The most appropriate treatment is to start pulmonary rehabilitation. Pulmonary rehabilitation is recommended for all symptomatic patients with COPD and an FEV1 less than 50% of predicted and specifically for those hospitalized with an acute exacerbation of COPD. Pulmonary rehabilitation may also be considered in symptomatic or exercise-limited patients with an FEV1 greater than or equal to 50% of predicted, such as this patient. This patient has had a recent acute exacerbation, has diminished exercise capacity, and is on maximal medical treatment; therefore, she would benefit from pulmonary rehabilitation.
Roflumilast is indicated only in patients with severe or very severe COPD with recurrent exacerbations. This is this patient's first exacerbation, and this treatment is therefore not indicated.
Long-term glucocorticoid therapy is not indicated in patients with COPD owing to serious side effects; however, short-term use is helpful during an acute exacerbation. A recent study showed that, in addition to optimizing COPD therapy, a 5-day course of an oral glucocorticoid is adequate for most patients with COPD exacerbation. Increasing the duration of therapy by an additional 5 days would not likely be of benefit because this patient is completing a 5-day course of glucocorticoids, her symptoms have already improved, and the anti-inflammatory effect of glucocorticoids extends beyond completion of the course of medication.
Long-term oxygen therapy is indicated in patients with an arterial PO2 at or below 55 mm Hg (7.3 kPa) or oxygen saturation breathing ambient air at or below 88% (confirmed twice over a 3-week period), with or without hypercapnia. Other indications are evidence of pulmonary hypertension, peripheral edema suggesting right-sided heart failure, or polycythemia, in combination with an arterial PO2 less than 60 mm Hg (8.0 kPa), or oxygen saturation less than 88% breathing ambient air. This patient's oxygen saturation is 92% breathing ambient air; therefore, oxygen supplementation is not currently indicated.