For August 29, 2023

A 68-year-old man with a history of coronary artery disease, type 2 diabetes, hypertension, and chronic obstructive pulmonary disease (COPD) presents for initial evaluation of COPD. He has a 60-pack-year history of cigarette use and is currently smoking one pack of cigarettes per day. Four months ago, he was admitted to the hospital with increased cough and sputum production with severe shortness of breath and was found to have acute hypercapnic respiratory failure necessitating noninvasive positive pressure ventilation (NPPV) for one day. He was treated with prednisone and doxycycline and was discharged after 3 days. He was also admitted to the hospital about 6 months earlier with an exacerbation but did not require NPPV at that time.

Today, he reports mild dyspnea and an occasional nonproductive cough. He is able to walk comfortably on level ground but gets “winded" walking uphill. He can accomplish all of his activities of daily living without limitation. His current medications include carvedilol 6.25 mg twice daily, atorvastatin 40 mg daily, chlorthalidone 12.5 mg daily, potassium chloride 20 mEq daily, and inhaled albuterol as needed.

A transthoracic echocardiogram reveals a regional anterolateral wall-motion abnormality, a left ventricular ejection fraction estimated at 55% to 60%, and normal right ventricular function without evidence of pulmonary hypertension. There is no evidence of any significant valvular dysfunction. An electrocardiogram reveals normal sinus rhythm with left-axis deviation, a left anterior fascicular block, and a corrected QT interval of 507 msec.

Pulmonary function test results are as follows:

  • FEV1 /FVC ratio: 58%
  • FEV1 : 44% of predicted and without significant bronchodilator responsiveness
  • Total lung capacity: 120% of predicted
  • Carbon monoxide diffusing capacity: 79% of predicted

A complete blood count with differential shows an eosinophil count of 99 cells/mm3 (reference range, 0–350).

In addition to recommending smoking cessation, providing appropriate vaccinations, and referring to pulmonary rehabilitation, which one of the following pharmacologic therapies should be initiated?

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