AME 9.15.08 – 9.19.08 COPD
Author: Russ Bedsole, M.D.
Competencies: Medical Knowledge, Practice Based Learning
Learning Objectives: After this AME the learner should be able to: Attending Version
1. Properly diagnose and classify COPD from PFTs
2. Prescribe the proper medications for chronic and acute COPD
3. Properly prescribe interventions (flu/pneumo vaccine, pulm rehab, d/c smoking) for COPD
1. “COPD” Annals of Internal Medicine 4 March 2008; 148 (5)
o COPD is the 4th leading cause of death worldwide
o Approximately 80-90% of cases of COPD are secondary to tobacco smoke
o The approximate risk of clinically significant COPD among smokers is 15%
Bronchitis and Emphysema:
o Chronic bronchitis is defined as at least 90 days of cough and production of
sputum for 2 consecutive years
o Emphysema is defined as a ‘pathologic diagnosis’ which is suggested by
hyperinflation on exam or imaging
o Neither chronic bronchitis nor emphysema is required to diagnose COPD
o The diagnosis of COPD requires an FEV1/FVC ratio after bronchodilation of less
o The FEV1 percentage predicted can be utilized to classify COPD as mild
(>80%), moderate (50-80%), severe (30-50%) or very severe (<30%)
o Consider ordering an alpha 1-antitrypsin level in patients <50 yrs presenting with
o Inhaled medications form the cornerstone of treatment for COPD, though no
formulations leads to decreased rates of mortality, but rather decrease morbidity
o The ACP recommends that, in general, long-acting bronchodilators and inhaled
steroids be reserved for those with symptoms and an FEV1 less than 60% of
o Therapy generally is initiated with a short-acting inhaler prn, with subsequent
addition of long-acting bronchodilator and/or inhaled steroid for continued
o Acute exacerbations of COPD should be treated with bronchodilators, steroids,
and (likely) antibiotics, as antibiotics should be strongly considered in moderate-
o The only therapeutic intervention that has been shown to prolong life in
hypoxemic patients with chronic obstructive pulmonary disease is
supplemental oxygen therapy
o All patients with moderate to severe symptomatic COPD should be offered
The BODE Index consists of measures of Body mass index, obstruction, dyspnea, and
exercise, and can be utilized to determine prognosis and need for hospitalization
All patients with COPD should be encouraged to stop smoking
Patients should be offered influenza and pneumococcal vaccines
AME answers are due in clinic by September 26 for credit
Questions Name ________________________
1. A 60 yo male presents for evaluation of increased shortness of breath x 2 weeks.
He has a history of COPD. He has no recent hospitalizations, no recent
antibiotics, no known sick contacts. He notes increased sputum production, but no
change in color of sputum. He denies any fever, chills, and increase in cough or
wheezing. Vital signs reveal pulse of 70, RR of 18, sat of 95% on ra, which are
identical to previous values when patient was at his baseline. Exam is essentially
unchanged from prior exams. Based on the above, this patient has:
a. A mild COPD exacerbation
b. A moderate COPD exacerbation
c. A severe COPD exacerbation
Answer: B. Based on generally accepted criteria, the patient has a moderate COPD
exacerbation. See box in article for full delineation-the three major criteria for
exacerbation are: 1)worsening dyspnea 2)increase in sputum volume 3)increase in
2. What are the most likely bacterial pathogens in this case? (more than one answer)
a. Haemophilus influenza
b. Streptococcus pneumoniae
c. Moraxella catarrhalis
d. Staphylococcus aureus
e. Pseudomonas aeruginosa
f. Klebsiella pneumoniae
Answer: A, B, and C. The most common bacterial pathogens in a COPD exacerbation are
the first 3.
3. A randomized, double-blind trial demonstrated that the combination of salmeterol
and fluticasone in patients with an FEV1 of less than 60% predicted, (compared to
placebo, salmeterol alone, or fluticasone alone), demonstrated what?
a. No effect on COPD exacerbations
b. Decreased mortality
c. Decrease in COPD exacerbations
d. Increase in hospitalizations
Answer: C. The study in question demonstrated a decrease in moderate-severe COPD
exacerbations, with no effect on mortality.
4. You are on the medicine consult service, and are asked to see a patient with a
history of moderate COPD on POD #0 s/p total knee replacement. What
recommendations can you make to the orthopedic service as regards the patient’s
COPD which have been clearly shown to reduce post-op pulmonary
complications? (more than 1 answer)
a. Nasogastric tube
b. Incentive spirometry
c. Early ambulation
Answer: B and C. These interventions have been shown to reduce rates of pneumonia,
atelectasis, et al.
5. Ms. Jones is a 65 yo patient with severe COPD, with cont symptoms despite pulm
rehab. Chest ct reveals bilateral emphysema. Post bronchodilator total lung
capacity and residual volume are greater than 150% and 100% of predicted,
respectively. FEV1 is 18% of predicted. Room air PaO2 and PaCO2 are 55
mmHg predicted, respectively. Does she meet the criteria for total lung reduction
Answer: The patient does NOT meet the criteria for lung reductions surgery, as her FEV1
is less than 20% of predicted. In general, lung volume reduction surgery does not
6. Please review the Figure on page 6 for a suggested approach to COPD treatment.
7. Bonus Question: Dr. Richard Light, the author of ‘Light’s criteria’ for pleural
effusions, is a professor of medicine at what institution?
Answer: Vanderbilt University
1. C Upper abdominal and thoracic surgeries pose the greatest risk to patients with
obstructive lung disease. Anesthesia- and narcotic-induced respiratory depression adds to
In general, the farther the surgical site is from the diaphragm, the lower the surgical risk
to patients with obstructive lung disease. Ophthalmologic procedures have a very low
mortality rate. Short endoscopic procedures, especially with the use of local anesthesia
pose a reasonably low risk.
2. C This patient's physical findings suggest pulmonary hypertension and cor
pulmonale. Even though his PaO2 is greater than 60 mm Hg while he is awake, he may
have nocturnal oxygen desaturation that is responsible for pulmonary hypertension. Pulse
oximetry could document the presence of nocturnal hypoxemia. A full polysomnography
is useful if sleep staging is required to document rapid eye movement (REM) sleep–
related oxygen desaturation. Supplemental oxygen would be appropriate if marked
nocturnal hypoxemia is documented. Nocturnal mechanical ventilation would not be
indicated unless nocturnal hypoventilation is present. A phlebotomy is not likely to
improve symptoms at this modest level of polycythemia. Adding ipratropium bromide is
unlikely to reverse the nocturnal hypoxemia associated with COPD.
3. B Ciprofloxacin and other quinolones inhibit hepatic metabolism of theophylline and
can cause a clinically important increase in serum theophylline levels. Elevated serum
theophylline levels commonly cause nausea or vomiting and occasionally seizures.
Because the therapeutic-to-toxic window is narrow for theophylline and many agents
interact with this drug, it is necessary to exercise caution when adding a new medication
to the regimens of patients already taking theophylline.
Ciprofloxacin can cause nausea but, by itself, is not known to cause syncope, except by
precipitating anaphylaxis. Albuterol, lisinopril, oxygen, and ipratropium bromide do not
significantly interact with theophylline.
4. D The only therapeutic intervention that has been shown to prolong life in hypoxemic
patients with chronic obstructive pulmonary disease is supplemental oxygen therapy.
Two nonpharmacologic interventions have also been shown to prolong life for patients
with chronic airflow obstruction: smoking cessation and lung-volume-reduction surgery
in carefully selected patients.
5. A Pulmonary rehabilitation is indicated for patients with chronic respiratory
impairment who, despite optimal medical management, are dyspneic, have reduced
exercise tolerance, or experience a restriction in activities.
Symptoms, disabilities, and handicaps, rather than the severity of lung impairment,
dictate the need for pulmonary rehabilitation. Although pulmonary rehabilitation may
improve symptoms and exercise tolerance, often there is no improvement in pulmonary
6. B Immunization with the influenza and pneumococcal vaccines is important to prevent
infectious respiratory complications. Although the vaccines are not entirely protective,
they are likely to benefit patients with emphysema. This patient should continue her
social activities and continue with the rehabilitation program to maintain her strength and
There is no evidence that prophylactic antibiotic use or wearing a surgical mask will
prevent colds or pneumonia.