Detection of PH in patients with COPD can be challenging because symptoms such as dyspnea and fatigue are common and are usually the results of airflow limitation and hyperinflation in COPD. Indeed, in these patients, there was a prolonged duration of symptoms until the diagnosis of severe PH was made. Therefore, when a patient presents with severe dyspnea somewhat disproportionate to the severity (or even absence in our present cases) of airflow limitation, the presence of PH might be suspected. It is important to identify this subgroup of patients because they have a poor prognosis and may be candidates for specific management.12 Long-term oxygen therapy is recommended in patients with COPD and hypoxemia. However, although in patients with mild to moderate PH long-term oxygen therapy improves or at least stabilizes PAP, in patients with severe PH, oxygen therapy appears insufficient to reverse or even stabilize PAP.13 In the absence of lung pathologic assessment in these patients, we can only speculate that the severe PH might be due to a significant and irreversible pulmonary vascular remodeling component, similar to that observed in pulmonary arterial hypertension. This hypothesis might argue in favor of the use of drugs approved for pulmonary arterial hypertension in this group of patients, but, based on the present evidence, it is strongly recommended not to treat patients with COPD with drugs dedicated to pulmonary arterial hypertension outside randomized controlled trials. Obviously, eligible patients should be considered for lung transplant when they present with this severe phenotype, but this was not possible in this elderly population. Interestingly, these patients were older and had comorbidities, including systemic hypertension. As in the systemic circulation, the pulmonary vasculature may be affected by age-associated arterial remodeling,14 leading to pulmonary vascular stiffness and increases in systolic PAP. A recent population-based study15 demonstrated that PAP increases with age.