MKSAP Quiz: COPD evaluated during a routine visit
A 66-year-old man with a history of COPD is evaluated during a routine visit. He is able to walk one flight of stairs and one block before he develops dyspnea. He was last treated for two acute exacerbations of COPD within the last year, one of which required hospitalization. Following a physical exam and other tests, what patient characteristics place him at highest risk for a recurrent acute exacerbation?
A 66-year-old man with a history of COPD is evaluated during a routine visit. He is able to walk one flight of stairs and one block before he develops dyspnea. He was last treated for two acute exacerbations of COPD within the last year, one of which required hospitalization. He recently completed a pulmonary rehabilitation program. His medical history is significant for hypertension and a 60-pack-year smoking history. He quit smoking 5 years ago. Current medications are hydrochlorothiazide, glycopyrrolate/formoterol, and albuterol.
On physical examination, vital signs are normal; oxygen saturation is 94% on ambient air. Pulmonary examination reveals a prolonged expiratory phase. The cardiac and remainder of the physical examination are unremarkable.
Spirometry today shows a postbronchodilator FEV1 of 35% of predicted. Chest radiograph at the time of his last exacerbation shows hyperinflation and no other findings. An electrocardiogram is normal.
Which of the following patient characteristics places him at highest risk for a recurrent acute exacerbation?
A. Enrollment in a pulmonary rehabilitation program
B. Hypertension
C. Previous COPD exacerbations and FEV1 level
D. Smoking history and use of COPD medications
MKSAP Answer and Critique
The correct answer is C. Previous COPD exacerbations and FEV1 level. This content is available to MKSAP 18 subscribers as Question 57 in the Pulmonary and Critical Care Medicine section. More information about MKSAP is available online.
The patient's previous COPD exacerbations and FEV1 of 35% of predicted are most associated with high risk for recurrent acute exacerbations of COPD. In the Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE) prospective study, the best predictor of exacerbations was a history of exacerbations, regardless of COPD severity. In this study the number of exacerbations in the previous 12 months, degree of airflow obstruction, and number of hospitalizations for an exacerbation refined the risk estimate. A history of 0 or 1 exacerbation, FEV1 of 50% or better, and no hospitalizations predicts a low risk of future exacerbations, whereas more than 1 exacerbation, FEV1 less than 50% predicted, and hospitalization predicts a high future risk of exacerbation. Exacerbations of COPD can be prevented by optimizing treatment with appropriate interventions based on risk classification and overall disease management; this includes immunizations and lifestyle changes such as maintaining physical activity and addressing anxiety and depression.
Pulmonary rehabilitation is recommended for all symptomatic patients with an FEV1 of less than 50% of predicted and specifically for those hospitalized with an acute exacerbation of COPD. Use of such a program is not causally linked with an increased risk of COPD exacerbation.
Several comorbidities are associated with an increased risk of acute exacerbation, including heart failure, ischemic heart disease, diabetes, kidney failure, and hepatic failure. However, hypertension has not been associated with an increased risk of acute COPD exacerbations.
Current tobacco use is an independent risk factor for the development of COPD. However, past tobacco use and significant pack-year history are not associated with an increased risk for acute exacerbation. Discontinuing maintenance COPD mediations is associated with COPD exacerbations, whereas the use of such medications is not.
Key Point
- Patients with COPD who have had two or more acute exacerbations within the last year, who have an FEV1 of less than 50% of predicted, or who have ever been hospitalized for an acute exacerbation are considered to be at high risk for recurrent acute exacerbations.