Chronic Obstructive Pulmonary Disease

Pulmonary and Critical Care Medicine · Airways Disease · study mode — pick an answer, then reveal.

Question · easy

A 62-year-old with a 40-pack-year smoking history reports progressive exertional dyspnea and chronic cough. Which spirometric finding establishes the diagnosis of COPD?

Increase in FEV1 of at least 12% and 200 mL after a bronchodilator Postbronchodilator FEV1/FVC ratio less than 0.70 FEV1 less than 80% of predicted Reduced diffusing capacity of the lung for carbon monoxide (DLCO)

COPD is confirmed by a postbronchodilator FEV1/FVC ratio < 0.70, reflecting airflow limitation that is not fully reversible. Significant bronchodilator reversibility (≥12% and 200 mL) suggests asthma. An FEV1 < 80% predicted grades severity (GOLD 2+) but does not by itself diagnose obstruction, and a reduced DLCO supports emphysema/severity but is not required for diagnosis.

MKSAP 19 B.5 Ch.2; Harrison's 22e Ch.303

Question · medium

Which statement about inhaled glucocorticoids (ICS) in stable COPD is correct?

They are recommended as monotherapy for all patients with moderate disease Their exacerbation-reduction benefit is greatest when blood eosinophils exceed 300/µL They reduce the incidence of pneumonia in severe COPD They are the preferred initial single agent for GOLD Group A patients

ICS benefit in COPD is eosinophil-dependent: little benefit below 100/µL, increasing benefit above 100, and recommended as part of initial therapy above 300/µL. ICS are never used as monotherapy in COPD (they are combined with a LABA/LAMA), they INCREASE rather than reduce pneumonia risk, and Group A is treated with a bronchodilator, not ICS.

MKSAP 19 B.5 Ch.2; Harrison's 22e Ch.303; GOLD 2025 Report

Question · medium

Which patient with COPD meets criteria for long-term supplemental oxygen with a proven mortality benefit?

Resting arterial Po2 of 54 mm Hg Oxygen saturation of 89% only during a 6-minute walk test Resting oxygen saturation of 91% on room air Resting oxygen saturation of 90% with no comorbidities

Long-term oxygen improves survival for resting hypoxemia: PaO2 ≤ 55 mm Hg or SpO2 ≤ 88% (or ≤ 59 mm Hg / ≤ 89% with cor pulmonale, heart failure, or erythrocytosis). A resting PaO2 of 54 mm Hg qualifies. No mortality or symptomatic benefit has been shown for moderate resting hypoxemia or for desaturation only with exertion.

MKSAP 19 B.5 Ch.2; Harrison's 22e Ch.303

Question · hard

In which clinical scenario does noninvasive positive-pressure ventilation (NPPV) reduce mortality during a COPD exacerbation?

Respiratory arrest Isolated hypoxemia that corrects with low-flow oxygen Acute hypercapnic respiratory failure with respiratory acidosis (PaCO2 > 45 mm Hg and pH ≤ 7.35) Coma with inability to protect the airway

NPPV reduces mortality, intubation rates, complications, and length of stay in COPD exacerbations with acute hypercapnic respiratory failure and acidosis (PaCO2 > 45, pH ≤ 7.35). It does not replace intubation in respiratory arrest, coma, cardiovascular instability, or inability to clear secretions — these are contraindications to NPPV.

MKSAP 19 B.5 Ch.2; Harrison's 22e Ch.303

Question · hard

A patient with spirometrically confirmed COPD had 2 moderate exacerbations in the past year but reports few symptoms (mMRC 0, CAT 8). Under the current GOLD grouping, how is this patient classified and what is the recommended initial therapy?

Group E — LABA plus LAMA Group C — LAMA monotherapy Group A — a single bronchodilator Group D — immediate triple therapy (LABA + LAMA + ICS)

Since 2023 GOLD collapsed the former C and D categories into a single Group E ("exacerbation") category, defined by ≥ 2 moderate exacerbations/year or ≥ 1 hospitalization, regardless of symptom burden. This patient is Group E. Initial therapy for Group E is LABA + LAMA, with LABA + LAMA + ICS considered when blood eosinophils are ≥ 300/µL.

GOLD 2025 Report; Harrison's 22e Ch.303

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