1
Q
What is the mandatory diagnostic criterion to establish a diagnosis of COPD according to the GOLD 2025 report?
A
The presence of a post-bronchodilator FEV1/FVC ratio of less than 0.7 demonstrated by forced spirometry.
2
Q
The term _____ describes individuals with a preserved FEV1/FVC ratio (≥ 0.7) but impaired spirometry (FEV1 < 80% predicted).
A
PRISm (Preserved Ratio Impaired Spirometry)
3
Q
According to the GOLD 2025 report, what blood eosinophil count threshold is used to identify patients with the greatest likelihood of treatment benefit with ICS?
A
A blood eosinophil count of \geq 300 cells/µL.
4
Q
What is the recommended duration of systemic corticosteroid treatment for a moderate COPD exacerbation?
A
A 5-day course of oral corticosteroids.
5
Q
For which two specific criteria is Long-Term Oxygen Therapy (LTOT) indicated in stable COPD patients?
A
PaO2 \leq 55 mmHg (7.3 kPa) or SaO2 \leq 88%, confirmed twice over a three-week period.
6
Q
What is the strongest predictor of a COPD patient’s future exacerbation frequency?
A
The number of exacerbations the patient has experienced in the prior year.
7
Q
In the context of COPD pathogenesis, the ‘gut-lung axis’ refers to the interaction between gut and airway microbiota through what two primary mechanisms?
A
Immune cross-talk and the circulation of microbial metabolites and peptides.
8
Q
The GOLD 2025 report highlights the addition of which two new treatments to the pharmacological management algorithms for stable COPD?
A
Ensifentrine and dupilumab.
9
Q
In the GOLD 2025 report, what is the new section that addresses the imbalance of microbial communities in the lungs of COPD patients called?
A
Dysbiosis.
10
Q
What is the primary recommendation of the World Health Organization regarding screening for Alpha-1 antitrypsin deficiency (AATD)?
A
All patients diagnosed with COPD should be screened once for AATD.
11
Q
What is the primary mechanism by which non-invasive ventilation (NIV) improves outcomes in patients hospitalized for acute exacerbations of COPD?
A
NIV improves oxygenation and acute respiratory acidosis by increasing pH and decreasing PaCO2.
12
Q
According to the ERS 2017 guidelines, long-term antibiotic treatment is suggested for adults with bronchiectasis who have how many exacerbations per year?
A
Three or more exacerbations per year.
13
Q
What is the term for the pathophysiological concept in bronchiectasis that describes the interplay between airway dysfunction, chronic infection, inflammation, and progressive airway injury?
A
The vicious vortex (or vicious cycle).
14
Q
In a patient with bronchiectasis and chronic Pseudomonas aeruginosa infection, what is the suggested first-line long-term antibiotic therapy according to ERS guidelines?
A
Long-term treatment with an inhaled antibiotic.
15
Q
What clinical syndrome is characterized by the triad of situs inversus, chronic sinusitis, and bronchiectasis?
A
Kartagener syndrome, a subtype of Primary Ciliary Dyskinesia (PCD).
16
Q
In COPD, the ratio of the pulmonary artery (PA) to aortic diameters greater than _____ on a CT scan is a strong independent predictor of acute exacerbations.
A
1
17
Q
The BODE index is a composite score used to predict survival in COPD. What do the letters B, O, D, and E stand for?
A
Body mass index, Obstruction (FEV1), Dyspnea (mMRC scale), and Exercise capacity (6-minute walk distance).
18
Q
What is the primary role of blood eosinophil counts in managing stable COPD?
A
To help estimate the likelihood of a beneficial preventive response to the addition of inhaled corticosteroids (ICS) to regular bronchodilator treatment.
19
Q
A patient with COPD has a PaO2 of 57 mmHg and evidence of cor pulmonale. Does this patient meet the criteria for LTOT?
A
Yes, patients with PaO2 between 55 and 60 mmHg qualify if there is evidence of pulmonary hypertension, peripheral edema suggesting congestive cardiac failure, or polycythemia (hematocrit > 55%).
20
Q
How is a ‘severe’ COPD exacerbation defined according to the GOLD 2025 report?
A
The patient requires hospitalization or a visit to the emergency room.
21
Q
Which two classes of long-acting bronchodilators form the cornerstone of maintenance pharmacological therapy for symptomatic COPD?
A
Long-acting muscarinic antagonists (LAMAs) and long-acting beta2-agonists (LABAs).
22
Q
The clinical definition of chronic bronchitis is a chronic productive cough for at least _____ months per year for _____ consecutive years.
A
three; two
23
Q
In the pathogenesis of COPD, the _____ gene, which encodes for alpha-1 antitrypsin, is the most important confirmed genetic risk factor.
A
SERPINA1
24
Q
What is the most effective intervention that has the greatest capacity to influence the natural history of COPD?
A
Smoking cessation.
25
According to the GOLD 2025 report, what is the recommended vaccination to protect against pertussis in adults with COPD who were not vaccinated in adolescence?
The Tdap vaccination.
26
For a COPD patient using a dry powder inhaler (DPI), what type of inspiratory effort is required for effective drug delivery?
A forceful and deep inspiration.
27
In which specific subgroup of emphysema patients did the National Emphysema Treatment Trial (NETT) show a survival benefit with bilateral lung volume reduction surgery (LVRS)?
Patients with upper-lobe predominant emphysema and low post-rehabilitation exercise capacity.
28
A hospitalized COPD patient presents with acute respiratory failure, a respiratory rate > 24, use of accessory muscles, and a pH of 7.28 with a PaCO2 of 65 mmHg. What is the preferred initial mode of ventilation?
Noninvasive ventilation (NIV).
29
What is the term 'Pre-COPD' used to describe?
Individuals with respiratory symptoms and/or structural lung abnormalities (e.g., emphysema) but without airflow obstruction on spirometry.
30
In low- and middle-income countries (LMICs), what is a major cause of COPD, responsible for approximately 50% of the attributable risk?
Household air pollution from the burning of biomass fuels.
31
What is dysanapsis in the context of lung development?
A mismatch between the size of the airways and the size of the lung parenchyma.
32
What is the primary pathophysiological consequence of dynamic hyperinflation in COPD during exercise?
It significantly contributes to dyspnea and impaired exercise tolerance by increasing the work of breathing.
33
In bronchiectasis, what minimum bundle of aetiological tests is suggested for a new diagnosis according to ERS guidelines?
Differential blood count, serum immunoglobulins (IgG, IgA, IgM), and testing for allergic bronchopulmonary aspergillosis (ABPA).
34
What is the diagnostic hallmark of bronchiectasis on a high-resolution computed tomography (HRCT) scan?
Permanent and irreversible dilation of the bronchi, often described as cylindrical, varicoid, or cystic.
35
For adults with bronchiectasis not infected with P. aeruginosa, what class of oral antibiotic is suggested for long-term treatment if they have \geq3 exacerbations per year?
Macrolides (azithromycin or erythromycin).
36
What is the primary mechanism of action of N-acetylcysteine (NAC) when used in COPD?
It acts as both a mucolytic agent and an antioxidant.
37
A COPD patient with a history of pneumonia, blood eosinophils of 80 cells/µL, and one exacerbation in the past year is on LAMA/LABA/ICS. What management change should be considered?
Withdrawal of the inhaled corticosteroid (ICS) due to low likelihood of benefit and increased risk of pneumonia.
38
What is the primary goal of pulmonary rehabilitation in COPD?
To improve shortness of breath, health status, and exercise tolerance.
39
According to the GOLD report, what is the significance of a pulmonary artery to aorta diameter ratio > 1 on CT scan in COPD patients?
It is associated with an increased risk of suffering exacerbations, independent of a previous history of exacerbations.
40
What is the recommended antibiotic treatment strategy for a COPD exacerbation characterized by increased dyspnea, increased sputum volume, and increased sputum purulence?
Treatment with an antibiotic is recommended as all three cardinal symptoms are present.
41
The hedgehog interacting protein (_____) has been identified through genome-wide association studies as a likely causal gene influencing susceptibility to COPD.
HHIP
42
What is the primary difference in pathophysiology between the chronic airflow obstruction seen in non-asthmatic smokers and that seen in asthmatic non-smokers?
The pathology is markedly different, suggesting they remain distinct disease entities even when presenting with similarly reduced lung function.
43
What effect does continued smoking have on the efficacy of inhaled corticosteroids (ICS) in COPD patients?
The magnitude of the effect of ICS on lung function and exacerbation rates is lower in heavy or current smokers compared to light or ex-smokers.
44
In addition to reducing exacerbations, what effect has regular treatment with roflumilast been shown to have on lung function in patients with severe COPD?
Roflumilast produces a small but statistically significant improvement in post-bronchodilator FEV1.
45
What are the three most common bacterial pathogens isolated from sputum cultures during COPD exacerbations?
Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pneumoniae.
46
A patient with severe COPD and resting hypoxemia (PaO2 52 mmHg) is prescribed LTOT. To achieve a mortality benefit, what is the minimum recommended duration of oxygen use per day?
Greater than 15 hours per day.
47
What is the primary purpose of using an inert gas like helium or neon during the single-breath diffusing capacity for carbon monoxide (DLCO) test?
To correct for the dilution of inspired carbon monoxide and calculate the initial alveolar concentration.
48
The forced oscillation technique (FOT) measures respiratory system _____, which is the sum of all forces opposing airflow, including resistance and reactance.
impedance (Zrs)
49
What is the primary advantage of the 6-minute walk test (6MWT) over cardiopulmonary exercise testing (CPET) for assessing functional capacity in COPD?
It requires minimal training and specialized equipment, and may better reflect functional exercise capacity relevant to daily activities.
50
A patient is initiated on therapy for alpha-1 antitrypsin deficiency (AATD). What is this therapy called?
Augmentation therapy.
51
In the differential diagnosis of obstructive lung diseases, which condition is characterized by copious mucopurulent sputum and bronchial wall thickening/dilation on HRCT?
Bronchiectasis.
52
What is the significance of the GOLD 'E' group in the initial assessment of a COPD patient?
It identifies patients at high risk for future events, defined by a history of \geq2 moderate exacerbations or \geq1 severe exacerbation leading to hospitalization in the past year.
53
According to the GOLD 2025 follow-up algorithm, if a patient on LAMA/LABA therapy continues to have exacerbations, what is the next step if their blood eosinophil count is >300 cells/µL?
Add an inhaled corticosteroid (ICS) to escalate to triple therapy (LAMA/LABA/ICS).
54
Why is assessing the degree of reversibility of airflow obstruction no longer recommended to inform therapeutic decisions in COPD?
The degree of reversibility in a single patient varies over time and does not reliably predict the response to long-term treatment with bronchodilators or corticosteroids.
55
Which two new non-pharmacological topics are now included in the GOLD 2025 report, reflecting growing areas of concern and research?
Climate Change & COPD, and Dysbiosis.
56
In patients with both COPD and obstructive sleep apnea, what therapy has shown clear benefits in improving survival and reducing hospital admissions?
Continuous positive airway pressure (CPAP).
57
What is the primary safety concern associated with long-term inhaled corticosteroid (ICS) use in COPD?
An increased risk of developing pneumonia.
58
A COPD patient on LAMA therapy continues to experience significant dyspnea (mMRC \geq 2). What is the recommended next step in pharmacological management?
Escalate to dual bronchodilator therapy with a LABA/LAMA combination.
59
What effect do cardioselective beta-blockers, used for cardiovascular indications, have on the efficacy of LABAs in COPD patients?
There is no evidence that they reduce the benefits of treatment with LABA or increase cardiovascular risk in this population.
60
What is the role of surgery in the management of bronchiectasis?
It is reserved for selected cases with severe, localized disease, disabling infection, or life-threatening hemoptysis refractory to embolization.
61
What is the definition of allergic bronchopulmonary aspergillosis (ABPA)?
An allergic or hypersensitivity response to Aspergillus fumigatus, typically occurring in patients with asthma or cystic fibrosis.
62
What is the primary difference in patient action required between a metered-dose inhaler (MDI) and a dry-powder inhaler (DPI)?
MDIs require a slow, deep inspiration coordinated with actuation, while DPIs require a forceful, deep inspiration to de-aggregate the powder.
63
The DLCO can be used to estimate the diffusing capacity for oxygen (DlO2) by multiplying the DLCO value by what factor?
1.23
64
A patient with moderate COPD reports increased cough and sputum after starting a new medication. Which class of inhaled medication is most commonly associated with these side effects, especially at higher doses?
Inhaled corticosteroids (ICS).
65
The _____ scoring system is a clinical tool designed to help clinicians screen for Primary Ciliary Dyskinesia (PCD) in patients with chronic productive cough.
PICADAR (Primary Ciliary Dyskinesia Rule)
66
In addition to increased exacerbations, what other adverse outcome is associated with chronic bronchitis (CB) even in smokers without airflow obstruction?
CB independently contributes to increased hospitalizations and death.
67
Which genetic pathway, supported by GWAS findings near genes like TGFB2, SMAD3, and ACVR1B, is strongly implicated in COPD pathogenesis?
The transforming growth factor-β (TGF-β) pathway.
68
What is the primary mechanism by which carbon monoxide from cigarette smoke impairs oxygen delivery in patients with COPD?
It avidly binds to hemoglobin, creating carboxyhemoglobin and causing a functional anemia by reducing the blood's oxygen-carrying capacity.
69
Which two smoking-related interstitial lung diseases are characterized by the accumulation of pigmented macrophages within the alveoli?
Respiratory bronchiolitis–associated interstitial lung disease (RB-ILD) and desquamative interstitial pneumonitis (DIP).
70
The landmark 1977 study by Fletcher and Peto demonstrated that smoking cessation in patients with COPD had what effect on the rate of FEV1 decline?
It slowed the accelerated rate of lung function decline, causing it to more closely parallel the normal rate of decline seen in nonsmokers.
71
What is the mechanism by which hypertonic saline is thought to improve airway clearance in bronchiectasis?
It is a hyperosmotic agent that draws water into the airway lumen, hydrating mucus and facilitating its clearance.
72
A COPD patient with a blood eosinophil count of 50 cells/µL is unlikely to benefit from the addition of what class of medication for exacerbation prevention?
Inhaled corticosteroids (ICS).
73
What is the primary indication for using an oscillating positive expiratory pressure (OPEP) device in COPD management?
To improve mucus mobilization and clearance in patients who produce sputum daily or most days.
74
What is the key difference between 'Pre-COPD' and 'PRISm'?
'Pre-COPD' refers to individuals with symptoms/structural changes without airflow obstruction, while 'PRISm' is defined by spirometry (normal ratio, low FEV1).
75
In the Bronchiectasis Severity Index (BSI), what are the key factors used to predict mortality and hospitalization risk?
FEV1, age, chronic colonization (especially P. aeruginosa), extent of bronchiectasis, dyspnea, prior hospitalizations, and exacerbation frequency.
76
In a patient with suspected Common Variable Immunodeficiency (CVID) as the cause of bronchiectasis, what is the next diagnostic step after finding low serum IgG and IgA levels?
Assess for abnormal antibody responses to specific antigen challenge (vaccinations).
77
What is the primary role of the CAT (COPD Assessment Test) in the routine management of a COPD patient?
To provide a comprehensive, standardized assessment of the patient's symptom burden and its impact on their health status.
78
Why might venous blood gas (VBG) be used as an alternative to arterial blood gas (ABG) in the initial assessment of a COPD exacerbation?
VBG is less invasive and can be used to accurately screen for significant hypercarbia and acidosis by assessing pH and bicarbonate levels.
79
A patient with severe COPD and chronic hypercapnia is discharged after an exacerbation. What intervention has been shown to reduce the time to readmission or death in this population?
Home noninvasive ventilation (NIV) added to home oxygen therapy.
80
What is the primary reason that annual influenza vaccination is recommended for all COPD patients?
It is effective in reducing the incidence of lower respiratory tract infections, severe illness, and death in patients with COPD.
81
What is the '6-minute walk distance' (6MWD)?
The distance a patient can walk on a flat, hard surface in a period of 6 minutes, used to assess functional exercise capacity.
82
What are the key components of a comprehensive pulmonary rehabilitation program?
Exercise training, smoking cessation, nutrition counseling, and disease education.
83
In a patient with COPD, which comorbidity is a prominent cause of death, particularly in those with mild-to-moderate airflow obstruction?
Cardiovascular disease (CVD).
84
The GOLD 2025 report introduced a new figure (Figure 3.22) specifically to guide the management of patients currently on which combination therapy?
LABA + ICS.
85
A post-bronchodilator FEV1/FVC of 0.72 and an FEV1 of 65% predicted in a symptomatic smoker would be classified as _____.
PRISm (Preserved Ratio Impaired Spirometry)
86
What is the primary mechanism of action for methylxanthines like theophylline in COPD?
They act as non-selective phosphodiesterase inhibitors, leading to bronchodilation, and also have non-bronchodilator anti-inflammatory effects.
87
In a patient with bronchiectasis not infected with P. aeruginosa and intolerant to macrolides, what is the next suggested long-term antibiotic strategy for frequent exacerbations?
Long-term treatment with a different oral antibiotic, with the choice based on sputum culture susceptibility and patient tolerance.
88
A patient with severe COPD has a BODE index score of 8. What does this score indicate about their approximate 52-month mortality rate?
It indicates a very high mortality rate, estimated to be around 80% at 52 months.
89
What is the primary pathological feature of emphysema?
Destruction of the gas-exchanging air spaces (alveoli), leading to loss of elastic recoil and parenchymal destruction.
90
What is the significance of using race-neutral reference equations (like GLI-Global) for spirometry, as endorsed by the ATS and ERS?
They aim to avoid underestimation of disease severity that can result from race-correction, which may normalize the effects of malnutrition or childhood illness on lung development.
91
A patient with upper-lobe predominant emphysema and severe hyperinflation is a candidate for lung volume reduction. Besides surgery (LVRS), what is a common bronchoscopic alternative?
Endobronchial one-way valves (EBV).
92
According to the GOLD report, what is the recommendation regarding the use of e-cigarettes as a smoking cessation aid?
There is currently no evidence to support the effectiveness and safety of e-cigarettes as a smoking cessation aid.
93
Which pharmacologic agent, a PDE4 inhibitor, is recommended to reduce exacerbations in patients with chronic bronchitis, severe to very severe airflow limitation, and a history of exacerbations?
Roflumilast.
94
What is the primary limitation of classifying COPD exacerbation severity as mild, moderate, or severe?
The classification is based on the post-facto use of healthcare resources, which can vary significantly due to global and local differences in healthcare systems and practices.
95
What is the recommended initial pharmacological therapy for a newly diagnosed COPD patient in GOLD Group B (more symptoms, low exacerbation risk)?
A long-acting bronchodilator, either a LABA or a LAMA.
96
A patient with severe COPD develops secondary polycythemia (hematocrit > 55%). What is the most likely underlying cause and primary treatment?
The most likely cause is chronic, uncorrected hypoxemia, and the primary treatment is the initiation or optimization of long-term oxygen therapy (LTOT).
97
What is the main reason recombinant human DNase (rhDNase) is not recommended for non-CF bronchiectasis, despite its use in cystic fibrosis?
Studies showed it failed to reduce exacerbations and was associated with a trend toward more frequent and severe exacerbations in idiopathic bronchiectasis.
98
In COPD patients, a CT finding of emphysema, airway wall thickening, and air trapping should prompt the clinician to perform what diagnostic test if not already done?
Pulmonary function testing (spirometry) to confirm or rule out airflow obstruction.
99
What is the definition of 'static hyperinflation' in COPD?
An increase in gas volume in the lungs at the end of spontaneous expiration at rest, primarily due to the loss of elastic lung recoil from emphysema.
100
Which pneumococcal vaccine, PCV13 or PPSV23, showed more persistent clinical effectiveness in reducing pneumonia over a 5-year follow-up period in COPD patients?
PCV13 showed more persistent clinical effectiveness over the 5-year period.
101
What is the primary role of measuring inspiratory flow when choosing an inhaler device for a COPD patient?
To determine if the patient can generate a sufficient inspiratory effort to effectively use a dry-powder inhaler (DPI).
102
What is the primary safety concern that led to a trial comparing metoprolol versus placebo in COPD patients without a cardiovascular indication?
The concern was whether a cardioselective beta-blocker could prevent exacerbations; the trial found it did not and was associated with more hospitalizations.
103
What is the significance of airway hyper-responsiveness in the context of COPD risk?
It is the second leading risk factor for COPD after cigarette smoking and is an independent predictor of COPD and respiratory mortality.
104
In managing refractory dyspnea in advanced COPD, what class of medication may be cautiously used for palliation?
Opioids.
105
What is the purpose of a valved holding chamber (VHC) or spacer when used with a pressurized metered-dose inhaler (pMDI)?
It reduces the need for hand-breath coordination, increases pulmonary deposition, and reduces oropharyngeal deposition, minimizing local side effects of ICS.
106
According to the GOLD report, what is the impact of poverty and lower socioeconomic status on COPD risk?
Poverty is consistently associated with airflow obstruction, and lower socioeconomic status is associated with an increased risk of developing COPD.
107
For a patient flying on a commercial aircraft, the cabin is pressurized to an altitude equivalent of 8,000 feet. Why might a COPD patient require supplemental in-flight oxygen?
The reduced partial pressure of oxygen at that altitude can cause significant hypoxemia, especially in patients who are borderline or hypoxemic at sea level.
108
What is the term for the accumulation of organized tertiary lymphoid tissue with germinal centers in the lungs of patients with severe COPD?
Lung lymphoid follicles.
109
The _____ trial demonstrated that in smokers with COPD, smoking cessation, but not inhaled bronchodilator therapy, reduced the rate of decline in lung function.
Lung Health Study
110
In the differential diagnosis for COPD, what condition, seen primarily in Japan, involves both upper and lower respiratory tracts and often improves with macrolide antibiotics?
Diffuse panbronchiolitis.
111
What is the primary rationale for recommending the RSV vaccination for adults with COPD, especially those aged \geq 75 years?
Adults with chronic medical conditions like COPD are at increased risk of severe RSV disease.
112
What is the recommended initial pharmacological therapy for a newly diagnosed COPD patient in GOLD Group E (high exacerbation risk)?
Dual long-acting bronchodilator therapy (LABA + LAMA).
113
A patient with PRISm is at increased risk of transitioning to overt COPD. What are the most important predictors of this transition?
Lower baseline FEV1% and FEV1/FVC, higher age, current smoking, and female gender.
114
In the pathophysiology of COPD, what is the role of proteases derived from inflammatory cells like neutrophils and macrophages?
They cause structural changes by breaking down connective tissue components in the lung, contributing to emphysema.
115
What is the primary objective of using the mMRC dyspnea scale in COPD assessment?
To grade the severity of breathlessness by relating it to the physical activities that trigger it.
116
In the ERS guidelines for bronchiectasis, what is the role of inhaled corticosteroids (ICS)?
There is insufficient evidence to recommend for or against the use of ICS in bronchiectasis, and trials are needed to define their utility.
117
Why is the use of long-term oral corticosteroids generally avoided for the management of stable COPD?
Because of an unfavorable benefit-to-risk ratio, with numerous and significant side effects (e.g., steroid myopathy, osteoporosis) outweighing the benefits.
118
Juan Carlos, a 58 year old known COPD patient came to your clinic for follow up. He had occasional shortness of breath, cough, easy fatigability and had episodes of O 2 saturation at 88-89%. Physical exam showed stable vital signs with vesicular breath sounds, and bipedal edema. Recent laboratory tests revealed ABG: PaO 2 55 mmHg with hypercapnia; high cholesterol; a hematocrit level at 50% and hemoglobin 15 g/dL on CBC. He is currently maintained on triple inhaler therapy. Which of the following is not an indication to start long term oxygen therapy for this patient?
Choose the best answer
Answer
A. PaO 2 55 mmHg with hypercapnia
B. SaO 2 sat: 88-89%
C. bipedal edema
D. hematocrit 50% and hemoglobin 15 g/dL
D. hematocrit 50% and hemoglobin 15 g/dL
Hct 55%
119
Miguel, 49 year old, 15 pack year smoker working in the BPO industry had his annual physical
exam. Spirometry test revealed mild obstructive ventilatory defect consistent with COPD. Which of the following contributes more to the FEV1 decline?
Choose the best answer
Answer
A. small airway disease
B. emphysema
C. mucus hypersecretion
D. vascular dysfunction
A
120
Mr. Salvador, a 63 y/o male came to your clinic due to on and off cough for more than a year. He
is a 40 pack year smoker with post bronchodilator FEV 1 /FVC: < 0.7 & FEV 1 : 78% predicted. He claims to have no ER visits for the past year and no episode of shortness of breath except during strenuous exercise. How will you classify this patient based on the GOLD Classification System?
Answer
A. GOLD Grade 1 Group B
B. GOLD Grade 2 Group A
C. GOLD Grade 3 Group D
D. GOLD Grade 4 Group C
A
Take note: Class B basta MORE THAN OR EQUAL CAT SCORE of 10
121
5. A 45 year old male is a known case of Hypertension, Diabetes, and COPD. He was a previous
smoker but stopped 6 months ago after being treated for PTB. Since he started treatment with LAMA + LABA, he only had one episode of exacerbation that required him to consult the emergency room. Patient came to your clinic for his regular follow-up. A relative from the US gave your patient a sample medication of LAMA + LABA + ICS. He asked if he can use the medication for his COPD. Latest blood eosinophil showed 150 cells/ul with no active infiltrates on chest radiograph. The following favors the use of the above medication except:
Answer
A. no active infiltrates on chest radiograph
B. PTB, treated
C. one moderate exacerbation
D. blood eosinophil 150 cells/ul
B
uberculosis Risk: In the absence of randomized controlled trial data on the issue, studies suggest that ICS treatment could be associated with an increased risk of tuberculosis. Since the patient has a history of treated TB, introducing ICS carries a theoretical or observed risk of reactivation or new infection
122
This receptor is the predominant subtype of receptor mediating parasympathetic control of
smooth muscles
Choose the best answer
Answer
A. M4 receptor
B. M3 receptor
C. M2 receptor
D. M1 receptor
The receptor that is the predominant subtype mediating parasympathetic control of smooth muscles is the B. M3 receptor.
Antimuscarinic drugs block the bronchoconstrictor effects of acetylcholine on M3 muscarinic receptors expressed in airway smooth muscle. Long-acting muscarinic antagonists (LAMAs) have prolonged binding to these M3 muscarinic receptors, contributing to the bronchodilator effect.
123
Mr. Dela Cruz, a 59 year old male, came to your clinic due to easy fatigability, shortness of
breath after a few minutes on the level, with on & off non-productive cough for more than 6 months. He was recently admitted due to the above symptoms and was advised to consult a pulmonologist regarding his condition. He admitted that he is still currently smoking, consuming 2 packs per day since 20 years old. CXR showed flattened diaphragm with increase in the volume of the retrosternal air space. Spirometry test done showed an FEV 1 /FVC: 63 with a post bronchodilator FEV 1 : 48% predicted. Based on the above history, what is the classification of this patient?
Choose the best answer
Answer
A. Gold 1 Group A
B. Gold 2 Group B
C. Gold 3 Group E
D. Gold 4 Group B
C
124
A tool used in assessment that has been associated with mortality in COPD
Choose the best answer
Answer
A. SGRQ
B. mMRC scale
C. COPD Assessment Test
D. CAPTURE
mMrc
he mMRC scale is integrated into the current GOLD clinical classification scheme and predicts future mortality risk
SGRQ (St. George's Respiratory Questionnaire): This is a comprehensive disease-specific health status questionnaire. A composite score that predicts mortality, the BODE index (Body mass index, Obstruction, Dyspnea, Exercise), incorporates mMRC (Dyspnea component) rather than SGRQ. However, poor health status generally correlates with mortality.
* C. COPD Assessment Test (CAT): This is another short, comprehensive, 8-item questionnaire used to assess health status. While both CAT and SGRQ correlate closely, the mMRC is specifically mentioned as predicting mortality risk.
* D. CAPTURE (COPD Assessment in Primary Care to Identify Undiagnosed Respiratory Disease and Exacerbation Risk): This tool showed good sensitivity in a prospective study in China to identify COPD patients who may require treatment because of increased symptoms, risk of exacerbations, or hospitalization. The sources do not directly associate this tool with mortality.
125
These subsets of COPD patients appear to denote steroid responsiveness ?
Choose the best answer
Answer
A. CXCR2
B. CXCL8
C. Th17-high
D. Th2-high
T2 high
h2-high vs. Th17-high Subsets: Mutually exclusive subsets of COPD patients exist with predominantly Th2-high versus Th17-high inflammation, and these subsets are suggested to denote steroid-responsive versus unresponsive disease, respectivel
CXCR2 and B. CXCL8: Trials targeting the receptor CXCR2 (the receptor for CXCL8, among other chemokines) have been equivocal, showing some promise but also potential for toxicity. CXCL8 (also known as IL-8) is a chemokine traditionally considered a major driver of neutrophil recruitment in COPD. The Th2-high subset is generally identified as steroid-responsive, whereas the Th17-high subset is often associated with non-responsiveness and the neutrophil-driven inflammation pathways associated with CXCL8
126
The hospitalist on duty who recently passed the physician licensure exam consulted you on the
use of NIV for a patient rushed to the emergency room due to COPD exacerbation. Which of the
following is an indication for initiating non-invasive mechanical ventilation during an exacerbation?
Choose the best answer
Answer
A. diminished consciousness
B. severe dyspnea with noted use of the accessory muscles
C. persistent vomiting
D. supraventricular arrythmias
B
127
Maria, a diagnosed case of COPD was recently diagnosed with pulmonary hypertension. The
following are true for vascular dysfunction on COPD except ?
Choose the best answer
Answer
A. Healthy pulmonary circulation provides low resistance to blood flow during exercise by recruiting blood vessels in the lower lobes.
B. Severe pulmonary hypertension is uncommon in COPD in the absence of alternative causes.
C. Contributor to low resistance results from the balance between vasodilators and vasoconstrictors of the endothelin and serotonin pathways.
D. Mild pulmonary hypertension is detectable in 90% of COPD patients with severe airflow obstruction.
A. Healthy pulmonary circulation provides low resistance to blood flow during exercise by recruiting blood vessels in the lower lobes.
Why A is Incorrect: While the healthy pulmonary circulation maintains low resistance during exercise by recruiting blood vessels, this recruitment occurs "particularly in the upper lobes, not perfused at rest," according to the source material, not the lower lobes.
128
The only intervention demonstrated to alter the lung function decline?
Choose the best answer
Answer
A. bronchodilators
B. pulmonary rehabilitation
C. oxygen supplement
D. smoking cessation
Smoking Cessation (Option D): Smoking cessation has the greatest capacity to influence the natural history of COPD. Studies have shown that in patients with COPD who stopped smoking, the accelerated loss of lung function slowed until it more closely paralleled the annual decrement seen in nonsmokers. Furthermore, smoking cessation reduced the rate of decline in lung function, whereas inhaled bronchodilator therapy did not
129
Compared to male, female
A. who visits a physician are MORE likely to be diagnosed with COPD
B. has HIGHER airways luminal area
C. appear to be MORE susceptible to tobacco
D. with COPD suffer disproportionately from LOWER levels of anxiety & depression
C.
Female smokers exhibit higher wall area percentage com-pared with male smokers, but lower luminal area, inter-nal diameter, and airway thickness.
130
A patient with severe COPD developed dynamic hyperinflation during exercise. Which of the following is present?
A. Tidal volume decreases
B. Inspiratory capacity decreases
C. End expiratory volume decreases
D. Total lung capacity increases
B
Dynamic hyperinflation occurs during exercise when increased ventilatory demands and reduced expiratory times prevent the patient from fully exhaling before the next breath begins. This results in a progressive increase in the end-expiratory lung volume (EELV)
Clinical assessment of dynamic hyperinflation relies on the fact that the total lung capacity (TLC) is typically assumed to remain constant during exercise. Because the EELV (the volume of gas remaining in the lungs at the end of expiration) increases, the inspiratory capacity (IC)—which is the amount of air that can be inhaled starting from that end-expiratory level—must decrease to compensate
Consequently, the measurement of a decreasing inspiratory capacity at rest and during exercise serves as the primary indirect measurement to indicate the presence of dynamic hyperinflatio
131
Which of the following statements regarding the drugs used in COPD and its mechanism of action is correct?
A. Umeclidinium stimulates the Beta 2 airways receptors.
B. Vilanterol blocks the Muscarinic 2 airways receptors.
C. Theophylline stimulates the phosphodiesterase 2
D. Roflumilast inhibits phosphodiesterase 4
Roflumilast is an oral phosphodiesterase-4 (PDE4) inhibitor, Its primary mechanism of action is to reduce inflammation by inhibiting the breakdown of intracellular cyclic AMP
Umeclidinium is a Long-Acting Muscarinic Antagonist (LAMA). LAMAs work by blocking the bronchoconstrictor effects of acetylcholine on M3 muscarinic receptors in airway smooth muscle, not by stimulating Beta-2 receptors
Vilanterol is a Long-Acting Beta-2 Agonist (LABA). The principal action of Beta-2 agonists is to stimulate beta-2 adrenergic receptors to relax airway smooth muscle.
Theophylline is a methylxanthine that acts as a non-selective inhibitor of phosphodiesterase enzyme subsets. It inhibits the breakdown of cyclic AMP rather than stimulating the enzyme.
132
9-year-old male was recently diagnosed with COPD and was advised to undergo pulmonary rehabilitation. Which of the following best describes Pulmonary Rehabilitation?
A. Improved functional exercise capacity have been demonstrated across all grades of COPD severity
B. Additional benefits can be seen for Pulmonary Rehabilitation extended to 3 months
C. Optimum benefits are achieved for programs lasting 1 month
D. Supervised exercise training at least once weekly is recommended
A
A. Improved functional exercise capacity have been demonstrated across all grades of COPD severity - FEEDBACK: GOLD 2023 PAGE 74
B. Additional benefits can be seen for Pulmonary Rehabilitation extended to 3 months –
FEEDBACK: Available evidence indicates that there are no additional benefits from extending pulmonary rehabilitation to 12 week PAGE 74 GOLD 2023
Optimum benefits are achieved for programs lasting 1 month
SHOULD BE 6-8 WEEKS INSTEAD NA 1 MONTH PAGE 74 GOLD 2023
Supervised exercise training at least once weekly is recommended
SHOULD BE TWICE WEEKLY PAGE 74 GOLD 2023
133
Pulmonary Hypertension develops in the later course in COPD and the contributing factors include the following except?
A. Pulmonary arterial constriction secondary to hypoxia
B. Endothelial dysfunction
C. Pulmonary artery smooth muscle hypertrophy and hyperplasia causing remodelling
D. Thickening of epithelial reticular basement membrane
D
Thickening of the epithelial reticular basement membrane is mentioned in the sources specifically in the context of eosinophilic inflammation. While some COPD patients exhibit this airway-related change, it is a hallmark of airway remodeling (often seen in asthma) rather than a contributor to the vascular resistance and pressure changes that define pulmonary hypertension
134
This study demonstrated a reduction in all-cause mortality in COPD patients receiving ICS + LABA + LAMA or ICS + LABA compared to LAMA + LABA
TORCH study
IMPACT study
SMART study
INHALE study
Source: (Murray, p 884)
TORCH study – salmeterol + fluticasone vs salmeterol vs fluticasone. Salmeterol + fluticasone improved lung function, health status, exacerbations, and cost-effectiveness
IMPACT study
SMART study – budesonide + formoterol (symbicort) maintenance and reliever therapy
INHALE study – salmeterol + fluticasone vs tiotropium. Salmeterol + fluticasone had decreased mortality and better health status but more frequent pneumonia and no difference in exacerbations
135
Treatment of Advance COPD with HOMOGENEOUS emphysema with POSITIVE for collateral ventilation EXCEPT
Bronchoscopic lung volume reduction (BLVR)
Lung volume reduction surgery (LVRS)
Lung volume reduction coil (LVRC)
Vapor ablation (VA)
VA
136
Risk of postoperative complication from lung resection increased in patients with decreased predicted post operative pulmonary function
FEV1 or DLco <30−40% predicted; peak VO2 <10 ml/kg/min or 35% predicted.
Murray
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