COPD Exacerbation Quiz Answers


  1. A COPD exacerbation as defined by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) includes can include all of the following characteristics except:


    1. Increase in severity and frequency of cough

    2. Hypoxia with O2 saturation less than 88%

    3. Increase in dyspnea

    4. Increase in sputum production

    5. Change in purulence or nature of sputum


    Discussion: An exacerbation of COPD as defined by the Global Initiative for Chronic Obstructive Lung Disease includes an increase in dyspnea, an increase in frequency/severity of cough, and increase in purulence/volume of sputum. There is an increase in patient’s symptoms beyond normal day-to-day variation. While those with acute exacerbations are often hypoxic, there is no specific criteria for oxygen saturation as defined by the GOLD criteria.

  2. A 65 yo female with a previous 50 pack-year history of tobacco use and diagnosis of COPD presents to the Emergency Department with 2 days of worsening shortness of breath, increased wheezing, and worsening chronic cough. Vitals show a BP of 120/80, HR of 105, RR of 22, Pulse oximetry 92% on room air.
    Initial diagnostic modalities that should be performed in the ED include which of the following:


    1. Chest radiograph

    2. Bedside spirometry

    3. Chest CT

    4. Arterial blood gas

    5. D-dimer

    6. Sputum Culture


    Discussion: A patient who presents with a history of previously diagnosed COPD and symptoms typical for an exacerbation should be evaluated as such. According to AFP review article 2010, a recommended diagnostic evaluation in an emergency department includes pulse oximetry measurements, chest radiography, and an arterial blood gas. Bedside spirometry has not proven beneficial in the hospitalized setting. In addition peak flows are not recommended in the inpatient setting for COPD exacerbations due to their predisposition to induce bronchospasm. A d-dimer and chest CT should also not routinely be performed as initial work-up unless other suggestions for pulmonary embolism or other underlying pulmonary etiology are suspected. Sputum cultures are not routinely recommended for COPD exacerbations because many patients with COPD are carriers of the same pathogens that will cause an exacerbation. It would be difficult to assess if the bacteria is causing the exacerbation or simply the patients normal flora.

  3. Upon evaluation of the above patient, a decision to admit the patient to the hospital is made. As the resident on call you are asked to place initial admission orders.
    On examination you find a pleasant female in mild respiratory distress, a RR of 22 with diffuse expiratory wheezing and intermittent rhonchi with no crackles appreciated.
    Initial admission orders should include which of the following:


    1. prednisone 40mg po daily

    2. Oxygen supplementation to keep oxygen saturations greater than 94%

    3. Albuterol nebulizer every 2 hours

    4. Ipratroprium nebulizer every 2 hours

    5. Fluticasone inhaled twice daily

    6. Avelox 400mg po daily


    Discussion: Patients requiring admission to the hospital for an acute exacerbation of COPD should be classified as having a severe exacerbation. Mild exacerbations are those that only require a change in dosage or frequency of controller medications. A moderate exacerbation is classified as requiring systemic steroids or antibiotics. A severe exacerbation is classified as requiring inpatient hospitalization due to symptoms of respiratory distress and need for access to critical care personnel and mechanical ventilation. Those patients requiring hospitalization benefit from short-acting, symptom-relieving medications including b-agonists such as albuterol and anticholinergics such as ipratroprium. In addition the use of systemic steroids is indicated as they have been shown to decrease length of hospital stays, decrease rates of treatment failure, and improve hypoxemia. There is generally no difference in oral vs parenteral steroids though no clear studies .
    Antibiotics are shown to have significant benefit in those with moderate to severe exacerbations, or essentially those requiring hospitalization. Antibiotics reduce the risk of short-term mortality by 77%, decrease risk of treatment failure by 53%, and decrease sputum purulence by 44% (Puhan et al. BMC Med 2008 Oct 10;6:28).
    There is no role of inhaled steroids in acute exacerbations. Also the goal spO2 for those with COPD is between 90-94%, not greater than 94%.

  4. The same patient as above improves and is likely ready for discharge after a 3 day stay in the hospital.
    Her resting pulse oximetry is 94% on room air and her oximetry with activity drops to 88%
    Which of the statements below are correct regarding her discharge orders: (Pick all that apply)


    1. The oral steroids should be stopped at time of discharge

    2. The patient should be offered a pneumonia and influenza vaccine

    3. The patient should be counseled on smoking cessation

    4. She should complete a full 8 day course of antibiotics

    5. The patient should be discharged with home O2


    Discussion: Interventions that have been shown to reduce future exacerbations of COPD include cessation of tobacco smoking, immunization against influenza and pneumonia, pulmonary rehabilitation, long-term oxygen therapy, and initiation of long-acting bronchodilators with inhaled corticosteroids such as Advair or Symbicort. Long term use of systemic steroids may help prevent future exacerbations but also have multiple other comorbidities associated with their use. Short bursts (5 days of same dose) or tapers (step-wise decreasing strength of steroid over 1-2 weeks) of oral steroids have been shown to prevent recurrent exacerbations. A 5 day course of antibiotics is all that is recommended for an acute COPD exacerbation. Oxygen therapy is recommended and the criteria for home O2 is based on an ambulatory O2 saturation of 88% or less.

  5. As the patient is being prepared for discharge later that afternoon, you receive a call from the floor nurse stating that the patient seems to be more somnolent and difficult to arouse than early morning. You go to examine the patient and find her somnolent and poorly arousable to external stimulation. Vitals show BP- 122/20, HR- 96, T-98.8, RR- 22, O2 sats- 88% on 3L O2. Lungs with occasional wheeze but moderately good air movement without crackles or rhonchi.
    Initial orders for the patient should include: (Pick all that apply)


    1. CXR

    2. ABG

    3. Duoneb treatment

    4. Head CT

    5. Ammonia level

    Discussion: As mentioned in the previous questions, this patient has been admitted and treated for a COPD exacerbation. She seems to have acquired an O2 requirement and is now more somnolent. Upon seeing a more somnolent patient with a diagnosis of COPD the most urgent INITIAL orders would be a stat duoneb treatment and an ABG. Without any other neurological deficits mentioned a CT head would not be an immediate initial order. In addition no mention of liver disease has been mentioned so an ammonia level would be a low yield test. A CXR could be considered if the ABG is normal but for cost-effective reasons would not order as an initial test without other findings on the lung exam. Considering the patients admitting diagnosis of COPD exacerbation, the likely cause of her somnolence is a hypercapnic state and initial orders would be a duoneb treatment and a stat ABG to assess her CO2.

  6. Seeing as you are very busy and do not want to miss anything, you order all of the modalities above. Head CT and ammonia levels come back normal. CXR is read as “hyperinflation with no acute cardiopulmonary disease”. ABG shows pH- 7.31, pCO2- 72, pO2- 80, HCO3- 23. A duoneb treatment is given without much improvement in mental status.
    The ABG result suggests which of the following:


    1. Compensated Respiratory Alkalosis

    2. Uncompensated Respiratory Acidosis

    3. Uncompensated Respiratory Alkalosis

    4. Compensated Respiratory Acidosis


    Discussion: The patient is demonstrating an uncompensated respiratory acidosis at this time. The pH is acidotic and the pCO2 is elevated resulting in a respiratory acidosis. In acute respiratory acidosis, the plasma bicarbonate concentration rises 1 meq/L for every 10 mmHg elevation in the PCO2, this ratio increases to 3.5 meq/L per 10 mmHg in chronic respiratory acidosis. Based on a normal HCO3 to be around 24, one would expect an acute compensation of HCO3 to be around 26 with a chronic compensation of HCO3 to be around 31.

  7. The next step(s) in the care of this patient should include:


    1. Give back to back duoneb treatments

    2. Initiation of Bipap ventilation

    3. Start a HCO3 drip at 75cc/hr

    4. Call ICU team for stat intubation


    Discussion: This patient is demonstrating the classic signs of hypercarbic respiratory failure, which include somnolence with altered mental status and an abnormally elevated pCO2 well above baseline. The major cause of hypercapnia in patients with COPD is impaired matching of ventilation (V) and perfusion (Q). In this case the most likely cause for the hypercapnia is due to the increased oxygen given by nasal cannula in an effort to reach an O2 saturation of 100%. It is important to clarify with nursing staff the goal O2 saturation of being between 90-94% only with supplemental oxygen.
    Further duoneb treatments are not likely to be of benefit and the initiation of a HCO3 drip would likely be counterproductive. While intubation would certainly help the situation, initiation of a less invasive therapy such as Bipap would be the first line therapy in this situation.

  8. The three most common bacterial pathogens responsible for most COPD exacerbations are: (Pick three):


    1. Moraxella catarrhalis

    2. Streptococcus pneumonia

    3. Staphylococcus aureus

    4. Hemophilus influenzae

    5. Klebsiella pneumonia


    Discussion: The three most common bacterial pathogens responsible for the majority of COPD exacerbations includes M. catarrhalis, S. pneumoniae, and H. influenzae. While S. aureus and K. pneumoniae are potential pathogens, neither are particularly common causes of most COPD exacerbations. As mentioned in a prior question, sputum cultures are not routinely recommended because many patients with COPD are carriers of M catarrhalis, S. pneumoniae, and H. influenzae, and will be positive at baseline.

  9. The most common infectious etiologies associated with causing an exacerbation of COPD includes the three mentioned in the previous question. Another common etiology for an acute COPD exacerbation is Pseudomonas infection. Risk factors for Pseudomonas as an etiology include all of the following except:


    1. Frequent antibiotics use (> 4 times in last 1 year)

    2. Recent hospitalization ( > 2 days in last 90 days)

    3. Tobacco use 1 pack per day or greater

    4. History of previous Pseudomonal infection

    5. Severe COPD (FEV1 < 50%)


    Discussion: Current guidelines suggest that risk factors that increase the likelihood of Pseudomonas infection as a cause for a COPD exacerbation include frequent use of antibiotics, recent hospitalization, severe COPD with FEV1 < 50%, history of previous Pseudomonal infections, frequent systemic glucocorticoid use, and colonization during stable periods. While continuing to smoke tobacco increases the risk of COPD-related morbidity and mortality, it is not specifically a risk factor for Pseudomonal infection.

  10. Appropriate antibiotic treatment options to treat patients identified as being at risk for Pseudomonal infection based on the risk factors in the above question include all of the following except:


    1. Levofloxacin 750mg daily

    2. Moxifloxacin 400mg daily

    3. Cefepime 1-2G twice daily

    4. Ceftazidime 1G twice daily

    5. Zosyn 4.5G every 6 hours


    Discussion: All of the antibiotics mentioned above can be used to treat a patient with a COPD exacerbation with risk factor(s) for Pseudomonas with exception of Moxifloxacin, which does not have Pseudomonal coverage.