The most appropriate management is to evaluate for lung transplantation. Criteria for referral for lung transplantation include a history of COPD exacerbations associated with acute hypercapnia (arterial PCO₂ >50 mm Hg [6.7 kPa]); pulmonary hypertension, cor pulmonale, or both despite oxygen therapy; or FEV₁ less than 20% of predicted with DLCO less than 20% of predicted or homogeneous distribution of emphysema. This 60-year-old patient has a history of hospitalization for exacerbations, hypercapnia, an FEV₁ of less than 20% of predicted, and bilateral homogeneous distribution of emphysema. Therefore, he is a candidate for lung transplantation. Absolute contraindications to lung transplantation include malignancy within the last 2 years, infection with hepatitis B or C virus with histologic evidence of significant liver damage, active or recent cigarette smoking, drug or alcohol abuse, severe psychiatric illness, documented nonadherence with medical care, and absence of social support. Age greater than 65 years is a relative contraindication, as well as the presence of multiple comorbid conditions, which are not present in this patient.

Short-term use of systemic glucocorticoids is recommended for acute exacerbations of COPD. However, long-term use of oral glucocorticoids has not been shown to improve quality of life or reduce the rate of exacerbations. Because this patient has no evidence of an acute exacerbation, there is no indication for oral glucocorticoid therapy.

Lung volume reduction surgery (LVRS) is indicated in patients with predominantly upper lobe emphysema. Because this patient has homogeneous emphysema, LVRS is not an option. Additionally, LVRS results in higher mortality in patients with an FEV₁ less than 20% of predicted.

Hospice is an approach to care in patients with life-limiting illness and focuses on quality of life rather than an attempt at cure of the underlying disease based on the patient's and family's goals and values. Although this patient is significantly limited in his daily activities, it is not clear that he has entered the last months to weeks of life, which is the usual time frame for hospice care (compared with palliative care, which is appropriate for all patients with severe or advanced disease). Additionally, because this patient meets criteria for possible lung transplantation, it is reasonable to offer this as a potential treatment option. Hospice care may be a consideration if he is not a transplant candidate or if he declines further aggressive treatment and his condition progresses.