COPD Flashcards
You see a 58-year-old female whom you suspect has COPD and you recommend formal testing in order to confirm this diagnosis. The cutoff most often used for COPD diagnosis on a spirometry test performed while the patient is stable (not experiencing an acute exacerbation of symptoms) is a postbronchodilator FEV1/FVC ratio (check one)
) <50% of predicted
<70% of predicted
<85% of predicted
>70% of predicted
>85% of predicted
<70% of predicted
Suspected COPD should be confirmed by spirometry in stable patients, based on a postbronchodilator FEV1/FVC ratio <70% of predicted (SOR C). While guidelines for the treatment of COPD differ slightly among the leading national and international organizations, most have come to a consensus on using this criterion for the diagnosis (SOR C).
In patients with severe COPD associated with chronic hypoxemia and hypercapnia, which one of the following has been shown to decrease mortality? (check one)
Oxygen therapy
Inhaled fluticasone (Flovent)
Inhaled formoterol (Perforomist)
Oral azithromycin (Zithromax)
Oral prednisone
Oxygen therapy
Hospice and palliative care should be considered in patients with severe COPD. Oxygen therapy has been shown to reduce mortality in patients with severe hypoxemia and hypercapnia. Additionally, noninvasive ventilation (i.e., CPAP therapy) added to oxygen can also improve mortality. While inhaled therapies such as fluticasone and formoterol can decrease hospitalizations and improve dyspnea, they have not been shown to improve mortality. There is some evidence that inhaled triple therapy with a long-acting muscarinic antagonist, a long-acting β-agonist, and an inhaled corticosteroid may improve mortality, but that possibility has not been demonstrated consistently and additional studies are needed. In select patients, lung reduction surgery may also reduce mortality. Azithromycin and oral prednisone are options for adjunctive therapy to reduce exacerbations for some patients, but neither has been shown to decrease mortality in patients with severe COPD associated with chronic hypoxemia and hypercapnia.
A 57-year-old male who uses tobacco presents with cough and dyspnea. His symptoms were previously controlled with an albuterol (Proventil, Ventolin) inhaler once or twice a month. After a 3-week trial of a tiotropium (Spiriva) inhaler his symptoms are better, but he is still having frequent episodes of coughing and dyspnea. He has been smoking 1–2 packs of cigarettes a day since age 13 and is not interested in quitting.
On examination he is afebrile, his vital signs are stable, and his oxygen saturation is 95% on room air. His lung sounds are diminished, and the remainder of the examination is unremarkable. His in-office peak flow is 300 L/min. You suspect he has moderate COPD and recommend pulmonary function tests but he declines.
In addition to continuing tiotropium, which one of the following medications would you recommend adding to his current regimen? (check one)
An oral antibiotic
An oral corticosteroid
An inhaled corticosteroid
An inhaled long-acting β-agonist
A nebulized short-acting β-agonist
An inhaled long-acting β-agonist
Guidelines from the Global Initiative for Chronic Obstructive Lung Disease (GOLD), the National Initiative for Health and Care Excellence, and the American College of Chest Physicians all recommend that in addition to smoking cessation, COPD should be treated initially with either a long-acting β-agonist (LABA) or a long-acting muscarinic antagonist (LAMA). If symptoms persist with either of those inhaled medications then combination therapy should be initiated. An inhaled corticosteroid (ICS) can be added to the LABA/LAMA regimen for triple therapy if symptoms continue. Long-term use of an ICS as monotherapy is not recommended due to a slight increase in the incidence of pneumonia.
A 67-year-old male is admitted to your inpatient service with a week-long acute exacerbation of COPD. He also has hypertension and type 2 diabetes mellitus. After 24 hours of intravenous fluids and intravenous methylprednisolone, he is now tolerating oral intake.
Which one of the following corticosteroid regimens is best for this patient at this time? (check one)
Continue intravenous methylprednisolone until his COPD is back to baseline, then switch to oral methylprednisolone for a 14-day total course of treatment
Switch to oral prednisone for a 14-day total course of treatment, including the initial 24-hour intravenous treatment
Switch to oral prednisone for 4 more days of treatment
Use only inhaled corticosteroids by nebulizer
Discontinue corticosteroid treatment altogether after 24 hours
Switch to oral prednisone for 4 more days of treatment
Systemic corticosteroid therapy reduces the hospital length of stay in patients with acute COPD exacerbations (SOR A). Oral therapy has been shown to be as effective as the intravenous route in patients who can tolerate oral intake (SOR B). A randomized, controlled trial has demonstrated that 5-day courses of systemic corticosteroid therapy are at least as effective as 14-day courses (SOR A). Inhaled corticosteroids are beneficial in some COPD patients but nebulizers generally do not offer significant advantages over metered-dose inhalers in most patients.
A 55-year-old male with oxygen-dependent COPD plans to visit family 2000 miles away. For the last year, his COPD has been well controlled on medications and oxygen at 2 L/min. He wants to travel by commercial airline.
Which one of the following would be the most appropriate advice for this patient regarding air travel? (check one)
Choosing another mode of transit
Flying first class only
Continuing his oxygen flow rate at 2 L/min during the flight
Lowering his oxygen flow rate to 1 L/min during the flight
Doubling his oxygen flow rate to 4 L/min during the flight
Doubling his oxygen flow rate to 4 L/min during the flight
Commercial airline carriers typically permit Federal Aviation Administration–approved portable oxygen compressors. Patients whose usual oxygen requirements are <4 L/min are advised to double the flow rate during the flight. Conditions such as bullous lung disease, cystic fibrosis, and severe COPD may require the Hypoxia Altitude Simulation Test to determine in-flight oxygen requirements prior to air travel. It would not be appropriate to recommend this patient choose another mode of transit, fly first class only, continue his current oxygen flow rate, or lower his oxygen flow rate.
A 52-year-old male with hypertension complains of increased dyspnea for the past 6 months. He reports that he has increased fatigue and dyspnea with normal activities. There is no cough or chest pain. He has a 30-pack-year history of smoking.
On examination his blood pressure is 130/85 mm Hg, pulse rate 90 beats/min, respiratory rate 18/min, and O2 saturation 95% on room air. Heart sounds are normal with no murmurs. Auscultation of the lungs reveals bilateral rhonchi.
In addition to ordering a chest radiograph, which one of the following should be performed next in the evaluation of this patient’s dyspnea?
(check one)
A B-type natriuretic peptide (BNP) level
A D-dimer level
Arterial blood gas measurement
Spirometry
High-resolution CT of the chest
Spirometry
Based on this patient’s history and physical examination, COPD is the most likely cause of his dyspnea. Initial testing should include spirometry to diagnose airflow obstruction (SOR C). CT, a BNP level, a D-dimer level, and arterial blood gas measurements would not be the best initial tests in the evaluation of this patient’s dyspnea.
A 55-year-old male presents to your clinic for evaluation of COPD. He has a history of tobacco use and quit smoking 2 years ago. He reports occasional symptoms that limit his activities but has not had any exacerbations or hospitalizations. Pulmonary function tests indicate an FEV1/FVC ratio <0.7 and an FEV1 of 75%. His vital signs are normal.
Which one of the following would be the most appropriate initial pharmacotherapy? (check one)
Budesonide/formoterol (Symbicort)
Ipratropium (Atrovent)
Levalbuterol
Tiotropium (Spiriva)
Umeclidinium/vilanterol (Anoro Ellipta)
Tiotropium (Spiriva)
COPD is a common condition, which led to 3.23 million deaths worldwide in 2019. A variety of treatments are available to alleviate symptoms, and family physicians are well suited to manage this condition through lifestyle modifications and pharmacotherapy. Guidelines suggest that patients with mild disease, as in this patient’s case per the Global Initiative for Chronic Obstructive Lung Disease (GOLD) class 2 findings on pulmonary function tests and no exacerbations, are best managed through once-daily inhalation of a long-acting muscarinic antagonist (LAMA) such as tiotropium. Short-acting medications such as ipratropium and levalbuterol require frequent dosing and lack the mortality benefit seen with LAMAs. The combination of LAMAs and long-acting β-agonists (LABAs) can be initiated in those with persistent symptoms but would not be used as initial therapy. Inhaled corticosteroids may be beneficial in those with significant asthma and COPD overlap, but in general corticosteroids should be reserved for those with persistent symptoms despite LAMA and LABA therapy.
A 43-year-old male with hypertension and steatohepatitis sees you for follow-up after being treated for pneumonia and wheezing. On further questioning he reports mild shortness of breath for the past year. He is a former smoker with a 5-pack-year history. An examination is significant for diminished breath sounds diffusely, but no crackles or wheezing. Pulmonary function testing reveals a moderate nonreversible obstructive defect.
Which one of the following tests for genetic conditions would be most appropriate to order in this patient? (check one)
α1-Antitrypsin levels
Cystic fibrosis gene panel
Ehlers-Danlos gene panel
Hemochromatosis HFE
HLA-B27
α1-Antitrypsin levels
This patient is a relatively young person with a limited smoking history who has significant COPD, which should prompt consideration of testing for α1-antitrypsin deficiency. Cystic fibrosis primarily causes restrictive lung disease, typically presents in childhood, and is now often included in routine prenatal and newborn screening tests. Ehlers-Danlos syndrome is a genetic connective tissue disease. Genetic testing is available for rare subtypes, but not the most common hypermobile form. Hemochromatosis can cause cardiac disease but does not typically cause obstructive lung disease. Both α1-antitrypsin and hemochromatosis can cause liver inflammation. HLA-B27 is associated with seronegative spondyloarthropathies rather than COPD.
A 60-year-old male with moderate COPD presents to your office with shortness of breath and a cough with increased sputum volume. After appropriate evaluation, you diagnose an acute COPD exacerbation.
According to Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, which one of the following additional factors would provide the strongest indication for treatment with antibiotics? (check one)
A decline in oxygen saturation from baseline
Diffuse wheezing on lung auscultation
A fever
Increased sputum purulence
Leukocytosis
Increased sputum purulence
COPD exacerbations, when caused by an infectious agent, may be bacterial or viral. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines support the use of antibiotics in patients with an acute COPD exacerbation with the three cardinal symptoms of increased dyspnea, increased sputum volume, and increased sputum purulence; in patients with increased sputum purulence and one of the other cardinal symptoms; and in patients who require invasive or noninvasive mechanical ventilation. Hypoxemia and fever, although often seen in the setting of COPD exacerbations, do not provide as strong an indication for treatment with antibiotics. Diffuse wheezing is a hallmark examination finding that is present in most COPD exacerbations, regardless of the underlying cause. Leukocytosis is a relatively nonspecific marker for acute inflammation and may be seen with either viral or bacterial etiologies. Serum biomarkers such as C-reactive protein and procalcitonin have yielded controversial and conflicting evidence in guiding antibiotic therapy.
A 48-year-old female presents with dyspnea with exertion. She has never smoked. A physical examination is normal, including vital signs and pulse oximetry. A chest radiograph reveals mild hyperexpansion of the chest, and pulmonary function testing reveals an FEV1/FVC ratio of 0.67, unchanged after bronchodilator use. An EKG and stress echocardiogram are normal. You suspect COPD.
Which one of the following is the most likely underlying cause of this patient’s pulmonary disease? (check one)
Allergic bronchopulmonary aspergillosis
α1-Antitrypsin deficiency
Hemochromatosis
Primary pulmonary hypertension
Hypertrophic obstructive cardiomyopathy
α1-Antitrypsin deficiency
This patient is a nonsmoker but has typical symptoms and findings of COPD. α1-Antitrypsin deficiency should be considered in patients with very premature COPD or in patients without risk factors for COPD such as smoking, secondhand smoke exposure, or other smoke exposure. Dyspnea would be present and lung function would be normal in patients with primary pulmonary hypertension or hypertrophic obstructive cardiomyopathy. Hemochromatosis may cause liver function abnormalities but not abnormal lung function. Allergic bronchopulmonary aspergillosis is associated with asthma, not COPD.
In patients with COPD, which one of the following inhaled medications has been shown to reduce exacerbations and exacerbation-related hospitalizations? (check one)
Albuterol (Proventil, Ventolin)
Fluticasone (Flovent)
Ipratropium (Atrovent)
Salmeterol (Serevent)
Tiotropium (Spiriva)
Tiotropium (Spiriva)
A Cochrane review found that the long-acting antimuscarinic agent tiotropium improved quality of life and reduced exacerbations and exacerbation-related hospitalizations in patients with underlying COPD. Tiotropium was noted to be superior to long-acting β-agonists such as salmeterol. Albuterol, fluticasone, and ipratropium have not been shown to have these effects (SOR A).
A 62-year-old female has a history of COPD graded as moderate on pulmonary function testing, with an FEV1 of 65% of predicted and a PaO2 of 57 mm Hg. Because her symptoms of dyspnea on exertion and fatigue seem out of proportion to her pulmonary function tests, you order echocardiography, which shows a pulmonary artery systolic pressure of 50 mm Hg, indicating pulmonary hypertension.
Which one of the following would be most effective for decreasing mortality in this situation? (check one)
Supplemental oxygen
An endothelin receptor antagonist such as bosentan (Tracleer)
A calcium channel blocker such as nifedipine (Procardia)
A phosphodiesterase 5 inhibitor such as sildenafil (Revatio)
Referral for pulmonary artery endarterectomy
Supplemental oxygen
The only proven therapy for pulmonary hypertension related to COPD is supplemental oxygen. Supplemental oxygen should be recommended when the PaO2 is <60 mm Hg, because it has been shown to improve mortality by lowering pulmonary arterial pressures. Treatments effective for pulmonary artery hypertension should not be used. Pulmonary vasodilators such as nifedipine, sildenafil, and bosentan may cause a ventilation-perfusion mismatch. Pulmonary endarterectomy may be indicated for pulmonary hypertension caused by chronic thromboembolic disease.
A 58-year-old male with a 30-pack-year smoking history comes to your office to discuss screening for COPD. His older brother and sister have both recently been diagnosed with COPD and he wants to be screened for this soon. He continues to smoke and does not express a desire to quit. He does not have shortness of breath, cough, orthopnea, paroxysmal nocturnal dyspnea, or dyspnea on exertion. His only medication is aspirin, 81 mg daily. He has never used inhaled medications such as albuterol (Proventil, Ventolin). His family history is otherwise negative. You counsel him on tobacco cessation today.
Which one of the following is recommended with regard to COPD screening for this patient? (check one)
No screening
Spirometry with pre- and postbronchodilator testing
Posteroanterior and lateral chest radiographs
Noncontrast CT of the chest
α1-Antitrypsin deficiency gene testing
No screening
All patients with a smoking history and symptoms of COPD such as a chronic cough with sputum production and/or chronic and progressive dyspnea should be screened for COPD with spirometry. However, asymptomatic individuals such as this patient should not be screened with spirometry regardless of risk factors. Neither chest radiography nor chest CT has a role in screening for COPD. Screening for α1-antitrypsin deficiency in the absence of a family history is not recommended.
A 67-year-old female who recently moved to your city presents to your office as a new patient. Over the past year she has experienced wheezing and shortness of breath during her morning walks. She has a 35-pack-year smoking history and has been treated with antibiotics at least four times in the past year for respiratory infections. You suspect COPD and perform spirometry before and after a bronchodilator treatment.
Which one of the following pulmonary function test results would confirm COPD in this patient? (check one)
A reversible FEV1/FVC ratio <55%
A reversible FEV1/FVC ratio >75%
An irreversible FEV1/FVC ratio <65%
An irreversible FEV1/FVC ratio >85%
An irreversible FEV1/FVC ratio <65%
A large cohort study indicated that the Global Initiative for Chronic Obstructive Lung Disease criterion
(FEV1/FVC ratio <70%) is more sensitive for COPD in individuals 65 years and older compared to the
American Thoracic Society criteria (SOR C). COPD is present if the FEV1/FVC ratio is reduced to <70%
and is irreversible with bronchodilator therapy. A reversible response to bronchodilator therapy is more
consistent with asthma.
A 58-year-old female with COPD asks what she can do to avoid hospitalization. She does not have any other medical problems.
Which one of the following interventions has been shown to reduce respiratory-related hospital admissions in patients such as this? (check one)
Written self-management plans that include smoking cessation plans
Regular physical activity
Regular assessment of FEV1
Nightly CPAP therapy
Daily oxygen therapy
Written self-management plans that include smoking cessation plans
Written self-management plans have been shown to decrease respiratory-related hospitalizations in patients
with COPD. Although regular physical activity has clear health benefits, the methods are so varied in
studies of physical activity that there is currently no strong evidence to show it reduces hospitalizations in
COPD patients. Although FEV1 is important for predicting hospitalizations for a population, it is not
accurate enough to be useful in an individual patient. Daily oxygen therapy does not help to postpone the
first hospitalization. Nightly CPAP therapy reduces hospitalizations in patients with COPD and sleep
apnea, but not those with COPD alone.
