What is the best course of action for a patient with persistent shortness of breath (SOB), chronic obstructive pulmonary disease (COPD), and chronic bronchitis, with a widened mediastinum on chest X-ray (CXR) suggesting possible tortuous or aneurysmal aorta versus pulmonary artery enlargement?

From the Guidelines

The best course of action for this patient is to obtain a CT angiogram (CTA) of the chest to definitively evaluate the widened mediastinum, as recommended by the most recent guidelines 1. This imaging study is essential to distinguish between an aortic aneurysm, tortuous aorta, or pulmonary artery enlargement, as these conditions require different management approaches. While awaiting the CTA results, the patient's COPD and chronic bronchitis should be optimized with a combination of bronchodilators such as a long-acting beta-agonist (LABA) like formoterol 12 mcg twice daily and a long-acting muscarinic antagonist (LAMA) like tiotropium 18 mcg once daily, as suggested by the Global Initiative for Chronic Obstructive Lung Disease 1. Some key points to consider in managing the patient's COPD include:

• The use of inhaled corticosteroids like fluticasone 250 mcg twice daily may be added if the patient has frequent exacerbations, as indicated by various national guidelines 1.
• Supplemental oxygen should be provided if oxygen saturation is below 88%, as part of standard COPD management.
• The patient should also be advised to continue any previously prescribed antibiotics for bronchitis if currently taking them. If the CTA confirms an aortic aneurysm greater than 5.5 cm, urgent vascular surgery consultation is warranted. For pulmonary artery enlargement, further cardiac evaluation including echocardiography would be needed to assess for pulmonary hypertension, as outlined in guidelines for the diagnosis and treatment of pulmonary hypertension 1. This approach addresses both the acute diagnostic concern of the mediastinal widening while simultaneously managing the underlying respiratory conditions that are contributing to the patient's shortness of breath. Additionally, pulmonary rehabilitation may be beneficial for patients with chronic respiratory diseases, including those with COPD, as it can help improve exercise tolerance, reduce symptoms, and enhance quality of life 1.

From the Research

Patient Assessment and Diagnosis

• The patient presents with persistent shortness of breath (SOB), chronic obstructive pulmonary disease (COPD), and chronic bronchitis, with a widened mediastinum on chest X-ray (CXR) suggesting possible tortuous or aneurysmal aorta versus pulmonary artery enlargement 2, 3.
• The widened mediastinum may indicate aortic aneurysm (AA) or pulmonary artery enlargement, both of which are significant comorbidities in patients with COPD 2.
• Computed tomography (CT) scan is recommended for further assessment to determine the cause of the widened mediastinum and to evaluate the severity of COPD and chronic bronchitis 2, 3.

Aortic Aneurysm and COPD

• Studies have shown that patients with COPD have a high prevalence of aortic aneurysm, with a reported prevalence of 11.7% in one study 2.
• Aortic aneurysm is a significant comorbidity in patients with COPD, and its rupture is an important cause of death 2.
• The study by 2 found that a low attenuation area and aortic wall calcification were more severe in patients with AA than in those without AA.

Pulmonary Artery Enlargement and COPD

• Pulmonary artery enlargement is also a common comorbidity in patients with COPD, and is associated with an increased risk of exacerbations 3.
• The study by 3 found that a pulmonary artery to aorta diameter ratio greater than 1 was associated with an increased risk of pulmonary hypertension.
• Another study found that a PA/A ratio above 0.95 was an independent predictor of pulmonary hypertension with a specificity of 100% and a sensitivity of 74.51% 4.

Treatment and Management

• For patients with COPD and aortic aneurysm, endovascular aneurysm repair (EVAR) may be a preferred treatment option, as it has been shown to have improved outcomes compared to open repair 5.
• The study by 5 found that EVAR was associated with lower in-hospital mortality, fewer major complications, and shorter hospital length of stay compared to open repair.
• For patients with COPD and pulmonary artery enlargement, treatment should focus on managing the underlying COPD and preventing exacerbations 3.