Free Physician Assistant Board Review Question

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Free PA Board Review Question

A 49-year-old male presents to the emergency department with the complaints of cough and progressive shortness of breath over the past three days. Past medical history reveals a 30 pack-year smoking history.

Further history reveals the patient typically has a cough productive of thin white sputum that has turned green for the past day. Physical examination reveals a thin, chronically ill appearing man with diminished breath sounds bilaterally and scattered wheezes. Vitals reveal a temperature of 37 ºC (98.6 ºF), a blood pressure of 150/76 mmHg, a heart rate of 100/min, a respiratory rate of 30/min, and an oxygen saturation of 85% on room air.

A portable chest radiograph is obtained as shown in the exhibit. 

The most appropriate pharmacologic treatment is:

A) azithromycin and inhaled albuterol/ipratropium

B) inhaled albuterol/ipratropium

C) prednisone and azithromycin

D) prednisone and inhaled albuterol/ipratropium

E) prednisone, azithromycin, and inhaled albuterol/ipratropium

Answer and Explanation

An acute exacerbation of COPD is typically defined as a change or increase in sputum production, an increase in oxygen requirement, or an increase in dyspnea. This patient has a significant smoking history, is thin, ill appearing and has a chest radiograph demonstrating hyperexpansion, flattened diaphragms, and a thin cardiac silhouette.

These findings are consistent with COPD, most likely emphysema. The patient has acutely worsened with a change from white to green sputum and an increase in cough and shortness of breath and should be treated with systemic steroids, antibiotics, and inhaled bronchodilators. Systemic corticosteroids are widely accepted as a treatment to decrease inflammation in airways to improve ventilation. Bronchodilators act to decrease muscle tone in small and large airways in the lungs, thereby improving ventilation.

Antibiotics should be given and should include coverage for typical microbes that colonize the lower airways in COPD such as S. pneumoniae, H. influenzae, and M. catarrhalis. Commonly accepted antibiotic choices are doxycycline, azithromycin, amoxicillin, or trimethoprim/sulfamethoxazole.

Answer A: The treatment of COPD exacerbation must include medications that act to improve bronchial smooth muscle relaxation, decrease airway inflammation, and decrease airway secretions. The combination of azithromycin and an inhaled albuterol/ipratropium is inadequate because it lacks systemic corticosteroid administration.

Did you get it right? The correct answer is: E

Incorrect Answer Explanations

Answer B: As indicated above, the treatment of COPD exacerbation must target several pathways in the lungs that involve inflammatory, infectious, and hypersecretory states. Using inhaled medications alone is inadequate.

Answer C: Using a systemic corticosteroid in addition to antibiotics may be enough to eventually decrease the infection and inflammation that occur in a COPD exacerbation. However, an inhaled agent is indicated and will rapidly improve oxygenation, ventilation, and patient dyspnea by directly reducing bronchospasm in the airways.

Answer D: Using a systemic corticosteroid in addition to an inhaled beta-2 agonist and inhaled anticholinergic medication would affect inflammation and hyper-secretion that occurs in the airways of a patient experiencing a COPD exacerbation. However, this regimen lacks an antibiotic to decrease infectious burden in the lungs. Commonly accepted antibiotic choices are doxycycline, azithromycin, amoxicillin, or trimethoprim/sulfamethoxazole.

Bottom Line: Treat acute exacerbation of COPD with several different medications to target different components of the syndrome. An antibiotic, systemic corticosteroid, and inhaled bronchodilator are all used for initial treatment.

For more information, see:

“Chronic obstructive pulmonary disease treatment and management” on Medscape.

CXR

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