A 48-year-old Woman with Breathlessness and Cough

The diagnosis of chronic obstructive pulmonary disease (COPD) is a clinical art, with the important management goals of early diagnosis and appropriate staging. A broad definition of the disease, as suggested by international guidelines, includes a finding of airflow obstruction that is not fully reversible plus an appropriate risk factor and chronic symptoms, including cough, sputum production, dyspnea, or chest tightness. The following case highlights the importance of spirometry in diagnosing COPD and in selecting appropriate initial therapy. The recent multinational participants of the GOLD (The National Heart, Lung, and Blood Institute/World Health Organization Global Strategy for the Diagnosis, Management and Prevention of COPD) workshop recommended a clear and comprehensive COPD management plan that includes the assessment and monitoring of disease, reduction of risk factors, and management of stable disease. Effective management was also defined to include preventing disease progression, alleviating symptoms, improving exercise tolerance, improving health status, preventing and treating complications, preventing and treating exacerbations, and reducing mortality. Thus, while smoking cessation remains the vital component in any comprehensive approach to the patient with COPD, the clinician must be cognizant of the full range of diagnostic challenges and therapeutic goals for these difficult-totreat patients. HISTORY The patient is a 48-year-old woman with progressive breathlessness and increased cough for 2 days. While admitting to at least 2 years of breathlessness with moderate exertion, she attributes these symptoms to poor conditioning from decreased activity and increased weight. She is currently breathless at climbing 1 to 2 flights of stairs. She walks at a normal pace on level ground and sleeps well without breathlessness or cough. An intermittent daytime wheeze has been noted. She has had no nasal symptoms or signs suggestive of gastroesophageal reflux. Her previous primary care practitioner prescribed a short-acting beta-agonist (MDI) to be used intermittently. However, the patient has used it infrequently as she has noted "no change." She has smoked 2 packs of cigarettes each day for 30 years (ie, 60 pack-years). Because of her respiratory symptoms, she recently decreased her smoking to half a pack to1 pack per day. She has gained 30 pounds over the past year as her cigarette consumption decreased. She has a cat and dog in her home. She works as a glass etcher but has no other chemical exposures. There is no previous history of allergy, asthma, or cardiovascular disease. There is no family history of allergy, pulmonary disease, or skin disease.