USMLE Forum - Largest USMLE Community

2) The correct answer is B. This patient has emphysema. His long history of smoking, chronic cough, and œsome type of inhaler use all suggest this diagnosis. His chest x-ray shows hyperinflation of lung fields, flattening of the diaphragm, small heart size, and a paucity of lung markings. It is believed that although many patients seem to fit the picture of emphysema or chronic bronchitis, these classifications are artificia,l and that they have spectrums of chronic obstructive pulmonary disease (COPD). This patient is having an exacerbation of his underlying COPD. These exacerbations are treated with systemic steroids, oxygen as needed, empiric antibiotics, and nebulizer treatments with albuterol and ipratropium bromide.

This patient may require intubation at some point (choice A) but we do not have enough information to make that decision at this time. Some indications for intubation of a patient with COPD include extreme hypercarbia with decreased mental status, acidosis, or an inability to oxygenate through less invasive means. Extreme respiratory distress (subjectively) is another indication for intubation. The information provided does not give enough information to make the decision about intubation at this time.

This patient does not have any evidence of fluid overload or any history of congestive heart failure. Diuresis and a low salt diet (choice C), therefore, would have little effect on this patient™s outcome.

In the acute setting, systemic steroids, not inhaled steroids (choice D), are crucial. Studies have shown that MDI delivery of albuterol and ipratropium bromide is as effective as delivery with a nebulizer machine. The role of inhaled steroids in management of COPD is controversial. Many patients receive steroid MDI and note improvement, but the data does not conclusively support routine use. Inhaled steroids have no role in the treatment of acute COPD exacerbations.

Although it is true oxygen can depress respiratory drive in chronic carbon dioxide retainers, (choice E), if one deprives a patient of oxygen, hypoxic injury to vital organs (e.g., brain, heart) can occur. The role of oxygen therapy is therefore clear for COPD patients. Give them the minimum amount of oxygen needed to maintain a PaO2 of approximately 55-60 mm Hg at all times. If carbon dioxide retention and acidosis become a problem, the patient should receive mechanical ventilation.

2.c
3.e

what is the answer?

3) The correct answer is E. Patients with chronic disease, particularly chronic lung disease, should receive a pneumococcal vaccine once and then a repeat booster shot after age 65 years.

Antibiotics (choice A) have not been shown to have beneficial effect in COPD when used for prophylaxis. This patient has received a 5-day course of azithromycin, which is more than adequate for AECB (traditionally treatment has been for 5 days, though current recommendations are for 3 days of higher dose treatment).

Home oxygen therapy (choice B) has been shown effective only in patients with severe COPD, as evidenced by a baseline pO2 of less than 55 mm Hg. This patient has adequate, though reduced, oxygenation and is unlikely to benefit from (or qualify for) home oxygen therapy.

Inhaled steroids (choice C) are commonly used but rarely beneficial in COPD. Asthma, a predominantly eosinophilic inflammation, responds better to steroids than the neutrophilic inflammation of COPD. If this patient™s chronic condition worsens, he may benefit from a trial of oral steroids to gauge steroid responsiveness, and then may benefit from a transition to an inhaler.

Leukotriene modulators (choice D) work on an inflammatory cascade seen more in asthma than in COPD, and would be of little benefit in this patient.

Also All known Chronic COPD shud receive a H. Influenza vaccine if not previously vaccinated and then yearly

really good Q ..tnx arrythmia

can u plz more Q?

HI Arrythmia...left for a while ...

how r u buddy? thanks for qs!