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A 68-Year-Old Man Comes to the Office with a 2-Year

question 137

Multiple Choice

A 68-year-old man comes to the office with a 2-year history of increasing shortness of breath and daily cough with sputum for the past several months. The patient now becomes dyspneic walking 2 blocks or up 1 flight of stairs. He has had no fever or chest pain. The patient has not seen a physician for many years and takes no regular medication, but on several occasions, he has used his wife's albuterol inhaler, which provides some symptom relief. He has a 40-pack-year history and is trying to stop smoking.
Blood pressure is 140/80 mm Hg, pulse is 90/min, and respirations are 18/min. Pulse oximetry is 88% at rest on ambient air. Examination shows jugular venous distension, increased anteroposterior chest diameter, an accentuated S2, and a holosystolic murmur at the left sternal border, the intensity of which increases with inspiration. Lung auscultation reveals a prolonged expiration phase with decreased breath sounds throughout. There is mild bilateral pitting edema of the lower extremities.
Pulmonary function testing results are as follows:
Chest radiograph shows hyperinflated lungs with a flattened diaphragm but no parenchymal opacities.
In addition to smoking cessation, which of the following is most likely to prolong survival in this patient?

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