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Exam Section 2: Item 18 of 50 National Board of Medical Examiners®
Comprehensive Clinical Science Self-Assessment
18. A 52-year-old man comes to the physician because of a 6-month history of progressive shortness of breath with exertion. He
reports shortness of breath after climbing one flight of stairs and occasional whistling breath sounds. He has no history of
serious illness. He has smoked one and one-half packs of cigarettes daily for 36 years. His pulse is 88/min, respirations are
20/min, and blood pressure is 160/88 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 98% at rest. Jugular
venous pressure is within normal limits. Breath sounds are distant. There is no peripheral edema. Pulmonary function tests
show an FEV 1 of 60% of predicted; the FEV 1:FVC ratio is 50% of predicted. In addition to recommending smoking cessation,
which of the following is the most appropriate next step in management?
A) Oral glucocorticosteroid therapy

B) Oral leukotriene inhibitor therapy
C) Oral theophylline therapy
D) Long-acting inhaled bronchodilator therapy
E) Oxygen via nasal cannula during sleep
Correct Answer: D.
The patient is presenting with classic symptoms and findings of chronic obstructive pulmonary disease. Chronic obstructive
pulmonary disease is characterized by a progressive decline of lung function as a result of the combination of chronic bronchitis
and emphysema, resulting in airflow obstruction on expiration. Tobacco use is a major risk factor for developing chronic obstructive
pulmonary disease. Daily inhaled combination therapy with a long-acting bronchodilator, such as the 13-adrenergic agonist
salmeterol or the muscarinic antagonist tiotropium, and an inhaled glucocorticoid is first-line therapy for the chronic management of
chronic obstructive pulmonary disease in patients who experience frequent exacerbations (two or more in a year). Chronic
obstructive pulmonary disease exacerbations, marked by acute worsening of dyspnea, frequency or severity of cough , and
increased production of sputum , may be triggered by viral or bacterial respiratory infections, environmental irritants, pulmonary
embolism, or congestive heart failure, among other triggers. Management of chronic obstructive pulmonary disease exacerbations
involves the administration of supplemental oxygen to maintain peripheral saturations in the range of 88 to 92%, combination short-
acting 13-adrenergic agonist and antimuscarinic inhalers or nebulizers, consideration of antibiotics, and systemic corticosteroids.
Incorrect Answers: A, B, C, and E.
Oral glucocorticosteroid therapy (Choice A) is useful for the management of acute exacerbations of chronic obstructive pulmonary
disease but is not typically necessary for the management of stable chronic obstructive pulmonary disease. The use of oral
glucocorticoids is associated with significant side effects and should therefore be reserved for the management of acute
exacerbations .
Oral leukotriene inhibitor therapy (Choice B) is commonly used in the management of asthma but there is currently a lack of
evidence in clinical trials to support its efficacy in the management of chronic obstructive pulmonary disease.
Oral theophylline therapy (Choice C) is useful for its bronchodilatory and anti-inflammatory effects. Its usefulness is limited by its
narrow therapeutic window and side effect profile, which includes cardiac arrhythmias and central nervous system excitation, along
with its deleterious interactions with numerous medications. Inhaled long-acting bronchodilators, such as salmeterol or tiotropium,
are typically well-tolerated and have narrowed the clinical indications for theophylline.
Oxygen via nasal cannula during sleep (Choice E) is not necessary for this patient, as he demonstrates an oxygen saturation of
98% at rest. During chronic obstructive pulmonary disease exacerbations, the goal oxygen saturation should target between 88 to
92%. Historically, administration of supplemental oxygen to raise the saturation beyond this amount has been postulated to blunt
respiratory drive, though actual evidence for this is limited. It is more probable that the administration of supplemental oxygen
worsens ventilation-perfusion mismatch in this patient population .
Educational Objective: Chronic obstructive pulmonary disease is characterized by a progressive decline of lung function as a result
of the combination of chronic bronchitis and emphysema, resulting in airflow obstruction on expiration . It is frequently associated
with smoking. Daily inhaled combination therapy with a long-acting bronchodilator, such as the 13-adrenergic agonist salmeterol or
the muscarinic antagonist tiotropium, and an inhaled glucocorticoid is first-line for the chronic management of chronic obstructive
pulmonary disease in patients who experience frequent exacerbations.
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Exam Section 2: Item 18 of 50 National Board of Medical Examiners®

Comprehensive Clinical Science Self-Assessment

A) Oral glucocorticosteroid therapy

Incorrect Answers: A, B, C, and E.

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