MRCP2-4504
A 65-year-old man presents to the Respiratory Clinic for evaluation of his chronic obstructive pulmonary disease (COPD) symptoms. He has been referred by his primary care physician due to increasing shortness of breath. Despite his diagnosis, he continues to smoke ten cigarettes per day. He reports a history of childhood asthma and a positive response to oral steroids in the past. His most recent forced expiratory volume in 1 second (FEV1) is 40% of predicted, and he can only walk 50 m to the local bus stop. He currently takes a salbutamol inhaler as needed and carbocisteine. On examination, his blood pressure is 135/82 mmHg, pulse is 78 bpm and regular, and he has signs of right heart failure. What is the most appropriate intervention to decrease the risk of future exacerbations?