[Fan Favorite] COPD Exacerbation

As we step away for a holiday break, we’re excited to revisit some of the most popular episodes of the FNP Certification Q & A Podcast. These listener favorites have informed, inspired, and empowered aspiring NPs on their journey to certification success. Enjoy some of our favorites. We'll catch you in 2025 with fresh questions from Dr. Fitzgerald!

A 72-year-old woman with severe COPD, who uses an inhaled LAMA/ LAMA daily on a set schedule and SABA via MDI as needed for symptom relief, presents with a 4-day history of URI symptoms, starting with sore throat and clear nasal discharge, without fever. She denies N, V, or other GI upset. She now reports a 2-day history of increasing shortness of breath and production of clear to white sputum. SaO2= 97% and she is no acute distress. In considering the diagnosis of COPD exacerbation, which of the following best describes the role of imaging in the evaluation of COPD exacerbation?

A. A chest x-ray should be ordered in COPD exacerbation in the patient with fever and/or low SaO2 to help rule out concomitant pneumonia.

B.  A chest x-ray should be ordered routinely in the evaluation of a person with COPD exacerbation.

C. Given the frequency of COPD exacerbations that typically occur in a person with COPD, chest x-ray use should be limited due to radiation exposure risk.

D. A thoracic ultrasound is the preferred imaging study to order in a COPD exacerbation.
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Transcript

Welcome to PNP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for 90 students studying to pass their PNP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So, if you're ready, let's jump right in.  

 A 72-year-old woman with severe COPD, who uses an inhaled LAMA/ LABA daily on a set schedule and SABA via MDI as needed for symptom relief, presents with a 4-day history of URI symptoms, starting with sore throat and clear nasal discharge, without fever. She denies nausea, vomiting, diarrhea, or other GI upset. She now reports a 2-day history of increasing shortness of breath and production of clear to white sputum. SaO2= 97% and she is no acute distress. In considering the diagnosis of COPD exacerbation, which of the following best describes the role of imaging in the evaluation of this condition? 
 
A. A chest x-ray should be ordered in COPD exacerbation in the patient with fever and/or low SaO2 to help rule out concomitant pneumonia. 
 
B. A chest x-ray should be ordered routinely in the evaluation of a person with COPD exacerbation. 
 
C. Given the frequency of COPD exacerbations that typically occur in a person with COPD, chest x-ray use should be limited due to radiation exposure risk. 
 
D. A thoracic ultrasound is the preferred imaging study to order in a COPD exacerbation. 

 Well, the correct answer here actually is A., that CXR should be ordered in COPD exacerbation in the patient with fever and or low Sa02 to help will out common pneumonia. And I'll say this now to be really clear, chest xrays are not routinely indicated in the person with COPD exacerbation, which was option B.  

 But let's take a step back and say, where do you start? You want to determine what kind of a question this is. We're being asked about the need or not for studies when considering COPD exacerbation. This question focuses on what is recommended to support the diagnosis of COPD, and therefore you can look at this and call this a diagnosis question. Let's look at the background information in this scenario. First, what is COPD? What I've mentioned a number of times in these podcasts, keeping in mind the underlying pathology of a condition is key to diagnosis and treatment. COPD is a preventable and treatable disease with a pulmonary component characterized by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and is associated with abnormal inflammatory response of the lung to certain substances such as noxious gases and others. And key to those noxious gases, of course, are either first or secondhand tobacco smoke and sometimes industrial pollutants and air pollutants. The initial diagnosis of COPD is made by correlating clinical presentation, including objective measurement of reduced FEV1, Sa02, and physical exam through a thorough cardiac respiratory exam, in other words, looking at the entire patient. Given, we're told, she has severe COPD, which is part of the disease's classification where COPD is classified as either mild, moderate, severe or very severe. We know that our FEV1 at baseline is less than 50% of predicted. COPD exacerbation is an event in the natural course of the disease characterized by a change in the patient's baseline dyspnea, cough, and or sputum, beyond day-to-day variability sufficient to warrant a change in management. The most common trigger, around 60% of the time for COPD exacerbation is viral respiratory infection, which appears to be the case here. Other common triggers are air pollution and increase in tobacco use. If you're wondering why I say that viral URI is likely her triggering event, imagine the same question if we simply removed COPD from it. In other words, she came in with a four-day history of a sore throat and runny nose. No fever, no worsening of her baseline breathing, no nausea, vomiting, etc. What would you say? You would say, Oh, sounds like a viral respiratory tract infection. Lot of times it's helpful when people have other chronic health issues. Take that chronic health issue out for a moment. Take a look at the clinical scenario. When you're trying to determine whether it's a viral infection or something else along those lines, and then you go, oh, well, if she didn't have COPD, I would think that she had a cold. But of course she has COPD and that COPD complicates this scenario. Please also note timing is key and timing is one of the most important parts of doing your symptom analysis and coming up with your differential. She reports four day history of viral URI symptoms but only two day history of worsening respiratory symptoms. This is very common in COPD exacerbation. Less common reasons for a COPD exacerbation, about 40% of the time, are bacterial contributors. Most often the respiratory bacterial pathogens that we have talked about in a number of different scenarios already. Streptococcus pneumoniae, haemophilus influenzae, and Moraxella catarrhalis, those often also happen to be the three bugs that are major contributors to bacterial sinusitis and acute otitis media. And two of those are big pneumonia contributors. Strep pneumo and H flu. Moraxella catarrhalis seldom if ever, infects the lower airways unless there is COPD. The patient is already on one of the most commonly prescribed medication combinations for COPD management, this is a LAMA/LABA inhaler. The LAMA a.k.a long-acting muscarinic antagonist such as tiotropium bromide provides long duration bronchodilation plus activity to reduce the risk of COPD exacerbation. The LABA or long acting beta 2 agonists, something like salmeterol or Formoterol provide bronchodilation due to a different site of action when combined with a LAMA. And in other words, now you've got broncho dilation from two different mechanisms, plus a way of preventing COPD exacerbation. At the same time, even with prevention medication on board, people with COPD can still have flares, particularly when they have a viral respiratory tract infection. In all likelihood, however, their exacerbation is significantly less because they've got some preventive medicine on board. 

 Let's look at the question and the choices of response. The question again is asking whether imaging is needed to support or confirm the diagnosis of COPD exacerbation. A 72-year-old woman with COPD who uses an inhaled LABA/LAMA daily on a set schedule, presents for a same-day 

sick visit to a primary care practice. She has a four-day history of URI symptoms starting with sore throat and clear nasal discharge without fever. She denies nausea, vomiting or other GI upset. She now reports a two-day history of increasing shortness of breath and projection of clear to white sputum a Sa02 is 97% and she's in no acute distress. And considering the diagnosis of COPD exacerbation, which of the following best describes the role of imaging and the evaluation of COPD exacerbation?

A. A chest X-ray should be ordered in COPD exacerbation in the patient with fever and or low Sa02 to rule out concomitant pneumonia. A is actually our correct answer. 

According to the Gold COPD recommendations (and if you're not familiar with them, go to GoldCOPD.org great download there, very helpful website). Chest X-ray should only be done in COPD exacerbation when there are clinical findings that would trigger thoughts of pneumonia such as fever, evidence of consolidation, and/or low Sa02. The chest X-ray should be ordered routinely and the evaluation of the person with COPD exacerbation.  

Option B, to be candid with you all is the one that most RNs will choose and particularly the RN transitioning to the NP role, and particularly the RN who's currently practicing in the acute care setting. This is what the RN has seen done. What you need to keep in mind in hospital and, indeed, usually in the emergency department, you are seeing the sickest of the sick. Usually, chest xray is warranted because there is fever, there is low Sa02, there is evidence of consolidation, etc., etc. In other words, you truly are trying to rule out a concomitant pneumonia because this person's really very ill. As I talk to you, I honestly cannot remember the last time I saw a patient in my practice, and I do a lot of urgent care in my practice 40 to 60% of the time that I am seeing patients it is same day urgent care, I can't remember the last time I had to send a patient to the hospital for admission and I see some people with severe and very severe COPD, but the vast majority of people with COPD exacerbations are able to be treated as outpatients.  

Let's take a look at option C. So even though we chose the right answer, we're going to look at all the rest. C. Given the frequency of COPD exacerbations, they typically occur in a person with this disease, chest x-ray should be limited due to radiation exposure.  

This is obviously not correct because A is the correct option, but this is an example of an answer that sounds really good but is focused on a point that doesn't need to be made. The radiation exposure from a single chest x ray is fairly low about the amount of radiation exposure that a person would get in 7 hours of air travel. So envision a nonstop flight from New York City to London or something along those lines. We are exposed to radiation naturally in our environment every single day, and chest x rays are just not a huge contributor to radiation exposure. The other part, inIption C, it says given the frequency of COPD exacerbations, they typically occur. That assumes that people with COPD have very frequent exacerbations. And to tell you the truth now with current therapy, with a LABA/LAMA therapy, the rate of exacerbations is way, way down. And then even when there are a lot of breakthrough exacerbations with LABA/LAMA therapy, sometimes ICS, inhaled corticosteroid LABA/LAMA therapy issues and then the inhaled corticosteroid and the LAMA can help prevent the COPD exacerbation.

Option D: A thoracic ultrasound is the preferred imaging study to order in a COPD exacerbation, and that of course is not true there. Thoracic ultrasound is used in select relatively limited situations where the diagnosis of pneumonia is in question. This diagnostic modality plays no role in the workup of a person with COPD exacerbation.

Key takeaway: COPD exacerbation is a diagnosis made on health history, physical exam, and limited studies that do not routinely include a chest x ray. Remember when you're seeing the patient as a same-day urgent care visit within primary care, the question is likely going to focus on the clinical scenario without complications and therefore a more focused evaluation is appropriate.

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