From the Guidelines
The next step for this 89-year-old male with new radiographic findings suggestive of COPD would be to perform pulmonary function tests (PFTs) with bronchodilator challenge to confirm the diagnosis of COPD. Given the patient's shortness of breath with exertion and the chest X-ray findings, PFTs are essential to establish baseline lung function, determine the severity of any obstruction, and distinguish between COPD and other potential causes of his symptoms. Since the patient has severe aortic stenosis status post TAVR and hypertension, it's important to consider that his dyspnea could be multifactorial, potentially related to residual cardiac issues, valve function, or the newly identified pulmonary condition.
Following PFTs, if COPD is confirmed, treatment would typically begin with a short-acting bronchodilator such as albuterol (2 puffs every 4-6 hours as needed) and potentially a long-acting bronchodilator like tiotropium (18 mcg once daily) depending on symptom severity, as recommended by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) report 1. An echocardiogram would also be appropriate to evaluate the TAVR function and assess for other cardiac causes of dyspnea.
Some key points to consider in the management of this patient include:
- Smoking cessation is key, although the patient's history of smoking is not provided 1
- Pharmacologic therapy can reduce COPD symptoms, reduce the frequency and severity of exacerbations, and improve health status and exercise tolerance 1
- Pulmonary rehabilitation improves symptoms, quality of life, and physical and emotional participation in everyday activities, and may be beneficial for this patient 1
- Influenza and pneumococcal vaccinations are important to decrease the incidence of lower respiratory tract infections 1
The combination of cardiac and pulmonary evaluations is crucial in this elderly patient with multiple comorbidities to determine the primary cause of his exertional dyspnea and guide appropriate management.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Patient Assessment
- The patient is an 89-year-old male with a history of hypertension and severe aortic stenosis, status post TAVR.
- He has been reporting shortness of breath with exertion.
- A chest x-ray showed COPD with chronic changes, despite no prior history of COPD.
Considerations for Next Steps
- According to the study 2, TAVR can improve pulmonary function in patients with severe aortic stenosis, including those with COPD.
- The study 3 found that TAVR is associated with a significant reduction in pulmonary artery systolic pressure (PASP) in patients with pulmonary hypertension, which may be relevant to this patient's condition.
- However, the study 4 suggests that patients with pulmonary hypertension undergoing TAVR may be at increased risk for peri-interventional complications.
Potential Next Steps
- Further evaluation of the patient's pulmonary function and pulmonary hypertension status may be necessary to determine the best course of action.
- Consideration of antithrombotic therapy, as discussed in the study 5, may be relevant to this patient's treatment plan.
- The patient's symptoms and medical history should be carefully assessed to determine the underlying cause of his shortness of breath and to guide further treatment decisions.