Chronic Obstructive Pulmonary Disease

Chapter 28 Chronic Obstructive Pulmonary Disease




Clinical Case Problem 1 A 55-Year-Old Man with a Chronic Cough


A 55-year-old man presents to your office for assessment of a chronic cough. He complains of “coughing for the last 10   years.” The cough has become more bothersome lately. The cough is productive of sputum that is usually mucoid; it occasionally becomes purulent.


He has a 35-year history of smoking two packs of cigarettes a day (a history of 70 pack-years). He quit smoking approximately 2   years ago.


On physical examination, his blood pressure is 160/85   mm Hg. His pulse is 96 beats/minute and regular. He has a body mass index of 34. He weighs 280 pounds. He wheezes while he talks. On auscultation, adventitious breath sounds are heard in all lobes. His chest radiograph reveals significant bronchial wall thickening. There are increased markings at both lung bases.



Select the best answer to the following questions




1. What is the most likely diagnosis in this patient?


a. smoker’s cough

b. subacute bronchitis

c. emphysema

d. chronic bronchitis

e. allergic bronchitis

2. What is the most likely cause of this condition?


a. right-sided heart failure

b. cor pulmonale

c. cigarette smoking

d. obstructive sleep apnea

e. hypercapnia

3. Which of the following statements regarding this condition is (are) true?


a. the disease develops in 10% to 15% of cigarette smokers

b. cigarette smokers in whom this disease develops usually report the onset of cough with expectoration 10 to 12   years after smoking began

c. dyspnea is noted initially only on extreme exertion; as the condition progresses, it becomes more severe and occurs with mild activity

d. pneumonia, pulmonary hypertension, cor pulmonale, and chronic respiratory failure characterize the late stages of the disease

e. all of the above

4. Which of the following regarding the patient is (are) true?


a. this patient is a “pink puffer”

b. this patient’s blood gases likely will show a decreased PCO2

c. this patient’s chest radiograph will demonstrate normal to increased lung markings

d. this patient’s disease is a disease of the terminal bronchi

e. all of the above

5. Which of the following pulmonary function results is not associated with the condition described here?


a. reduced FEV1 (forced expiratory volume)

b. reduced FEV1/FVC (forced vital capacity)

c. reduced FEF25-75 (forced expiratory flow)

d. decreased residual volume

e. none of the above

6. Regarding the pathophysiologic mechanism of chronic bronchitis, which of the following statements is (are) false?


a. most histologic studies in patients with chronic bronchitis have shown an increase in the size of mucus-secreting glands as measured by the Reid index (a ratio of gland to bronchial wall thickness)

b. smooth muscle hyperplasia occurs in patients with chronic bronchitis

c. chronic bronchitis is characterized by chronic, excessive secretion of mucus

d. in chronic bronchitis, there is a clear relationship between smooth muscle hyperplasia and bronchodilator responsiveness or methacholine sensitivity

e. none of the above

7. Which of the following is (are) an established risk factor(s) for chronic obstructive pulmonary disease (COPD)?


a. smoking

b. atopy

c. elevated levels of immunoglobulin E (IgE)

d. bronchial hyperresponsiveness

e. all of the above

8. Which of the following is (are) accurate regarding the role of bacteria in chronic bronchitis?


a. the delay in mucociliary clearance allows inhaled bacteria to colonize the normally sterile airways and to multiply, leading to further infectious exacerbations

b. Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis account for 75% of all exacerbations of chronic bronchitis

c. bacteria may act synergistically with tobacco smoke to impede mucociliary clearance and allow organisms to colonize the airways further

d. nicotine stimulates the growth of H. influenzae

e. a, b, and c

f. a, b, c, and d

9. Which of the following is least likely to be considered in the diagnosis of chronic bronchitis?


a. asthma

b. pneumothorax

c. chronic angiotensin-converting enzyme (ACE) inhibitor therapy

d. gastroesophageal reflux disease

e. postnasal drip from sinusitis

10. Which of the following statements regarding smoking cessation is true?


a. cessation of smoking dramatically increases symptoms in patients with established COPD

b. cessation is difficult with a high relapse rate

c. stopping cold turkey is most successful

d. relapse should be considered a failure on the part of the patient and clinician

e. none of the above

11. Which medications are most effective in long-term management of COPD?


a. beta agonists

b. anticholinergic drugs

c. methylxanthines

d. inhaled glucocorticoids

e. oral glucocorticoids

12. Which of the following drugs is (are) recommended as symptomatic management for a patient with chronic bronchitis?


a. tiotropium

b. salmeterol

c. fluticasone

d. b and c

e. all of the above

13. Long-term home oxygen therapy is indicated in which of the patients with chronic bronchitis?


a. all patients who have established chronic bronchitis and who have met the criteria of symptoms for at least 5 years

b. all patients who have a resting PaO2 of 55    mm Hg or less

c. all patients who have a resting PaO2 of 60    mm Hg or less with evidence of chronic tissue hypoxia as demonstrated by cor pulmonale or polycythemia

d. b and c

e. all of the above


Clinical Case Problem 2: A Patient Whose Symptoms Are Exacerbated by Secondhand Smoke


The patient described in Clinical Case Problem 1 is stabilized with long-term therapy. Unfortunately, during the winter holiday, he travels to his son’s home in a distant state and finds himself in an environment in which six packs of cigarettes a day are being smoked by his son and his son’s wife (four packs for the son and two packs for his wife). There is a layer of definite haze that hangs approximately 1 foot below all the ceilings in the house. As he sits in the house one day (unable to go outside or walk any distance at all because of significantly increased shortness of breath since arriving), he counts the number of ashtrays; there are 21. His son, through the haze of smoke, finally notices that his dad is out of breath and his lips appear very blue. He takes him to the nearest emergency department (ED).


The ED physician diagnoses his condition as an acute exacerbation of chronic bronchitis. His major symptoms at this time include dyspnea, increased sputum production, and purulence. The patient’s PaO2 when measured in the ED is 44   mm Hg.



14. Which of the following should be instituted as therapy for this condition?


a. low-flow oxygen

b. intravenous corticosteroids

c. oral ciprofloxacin

d. a and b only

e. all of the above

15. Which of the following organisms that have been implicated in the pathogenesis of acute exacerbations of chronic bronchitis has (have) exhibited resistance in vivo to ampicillin?


a. Haemophilus influenzae

b. Streptococcus pneumoniae

c. Moraxella catarrhalis

d. a and b only

e. all of the above


Clinical Case Problem 3: An 82-Year-Old Woman with Shortness of Breath Recently Admitted to a Nursing Home


An 82-year-old woman with dementia is admitted to your nursing home service after a recent hip fracture due to her severe osteoporosis and kyphosis. There is no documentation of COPD in her transfer records. A nurse pages you regarding this patient and reports increased shortness of breath. The nurse also informs you that the patient is a retired millworker and has a 20 pack-year smoking history with multiple hospitalizations for “respiratory problems.” However, secondary to her dementia, the patient is unable to report a history of “emphysema.” Although the patient was transferred that day, the full history and physical examination were not completed yet. The nurse reports a temperature of 97.3°F; respiratory rate, 24 breaths/minute; heart rate, 96 beats/minute; blood pressure,110/66    mm Hg; and diminished breath sounds through all fields with occasional wheezes. She has an involved family, and the nurse gives you the daughter’s telephone number.


You call and speak with the daughter, who has power of attorney. She reports a long history of COPD with one prior episode of respiratory failure that required intubation and mechanical breathing. After the hospitalization for respiratory failure, her memory worsened, and overall the daughter believes her mother is “failing.” The daughter reports a 30-pound weight loss during the past year and notes increased frailty; she now weighs 114 pounds. The daughter starts crying on the phone and asks you to do “what you think is best.” Before the daughter hangs up, however, you are able to confirm that the patient has do-not-resuscitate (DNR) and do-not-hospitalize directives.



16. Which is the least likely cause of this shortness of breath?


a. asthma exacerbation

b. congestive heart failure (CHF) exacerbation

c. COPD exacerbation

d. aspiration pneumonia

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Oct 1, 2016 | Posted by in GENERAL SURGERY | Comments Off on Chronic Obstructive Pulmonary Disease

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