J.O. seemed to do reasonably well for a number of years, but

J.O. seemed to do reasonably well for a number of years, but

J.O. seemed to do reasonably well for a number of years, but now, 5 years later, she has noticed progressive dyspnea on exertion. She is now having difficulty carrying laundry up from her basement, and she has noticed that her overall activity level has been curtailed. Repeat office spirometry now shows an FEV1/FVC ratio of 0.49 and an absolute FEV1 of 49% of predicted. J.O. has been compliant with her tiotropium regimen and has had no other significant changes to her medical history. She remains smokefree and is not exposed to second-hand smoke in her home and work environments. What therapeutic intervention(s) should be considered at this point?