Question 1: Asthma Control
Vignette:
A 25-year-old female with a history of asthma presents to the clinic for a follow-up. She reports using her albuterol inhaler more than twice a week but less than once a day. She experiences nocturnal awakenings due to asthma symptoms about once a month. She has not had any recent asthma attacks requiring oral corticosteroids. Her current medications include albuterol PRN and low-dose inhaled corticosteroid (ICS).
Question:
Which of the following best describes her level of asthma control?
A) Well-controlled
B) Not well-controlled
C) Very poorly controlled
D) Asthma is in remission
E) Moderately controlled
Rationale:
The patient’s use of a short-acting beta-agonist (SABA) for symptom relief more than twice per week indicates her asthma is not well-controlled. According to asthma control guidelines, using SABA more than twice a week for symptom relief suggests a need for reevaluation of asthma management and possibly stepping up therapy. Additionally, experiencing nocturnal awakenings more than twice a month would also indicate not well-controlled asthma. This patient’s symptoms and medication use do not align with the criteria for well-controlled asthma, which would involve using SABA less than twice a week and having no nocturnal symptoms.
Question 2: COPD Treatment
Vignette:
A 67-year-old male with a history of COPD presents with increased shortness of breath and a productive cough. He has a 40 pack-year smoking history and currently smokes about 10 cigarettes a day. His current medications include tiotropium and PRN albuterol. He has had two exacerbations requiring oral corticosteroids in the past year.
Question:
Which of the following medications should be added to his regimen to reduce the risk of future COPD exacerbations?
A) Formoterol
B) Ipratropium
C) Fluticasone/Salmeterol
D) Montelukast
E) Aclidinium
Rationale:
Adding a combination inhaled corticosteroid (ICS) and long-acting beta-agonist (LABA), such as fluticasone/salmeterol, is recommended for patients with COPD who have had frequent exacerbations and are symptomatic despite the use of a long-acting muscarinic antagonist (LAMA) like tiotropium. ICS/LABA combinations have been shown to reduce the frequency of exacerbations in COPD patients with a history of exacerbations. The addition of fluticasone/salmeterol would provide both the anti-inflammatory benefits of an ICS and the bronchodilatory effects of a LABA. Montelukast and ipratropium are less effective in this scenario, and aclidinium, while a LAMA, does not offer the combined benefits of an ICS/LABA in reducing exacerbations.
Question 3: Asthma Step Therapy
Vignette:
A 15-year-old male has been diagnosed with moderate persistent asthma. He has daily symptoms and uses his albuterol inhaler every day. He also experiences nocturnal symptoms 3 times a week. His current medication is a medium-dose inhaled corticosteroid (ICS).
Question:
What is the next step in managing his asthma according to the stepwise approach?
A) Increase ICS to high-dose
B) Add a long-acting beta-agonist (LABA) to current ICS
C) Add leukotriene receptor antagonist (LTRA)
D) Add oral corticosteroid
E) Add tiotropium
Rationale:
For patients with moderate persistent asthma who are not well controlled on a medium-dose ICS, the next step is to add a long-acting beta-agonist (LABA) to the existing ICS regimen. This combination therapy improves asthma control by providing both anti-inflammatory and bronchodilatory actions, which are more effective together than either medication alone. Adding a LABA to an ICS has been shown to decrease the frequency of asthma exacerbations, improve lung function, and reduce the need for rescue inhaler use. The other options, such as increasing the ICS dose or adding an LTRA, may be considered in specific situations but are not the primary next step for this scenario.
Question 4: COPD Diagnosis
Vignette:
A 55-year-old female presents with a chronic cough, sputum production, and dyspnea. She has a 30-year history of smoking but quit 5 years ago. She mentions that her symptoms have progressively worsened over the past 2 years. Spirometry testing shows a FEV1/FVC ratio of 0.65 after bronchodilator administration.
Question:
Which of the following is the most appropriate diagnosis based on the spirometry results?
A) Asthma
B) COPD
C) Acute bronchitis
D) Pulmonary fibrosis
E) Heart failure
Rationale:
The hallmark spirometry finding for COPD diagnosis is a post-bronchodilator FEV1/FVC ratio of less than 0.70, which indicates persistent airflow limitation and is not fully reversible. The patient’s history of smoking, chronic cough, sputum production, and progressive dyspnea, coupled with spirometry results, support the diagnosis of COPD. Asthma, in contrast, often presents with reversible airflow obstruction and variability in symptoms. Acute bronchitis is typically a short-term condition, while pulmonary fibrosis would show a restrictive pattern on spirometry, not obstructive. Heart failure could cause dyspnea but would not directly affect the FEV1/FVC ratio.
Question 5: Asthma Exacerbation Treatment
Vignette:
A 32-year-old male with a history of asthma is brought to the emergency department with severe shortness of breath, wheezing, and an inability to speak in full sentences. He has used his albuterol inhaler multiple times in the past hour with no relief. His oxygen saturation is 88% on room air.
Question:
What is the most appropriate initial treatment?
A) Oral corticosteroids
B) High-dose inhaled corticosteroids
C) Intravenous corticosteroids
D) Nebulized albuterol and ipratropium
E) Magnesium sulfate
Rationale:
In the setting of an acute asthma exacerbation presenting with severe symptoms, the initial treatment should focus on rapid bronchodilation. Nebulized albuterol, a short-acting beta-agonist (SABA), provides quick bronchodilation, while adding ipratropium, a short-acting muscarinic antagonist (SAMA), offers additional bronchodilatory effects through a different mechanism. This combination is more effective in acute exacerbations than either medication alone. Although systemic corticosteroids are crucial in managing severe asthma exacerbations, the immediate priority is to relieve airway obstruction and improve oxygenation, which is best achieved with nebulized SABA and SAMA.
Question 6: Inhaler Technique in COPD
Vignette:
A 70-year-old male with COPD reports difficulty using his metered-dose inhaler (MDI) due to arthritis in his hands. He has been noncompliant with his medications because of this issue, leading to frequent exacerbations.
Question:
Which of the following interventions is most appropriate to improve his medication adherence?
A) Switch to a nebulizer treatment
B) Prescribe an oral bronchodilator
C) Add a spacer device to his MDI
D) Switch to a dry powder inhaler (DPI)
E) Increase the dose of his current medication
Rationale:
Adding a spacer device to a metered-dose inhaler (MDI) can significantly help patients with coordination issues or physical limitations such as arthritis. Spacers can make it easier to use MDIs by reducing the need for hand-breath coordination, allowing the patient more time to inhale the medication. This intervention is likely to improve adherence and the effectiveness of the medication, potentially reducing the frequency of COPD exacerbations. Switching to a nebulizer or DPI, prescribing oral bronchodilators, or increasing the medication dose may not address the specific issue of difficulty with inhaler use due to arthritis.
Question 7: Asthma and Pregnancy
Vignette:
A 28-year-old pregnant woman in her second trimester visits her healthcare provider for asthma management. She has been using a low-dose inhaled corticosteroid (ICS) and occasionally uses her albuterol inhaler for breakthrough symptoms. She reports an increase in asthma symptoms over the past month.
Question:
Which of the following steps should be taken next in managing her asthma?
A) Discontinue the inhaled corticosteroid due to pregnancy
B) Increase the dose of the inhaled corticosteroid
C) Add oral corticosteroids
D) Add a long-acting beta-agonist (LABA) to the ICS
E) Switch to nebulized treatments only
Rationale:
For pregnant women with asthma, maintaining optimal asthma control is crucial to ensure both maternal and fetal well-being. Increasing asthma symptoms indicate the need for a step-up in therapy. Adding a long-acting beta-agonist (LABA) to the existing low-dose inhaled corticosteroid (ICS) regimen is an appropriate next step, as this combination has been shown to improve asthma control more effectively than increasing the dose of ICS alone. LABAs and ICSs are considered safe during pregnancy and are preferred due to their ability to better control asthma symptoms and reduce the risk of exacerbations. Discontinuing ICS or solely relying on oral corticosteroids or nebulized treatments is not recommended without specific indications.
Question 8: Identifying COPD Exacerbation Early
Vignette:
A 63-year-old female with COPD reports increased shortness of breath, more frequent coughing, and a change in her sputum color from clear to greenish over the past three days. She has a history of two exacerbations in the previous year.
Question:
What is the most appropriate initial action for her reported symptoms?
A) Start an antibiotic and oral corticosteroid
B) Increase the dose of her current inhaled corticosteroid
C) Recommend rest and increased fluid intake
D) Initiate oxygen therapy at home
E) Perform a spirometry test
Rationale:
The patient’s symptoms indicate an acute exacerbation of COPD, characterized by increased shortness of breath, more frequent coughing, and a change in sputum color. The presence of purulent sputum (greenish in color) suggests a bacterial infection, which is a common cause of COPD exacerbations. Starting an antibiotic to treat the suspected bacterial infection, along with an oral corticosteroid to reduce inflammation and airway obstruction, is recommended in managing COPD exacerbations. This approach aims to mitigate the exacerbation’s severity and prevent further deterioration. Adjusting inhaled corticosteroid doses, recommending rest, or initiating oxygen therapy without addressing the exacerbation’s cause would not be appropriate as initial actions.
Question 9: Step Down Therapy in Asthma
Vignette:
A 40-year-old male with well-controlled asthma for the past year is currently on a regimen of medium-dose inhaled corticosteroid (ICS) and long-acting beta-agonist (LABA). He reports no exacerbations in the last 12 months and uses his albuterol inhaler less than once a week.
Question:
Considering his well-controlled asthma, what is the most appropriate next step in his asthma management?
A) Continue current regimen
B) Increase ICS to high-dose
C) Add a leukotriene receptor antagonist
D) Step down to low-dose ICS/LABA
E) Discontinue LABA and continue medium-dose ICS
Rationale:
In patients with well-controlled asthma for at least three months, guidelines recommend considering stepping down therapy to find the lowest medication amount that maintains control, thereby minimizing potential side effects. Since this patient has maintained good asthma control for a year without exacerbations and minimal use of rescue inhaler, stepping down to a lower dose of inhaled corticosteroid while continuing the long-acting beta-agonist (ICS/LABA) is appropriate. This approach maintains the benefits of both an anti-inflammatory and a bronchodilator with a reduced risk of side effects associated with higher doses. Increasing the dose or adding another controller medication is not indicated in the absence of control issues.
Question 10: Oxygen Therapy in COPD
Vignette:
A 72-year-old male with severe COPD has an FEV1 of 35% predicted. Despite optimal pharmacologic therapy, he reports significant dyspnea on exertion and his oxygen saturation drops to 88% during a 6-minute walk test. He has been hospitalized twice in the past year for COPD exacerbations.
Question:
Which of the following is the most appropriate addition to his treatment plan?
A) Initiate short-acting beta-agonists (SABA) as needed
B) Increase the dose of inhaled corticosteroids
C) Start long-term oxygen therapy (LTOT)
D) Add a phosphodiesterase-4 inhibitor
E) Refer for surgical evaluation
Rationale:
For patients with COPD and severe resting hypoxemia (oxygen saturation ≤ 88% during rest or exercise), long-term oxygen therapy (LTOT) has been shown to improve survival, quality of life, and exercise capacity. This patient, with severe COPD, demonstrated oxygen saturation dropping to 88% during exertion and has a history of frequent exacerbations, indicating significant disease impact and the potential benefit of supplemental oxygen. LTOT is specifically recommended for patients who meet these criteria as it can also reduce the workload on the heart in the setting of chronic hypoxemia. Initiating LTOT would address the underlying issue of hypoxemia more directly than increasing medication doses, adding new medications, or considering surgery at this stage.