[Solved]: Michael, a 58-year-old disabled construction…

Michael, a 58-year-old disabled construction worker, presents with progressive exertional dyspnea and a persistent dry cough which started 5 years ago. Oxygen dependent at 5L/min (non-compliant). Bilateral inspiratory crackles (“Velcro crackles”) at lung bases noted; no wheezing but has significantly reduced breath sounds. He has digital clubbing, and noted even walking to the kitchen or bathroom he has to use his walker as fear of “running out of air” and falling. He states he wakes up at night gasping for air at times and has to sleep in his chair in the living room and “I can’t even go to bed”. He states all throughout the day he does nothing but cough but states no sputum. His history notes he had asthma as a child and COPD diagnosed at the age of thirty from what was diagnosed at that time as “chronic bronchitis” [bronchial inflammation]. “I hate walking around with that cord like a dog-leash all day just to breath” “I don’t think I need it” and “I have been around smoke and smoked my whole life” [unfiltered – cigarettes]; “I just use an inhaler as I have for years when they diagnosed me with COPD”. He worked for over 30 years as a concrete mixer driver, frequently exposed to silica dust from cement. Over the last two years, his symptoms worsened, requiring continuous emergency room visits and treatment. Despite treatment with steroids and agents, his pulmonary function continued to decline, leading to his recent placement on organ list for bilateral lung transplant. Pulmonary Function Tests (PFTs) FVC: 48% predicted (severely reduced); DLCO: 35% predicted (severely impaired gas exchange); FEV1/FVC Ratio: Normal (>80%). Vitals: BP 128/76 mmHg, HR 92 bpm, RR 24/min, SpO2 89% on room air 91% on 5-liters O2; Weight: 240 pounds x 1 year ago now with unintentional weight loss at 170 pounds.