Case Challenge: Obesity and Shortness of Breath in a 52-Year-Old Man

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A man with morbid obesity, COPD, and OSA presents with shortness of breath and dyspnea on exertion.
A man with morbid obesity, COPD, and OSA presents with shortness of breath and dyspnea on exertion.

A 52-year-old man with morbid obesity (body mass index 37 kg/m2) presents for pulmonary consultation with complaints of shortness of breath at rest and dyspnea on exertion. He was diagnosed with chronic obstructive pulmonary disease (COPD) one year ago by his primary care provider and started on nebulizer treatments at home with no improvement in his symptoms. In fact, they have worsened.

He reports hypersomnolence during the day, fatigue, and an inability to concentrate. His wife states that he has snored loudly for the past 15 years, but during the past 5 years she has noted increased episodes of choking during sleep. He was diagnosed with obstructive sleep apnea 7 years ago, but did not tolerate continuous positive airway pressure therapy because of the uncomfortable face mask.

Pulse oximetry performed in the office shows an oxygen saturation level of 79%. Physical exam reveals a morbidly obese man with distant but clear lung sounds, mild jugular venous distention, and 1+ bilateral pitting lower extremity edema. Pulmonary function testing last year showed significant restrictive pattern. Echocardiography last month showed mild left ventricular (LV) hypertrophy with normal LV systolic function. The right ventricle was mildly dilated with elevated right ventricular (RV) systolic pressures of 42 mm Hg.

What is the next best step?

A.      Start positive airway pressure and refer to a weight-loss program

B.      Add albuterol rescue inhaler to current regimen

C.      Start bosentan for pulmonary hypertension

D.      Refer for right heart catheterization for pulmonary hypertension and RV failure

E.      Obtain a computed tomographic angiogram to rule out pulmonary embolism 

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