Lung transplantation for patients with COPD improves survival in which of the following situations?

• a. when both lungs are transplanted
• b. when only the left lung is transplanted
• c. when a patient has severe cardiac morbidity
• d. when a patient has localized lung cancer

Rationale: Answer A is correct: patients with COPD who receive two new lungs through lung transplantation have better quality of life and improved survival compared with those who receive only a single lung or those who do not receive lung transplantation. Patients with severe comorbidities such as significant cardiac morbidity or lung cancer are generally not good candidates for lung transplantation.

A 57 year-old current smoker with severe COPD, depression and anxiety reports dyspnea and wheezing during gardening and a daily cough (clear sputum) worsening over the last year. Her resting saturation is 92% on room air that decreases to 88% with exercise. What will likely provide the biggest impact to improve her anxiety and depression?

• a. pulmonary rehabilitation
• b. smoking cessation and abstinence
• c. avoid gardening
• d. supplemental oxygen therapy

Rationale: The correct answer is A: A COPD patient’s active participation in an interprofessional pulmonary rehabilitation program is one of the most effective strategies to manage anxiety and depressive symptoms that commonly coexist in patients with COPD. Although smoking cessation and abstinence (answer B) is associated with improved outcomes in many patients with COPD, it has not consistently been associated with improved symptoms of anxiety or depression. Avoiding any activity that a patient enjoys, but that causes symptoms of dyspnea and wheezing such as gardening (answer C) is likely to exacerbate or contribute to depressive symptoms, not improve them. Finally, answer D is incorrect – as supplemental oxygen therapy improves mortality when worn continuously for those with resting hypoxemia (saturation < 89% on room air at rest), but has not been shown to consistently improve depression/anxiety symptoms. For patients with COPD and mild hypoxemia or those with hypoxemia only with exertion, the most recent data demonstrate no significant improvement in mortality.

Which of the following has been shown to slow the rate of decline of lung function in an active smoker with severe COPD with resting saturation of 89% on room air?

• a. supplemental oxygen therapy
• b. pulmonary rehabilitation therapy
• c. influenza vaccination
• d. smoking abstinence

Rationale: The correct answer is D: Sustained smoking abstinence has been clearly demonstrated to slow the rate of decline of lung function in patients with COPD. Other therapies listed (A. supplemental oxygen, B. pulmonary rehabilitation, and C. influenza vaccination) do not change the rate of decline in lung function.

What reduces mortality in a smoker with very severe COPD, resting saturation of 85% on room air, and two exacerbations over the last year?

• a. pneumococcal vaccination
• b. continuous supplemental oxygen therapy
• c. nightly bilevel positive airway pressure (BiPAP) therapy
• d. chest physiotherapy

Rationale: The correct answer is B: continuous supplemental oxygen therapy for patients with resting hypoxemia (saturation of < 89% on room air at rest) worn at least >15 hours per day is associated with improved mortality. Although the pneumococcal vaccination is important in patients with COPD, it has not been shown to improve mortality. Nightly noninvasive positive pressure ventilation has been shown to improve outcomes in those patients with obstructive sleep apnea (OSA), but has not consistently been shown to improve outcomes or mortality in patients with COPD without OSA. Finally, answer D. is incorrect, in that chest physiotherapy has not been shown to be helpful in patients with COPD.

Lung volume reduction surgery improves outcomes for a COPD patient with which of the following?

• a. emphysema throughout both lungs (homogeneous pattern)
• b. very low lung function (FEV₁ <20% predicted)
• c. poor exercise capacity after pulmonary rehabilitation
• d. concomitant ischemic heart disease

Rationale:  The correct answer is C: patients with severe COPD with upper lobe bullae (heterogeneous pattern of emphysema) with poor exercise capacity after undergoing a comprehensive pulmonary rehabilitation program who undergo lung volume reduction surgery at a specialized center have improved outcomes.  Patients who do not benefit from lung volume reduction surgery include those with very severe lung function (FEV₁ < 20% predicted, diffusion capacity < 20% predicted), those with homogenous pattern of emphysema, and those with severe comorbidities such as concomitant ischemic heart disease do not do well with this surgical intervention and actually have worse outcomes. REFERENCE: Criner GJ, Sternberg AL, for the National Emphysema Treatment Trial Research Group. A Clinician’s Guide to the Use of Lung Volume Reduction Surgery. Proceedings of the American Thoracic Society. 2008;5(4):461-467. doi:10.1513/pats.200709-151ET.

What should a COPD patient with a saturation of 88% at rest be told about using supplemental oxygen?

• a. Must use with exertion regardless of symptoms
• b. May use as needed when feeling shortness of breath
• c. Must use >15 hours per day regardless of symptoms
• d. May use at night and when feeling shortness of breath

Rationale: Patients with resting hypoxemia (with a resting saturation on room air of <89%) significantly benefit from wearing supplemental oxygen continuously (24/7) regardless of symptoms of dyspnea. However, the studies demonstrated that patients with resting hypoxemic who wore supplemental oxygen > 15 hours per day had significantly improved survival.