Pulmonary Diseases Flashcards
1
Q
Questions 1–3 pertain to the following case:
A.S. is a 23-year-old woman who has been wheezing and
coughing for the past year. In the past few months, she has
used her albuterol inhaler about four times daily during
the day and about twice weekly for coughing that awakens her during the night. Spirometry is consistent with an
asthma diagnosis. Fractional exhaled nitric oxide (FeNO)
is greater than 50 ppb.
- Which best classifies A.S.’s asthma severity using the
National Asthma Education and Prevention Program
Expert Panel Report 3 (EPR-3) guidance?
A. Intermittent.
B. Mild persistent.
C. Moderate persistent.
D. Severe persistent. - Which is the best controller therapy for A.S.’s asthma
using the 2020 Focused Updates guidance?
A. Fluticasone (110 mcg/actuation) two inhalations
twice daily by metered dose inhaler (MDI).
B. Montelukast 10 mg 1 tablet orally daily.
C. Salmeterol 1 inhalation (50 mcg) twice daily by
dry powder inhaler (DPI).
D. Budesonide/formoterol (160 mcg/4.5 mcg) 1
inhalation twice daily by MDI. - The physician would like to start single maintenance
and reliever therapy (SMART) for A.S. Which is the
most accurate education for the physician?
A. Albuterol should be prescribed for reliever
therapy.
B. Any inhaled corticosteroid (ICS)/long-acting
β2-agonist (LABA) combination inhaler can be
prescribed.
C. ICS monotherapy is preferred to SMART.
D. Insurance coverage should be assessed for
coverage.
A
- Answer: D
EPR-3 classification of asthma severity is based on several
criteria, including short-acting inhaler use and nighttime
awakenings. The frequency of her nighttime awakenings
indicates that she falls into the moderate persistent category, because these are occurring more than one time
per week but not daily. However, because she uses her
inhaler four times daily, indicating frequency of symptoms
is throughout the day, this puts the patient in the severe
persistent category. Her nighttime symptoms are not in the
severe persistent category, but a patient should be classified
by the most severe category in any given area (Answer D
is correct) - Answer: D
Initial treatment of the severe persistent asthma class is
step 4 or 5 (Answer B is incorrect). Step 4 preferred is
an inhaled steroid (medium dose) with formoterol daily
(Answer A is incorrect). Step 5 preferred is an inhaled
steroid (medium-high dose) with formoterol (Answer D is
correct). Monotherapy with an LABA (salmeterol) is not
recommended in asthma (Answer C is incorrect). - Answer: D
The premise of SMART is to use a single inhaler for both
daily control and reliever therapy (Answer A is incorrect).
Use of SMART is specific to using formoterol as the LABA
because this has a much quicker onset than salmeterol that
is similar to albuterol (Answer B is incorrect). In neither
guideline is ICS monotherapy preferred to combination
therapy, except for step 2. Because this patient should be
initiated on step 4 or 5, this would be inaccurate (Answer
C is incorrect). Each patient’s insurance coverage should
be verified before prescribing SMART, when possible
(Answer D is correct).
2
Q
- A patient being initiated on a DPI has only used MDIs
in the past. Which is the most appropriate instruction
for the patient?
A. When using a DPI, the actuation will feel the same
as that from an hydrofluoroalkane (HFA) inhaler.
B. DPIs require a quick and forceful inhalation
technique.
C. DPIs should be shaken before each use.
D. DPIs should be used with a holding chamber.
A
- Answer: B
The inhaler technique with DPIs is very different from
that with MDIs. The inhalation must be quick, forceful,
and deep, rather than slow and deep (Answer B is correct).
When using a DPI, the “puff” feels different from that
of the MDIs; no aerosol puff is felt; the patient may not
feel anything (Answer A is incorrect). Dry powder inhalers should not be shaken or used with a holding chamber
(Answers C and D are incorrect).
3
Q
- A 70-year-old woman has persistent shortness of
breath, cough, and sputum production that has gradually worsened during the past year. Her chronic
obstructive pulmonary disease (COPD) assessment
test score is 12. She has been using albuterol HFA
two inhalations several times per day for persistent
shortness of breath. Her spirometry showed a forced
expiratory volume in 1 second (FEV1) equal to 70%
of predicted and an FEV1/forced vital capacity (FEV1/
FVC) equal to 60% of predicted after a bronchodilator. Her blood eosinophil count is 50 cells/mm3
. She
has never had a COPD exacerbation. Which is the best
medication to initiate?
A. Tiotropium DPI.
B. Beclomethasone MDI.
C. Montelukast orally.
D. Fluticasone plus salmeterol MDI
A
- Answer: A
The patient is in GOLD grade 2 group B. A single longacting bronchodilator is the first choice for medication
treatment. Tiotropium is an appropriate long-acting bronchodilator to initiate in this patient (Answer A is correct).
A LABA would also be appropriate, but it was not one of
the choices. Montelukast is recommended for asthma, not
COPD (Answer C is incorrect). An ICS is recommended
only in patient group E for those with eosinophil count
> 300 cells/μL (Answers B and D are incorrect).
4
Q
- A 65-year-old man with COPD (baseline FEV1 of 45%
predicted) presents with a 3-day history of worsening
shortness of breath and increased cough, which has
been keeping him up all night. His coughs have been
bringing up more sputum, which is mostly clear. He
denies cloudy, purulent sputum. Which is the most
appropriate treatment at this time?
A. No additional therapy needed.
B. Albuterol by nebulization.
C. Albuterol by nebulization plus oral prednisone
burst.
D. Albuterol by nebulization plus oral prednisone
burst plus oral antibiotics
A
- Answer: C
For all acute exacerbations of chronic COPD, albuterol
with or without ipratropium by nebulization should be
given (Answer A is incorrect). For most exacerbations,
a burst of OCSs should be given (Answer B is incorrect;
Answer C is correct). Antibiotics are only recommended
if all three cardinal symptoms of COPD exacerbations (increased dyspnea, increased sputum volume, and
increased sputum purulence) are present or if two cardinal symptoms are present and increased sputum purulence
is one of the symptoms. This patient does not meet these
criteria, so antibiotics are not indicated. He has only two
of the cardinal symptoms (increased dyspnea and volume),
and increased sputum purulence is not one of his symptoms (Answer D is incorrect).
5
Q
- A 50 year-old woman has been smoking for over 35
years, about 1–1.5 packs/day. Her medical history is
significant for COPD and obesity. She is reluctant to
quit smoking. Which of the following options would
be best to recommend for this patient for smoking
cessation?
A. Liraglutide.
B. Nicotine patch.
C. Bupropion.
D. Varenicline.
A
- Answer: D
At this time, we do not have enough information to recommend liraglutide for preventive weight loss use in smoking
cessation (Answer A is incorrect). All three medication
classes have been found to delay, but not prevent, weight
gain and may be helpful because the patient has obesity.
Although NRT is an option, single NRT is less effective
than varenicline, making varenicline the best option to recommend for this patient (Answer B is incorrect; Answer
D is correct). Bupropion is an option; however, in the ATS
2020 update, varenicline is recommended over bupropion
(Answer C is incorrect).
6
Q
- A 20-year-old woman wants to quit smoking. She has
never attempted to quit before and is determined to
quit “cold turkey.” You provide her with education
regarding withdrawal symptoms. Which of the following is the most likely symptom of smoking cessation
withdrawal?
A. Sedation.
B. Increased concentration.
C. Increased heart rate.
D. Weight gain.
A
- Answer: D
Patients quitting smoking can experience withdrawal
symptoms such as insomnia, difficulty concentrating, and
decreased heart rate (Answers A, B, and C are incorrect).
Patients quitting smoking can gain up to 4.3 kg on average
(Answer D is correct).
7
Q
- A 40-year-old man presents to the clinic wanting to
quit smoking. He rates how much he wants to quit as
10/10 and believes he can quit with help. Together,
you decide to use varenicline to help him quit smoking. Which is most accurate regarding medication use
and counseling for this patient?
A. A combination of behavioral counseling and
drugs is more effective than either behavioral
counseling or medication alone.
B. Varenicline is contraindicated in patients with
renal impairment.
C. Varenicline should be taken on an empty stomach.
D. Avoid using varenicline longer than 3 months.
A
- Answer: A
Patients with mild to moderate renal impairment can use
varenicline and those with severe impairment or dialysis should use a reduced dose (Answer B is incorrect).
Varenicline can be used for six months per the package
insert (Answer D is incorrect). Patients are advised to take
varenicline after meals with a full glass of water; this can
help reduce nausea (Answer C incorrect). A combination
of behavioral counseling and drugs is more effective than
either behavioral counseling or drugs alone (Answer A is
correct). Longer counseling sessions are more effective
than shorter ones, with efficacy plateauing at 90 minutes
