Treatment

• The patient's history of hypertension and severe aortic stenosis should be taken into account when developing a treatment plan for COPD.
• The study 2 notes that pharmaceutical treatment is only valid for patients with co-existing airway obstruction according to GOLD criteria, but non-pharmaceutical treatments such as pulmonary rehabilitation may still be beneficial for patients with progressive symptoms.
• A comprehensive health history, as described in the study 5, should be taken to gather important information about the patient's medical history, symptoms, and lifestyle, and to establish a therapeutic relationship with the patient.