COPD

What is your top differential for EM and CB? Which initial test would you order to confirm the diagnoses?

• Asthma; spirometry

• Heart failure; Echocardiogram

• Bronchietasis; High-resolution CT

• COPD; spirometry

Answer explanation

Correct! Top diff. dx is Chronic Obstructive Pulmonary Disease.

• Initial test of choice is a spirometry.

• The two patients had an abnormal post-bronchodilator FEV1/FVC ratio and is now diagnosed with COPD. Which of the following spirometry result is most likely?

• post-bronchodilator FEV1/FVC ratio of less than 0.70

• post-bronchodilator FEV1/FVC ratio of more than 0.70

Answer explanation

Correct! The FEV1/FVC ratio being less than 70% even after the administration of a bronchodilator in individuals with chronic obstructive pulmonary disease (COPD) is a key diagnostic criterion and reflects the irreversible nature of the airway obstruction characteristic of the disease.

Which of the following is expected to present in patients with COPD?

• Decreased diaphragm force

• Decreased lung compliance

• Increased chest recoil

• Increased left ventricular preload

Answer explanation

Obstructive lung disease leads to slower lung emptying, hyperinflation, and diaphragm flattening. The work of breathing is increased because the diaphragm has difficulty contracting further to generate inspiratory force.

Using their HPI and test results, which variant of COPD does each patient most likely have?

• Patient 1: Emphysema

  Patient 2: Chronic Bronchitis

• Patient 1: Chronic Bronchitis

  Patient 2: Emphysema

Answer explanation

Chronic bronchitis: productive cough for at least 3 months per year for 2 consecutive years that cannot be explained by an alternative diagnosis.

• Emphysema: permanent dilatation of pulmonary air spaces distal to the terminal bronchioles that is caused by the destruction of the alveolar walls and pulmonary capillaries required for gas exchange.

What is the expected diffusing capacity of the lung for carbon monoxide (DLCO) for EM with emphysema and CB with chronic bronchitis?

• Emphysema = low DLCO

  Chronic Bronchitis = high DLCO

• Emphysema = low DLCO

  Chronic Bronchitis = normal DLCO

Answer explanation

Diffusing Capacity for Carbon Monoxide (DLCO) is normal in chronic bronchitis (intact alveolar and capillary membrane) but is decreased in emphysema where destruction of the alveolar wall reduces the available gas exchange surface area.

What is the initial choice of medication for mild COPD (GOLD A) with no exacerbation resulting in a hospital admission and with ONLY exercise-induced dyspnea in the past year?

• LABA or LAMA

  salmaterol or tiotropium

• LABA +LAMA

  salmaterol+ tiotropium

• LABA+LAMA+ICS

  salmaterol+ tiotropium+

  fluticasone

• systemic corticosteroids + SABA

  prednisone+albuterol

What is the choice of medication for moderate COPD (GOLD B) with no exacerbation in the past year resulting in a hospital admission and with dyspnea present even at rest in the past year?

• LABA or LAMA salmaterol or tiotropium

• LABA +LAMA

  salmaterol+

  tiotropium

• LABA+LAMA+ICS

  salmaterol+ tiotropium+

  fluticasone

• systemic corticosteroids + SABA

  prednisone+albuterol

What is the choice of medication for severe COPD (GOLD E) with >1 exacerbation leading to hospital admission and >2 total exacerbation in the past year?

• LABA or LAMA

  salmaterol or tiotropium

• LABA +LAMA

  salmaterol+

  tiotropium

• LABA+LAMA+ICS

  salmaterol+tiotropium+

  fluticasone

• systemic corticosteroids + SABA

  prednisone+albuterol

What is the choice of medication for acute exacerbation of COPD

(low O2 Sat, SOB, increased RR, labored breathing, worsening cough)?

• LABA or LAMA salmaterol or tiotropium

• LABA +LAMA

  salmaterol +

  tiotropium

• LABA+LAMA+ICS

  salmaterol+tiotropium+

  fluticasone

• 4-7 days of systemic corticosteroids + SABA

  prednisone+albuterol

  +/- antibiotics such as macrolide

Answer explanation

A short course of systemic corticosteroids (e.g., prednisone) for 4–7 days is used to reduce airway inflammation and improve airflow in patients with AECOPD.

Antibiotics

There is no consensus on the routine use of antibiotics for the treatment of AECOPD. Some studies have shown an association with faster symptom resolution and a decreased risk of treatment failure. ^[2]

EM is on inhaled daily budesonide (ICS), formoterol (LABA) and tiotropium (LAMA) due to severe COPD. Today, his PaO2 was ≤ 55 mm Hg and SaO₂ ≤ 88%. In addition to smoking cessation, which of the following is most effective to improve his life expectancy?

• pneumococcal vaccination

• long-term oxygen therapy

• Sildenafil

• positive airway pressure therapy at night

Answer explanation

LTOT reduces hypoxic pulmonary vasoconstriction and, therefore, the risk of developing (or worsening) pulmonary hypertension. LTOT is indicated in patients with PaO2 ≤ 55 mm Hg or SaO₂ ≤ 88% at rest despite optimal medication. The target range of oxygen saturation should be 90–92% to reduce the risk of developing adverse effects from oxygen therapy, e.g., O₂-induced hypercapnia.