COPD & Asthma

Question 1

What is the first-line intervention for a COPD exacerbation with hypercapnia and respiratory distress?

Answer 1

BiPAP (noninvasive ventilation) — prevents intubation, improves ventilation

Dont Disrupts patients respiratory drive

Avoid O₂ > 92% — may worsen CO₂ retention

Question 2

1. When is long-term oxygen therapy (LTOT) indicated in COPD?
2. What about when there is Evidence with Cor Pulmonale?

Answer 2

1. PaO₂ ≤ 55 mmHg or SpO₂ ≤ 88%
2. PaO₂ ≤ 59 mmHg with Cor Pulmonale or Polycythemia

Question 3

A patient on LAMA + LABA + ICS still has ≥3 COPD Exacerbations/year and eosinophils <100. What next?

Answer 3

Add roflumilast (PDE-4 inhibitor)

Used in Chronic Bronchitis Subtype with Persistent Exacerbations

Question 4

What inhaler combo is not recommended in COPD and Why?

Answer 4

ICS monotherapy — increases pneumonia risk without benefit

ICS only in combo (LABA/ICS or triple therapy)

Question 5

When should you consider lung volume reduction surgery (LVRS) in COPD?

Answer 5

Severe COPD

Upper-lobe–predominant emphysema, Limited exercise tolerance, Optimized on medical therapy

Question 6

Which intervention reduces readmissions and mortality after a COPD hospitalization?

Answer 6

Pulmonary rehabilitation — improves functional capacity and long-term outcomes

Question 7

What Antibiotic Medication can be Added in former smokers with Frequent Exacerbations despite Triple Therapy?

Answer 7

Azithromycin — may reduce exacerbation frequency

Especially useful in ex-smokers

Question 8

What is the GOLD 2024 initial treatment for COPD Group B (High Symptom Burden+ No Hospitalizations)?

Group A is Low Symptom w/ NO Hospitalizations

Group E is Any symptoms + Hospitalizations

Answer 8

LAMA or LABA Monotherapy

You escalate to LAMA +LABA if symptoms Persist

Avoid ICS unless there is Asthma features or Eosinophils > 300

Question 9

When should ICS be added to COPD therapy?

Answer 9

Eosinophils ≥ 300 or ≥ 2 exacerbations/year despite LAMA/LABA

Question 10

Spirometry in COPD shows what?

Answer 10

↓ FEV1/FVC < 0.70, not fully reversible post-bronchodilator

Question 11

What are Light’s Criteria for exudative effusion?

Answer 11

Pleural protein/serum protein > 0.5
Pleural LDH/serum LDH > 0.6
Pleural LDH > 2/3 upper normal serum LDH

Question 12

When should you tap a pleural effusion (When is it the Next Step in Management) ?

Answer 12

1. Unilateral
2. New
3. Large
4. Symptomatic
5. Not resolving with treatment

Question 13

Common causes of bronchiectasis (4)?

Answer 13

1. Cystic fibrosis
2. Post-infection
3. Immunodeficiency
4. Aspiration

Question 14

Define cor pulmonale

Answer 14

Right heart dysfunction due to pulmonary hypertension (often from COPD, ILD)

Question 15

1. What are typical findings in pulmonary sarcoidosis?
2. When do you treat sarcoidosis?

Answer 15

1. 1. Bilateral Hilar
      lymphadenopathy
   2. Non-caseating
      granulomas
   3. Elevated ACE
2. 1. Symptomatic
      HyperCalcemia
   2. Vision/CNS
      involvement,
   3. Worsening PFTs

Question 17

Difference between peak and plateau pressure?

Answer 17

Peak: Airway resistance + compliance
Plateau: Alveolar compliance only

Question 18

What does a normal plateau pressure but high peak pressure indicate?

Answer 18

Airway issue (e.g., bronchospasm, mucus plug, kinked ET tube)

Question 19

According to GINA, should SABA be used alone in asthma?

Answer 19

❌ No — increases risk of severe exacerbations.

✅ Always combine with ICS or use ICS-formoterol

Question 20

1. What is the preferred reliever in GINA Step 1?
2. What is the Core Controller Treatment for Asthma according to GINA?

Answer 20

1. ICS-formoterol PRN
2. Low to Medium Dose ±
   LABA

(Alt: SABA + low-dose ICS)

Question 21

1. What is the first-line treatment for GOLD Group B?

2.When is ICS used in COPD (GOLD 2024)?

3.When should you consider Triple Therapy (ICS + LABA + LAMA)?

Answer 21

1. LAMA or LABA monotherapy
2. Eosinophils ≥300

Frequent exacerbations despite LABA/LAMA

OR if patient has asthma features

3.Persistent Symptoms OR Exacerbations despite dual therapy

Question 22

What is Contraindicated in Asthma (even with COPD)?

Answer 22

LABA Monotherapy (Without ICS)

Asthma is an inflammatory condition need to decrease the INFLAMMATION!!

Question 23

What Clinical Features suggest Asthma over COPD?

Answer 23

1. Childhood onset
2. Intermittent symptoms
3. Allergies/atopy
4. Good reversibility with bronchodilator!!!

Question 24

What clinical features suggest COPD over Asthma?

Answer 24

Later onset (≥40), progressive dyspnea, heavy smoking history, poor reversibility on PFT

Question 25

1. What is the Gold Standard test for Diagnosing Asthma? 2. What pattern on baseline Spirometry suggests Asthma?

Answer 25

1. Spirometry with Bronchodilator response 2.↓ FEV₁ and ↓ FEV₁/FVC (<0.70) ## Footnote Reversible obstruction = FEV₁ increases ≥12% AND ≥200 mL after albuterol

Question 26

What is a positive methacholine challenge test?

Answer 26

≥20% drop in FEV₁ at low methacholine dose ## Footnote High sensitivity; rules out asthma if negative

Question 27

How does Peak Expiratory Flow help in Asthma Diagnosis?

Answer 27

Shows variability in airflow ## Footnote Diurnal variation >10–13% supports asthma

Question 28

What does Elevated FeNO indicate?

Answer 28

Eosinophilic Airway Inflammation ## Footnote Can support asthma diagnosis or predict ICS response

Question 29

When should you order Allergy Testing in Asthma?

Answer 29

In patients with suspected Allergic Asthma or Unclear Triggers

Question 30

A 32-year-old woman has episodic wheezing and dyspnea. Her spirometry shows FEV₁/FVC = 0.68. After albuterol, her FEV₁ improves by 15% and 220 mL. What is the most appropriate next step?

Answer 30

Begin low-dose ICS ## Footnote Reversible obstruction = asthma confirmed, start low-dose ICS

Question 31

A 40-year-old man has intermittent cough and wheezing. Baseline spirometry is normal. What is the best next test to confirm asthma?

Answer 31

Methacholine challenge test ## Footnote Normal spirometry but symptoms = methacholine challenge

Question 32

1. Name a LABA ? Use? 2. Nama a SABA ? Use? 3. Name LAMA ? Use? 4. Name a SAMA? Use?

Answer 32

1. Formoterol used with ICS in intermittent asthma therapy 2. Albuterol used with ICS (budesonide) in intermittent asthma therapy 3. Tiotropium - Used in Step up therapy for COPD 4. Ipatropium - maximize bronchodilation in Asthma & COPD Exacerbations