A 63-year-old woman comes to the office during the winter due to shortness of breath and cough productive of thick, green sputum for the past 2 days. The patient has chronic obstructive pulmonary disease and mild dyspnea on exertion at baseline. The dyspnea has worsened over the past several days, and she is now also short of breath at rest. Other medical conditions include hypertension, gastroesophageal reflux, and seasonal allergies. She has been using her albuterol rescue inhaler more frequently than usual. The patient says she has cut down to 4 or 5 cigarettes per day and is trying to quit. Pulse oximetry shows 91% on room air. She appears to be in mild respiratory distress. Lung examination demonstrates diffuse bilateral wheezes. Chest x-ray reveals hyperinflation. Which of the following triggers is most likely responsible for the worsening of this patient's symptoms?

Question

A 63-year-old woman comes to the office during the winter due to shortness of breath and cough productive of thick, green sputum for the past 2 days.  The patient has chronic obstructive pulmonary disease and mild dyspnea on exertion at baseline.  The dyspnea has worsened over the past several days, and she is now also short of breath at rest.  Other medical conditions include hypertension, gastroesophageal reflux, and seasonal allergies.  She has been using her albuterol rescue inhaler more frequently than usual.  The patient says she has cut down to 4 or 5 cigarettes per day and is trying to quit.  Pulse oximetry shows 91% on room air.  She appears to be in mild respiratory distress.  Lung examination demonstrates diffuse bilateral wheezes.  Chest x-ray reveals hyperinflation.  Which of the following triggers is most likely responsible for the worsening of this patient's symptoms?

Quizplus · Accepted Answer

11ec160b_389a_9a46_9249_4341fe0da703_MD0001_00 This patient who has a worsening productive cough, dyspnea on exertion, mild hypoxemia, and wheezing likely has an exacerbation of chronic obstructive pulmonary disease (COPD). Patients with COPD have chronic airway inflammation, which is predominantly due to activated neutrophils, CD8+ lymphocytes, and macrophages. Exacerbations of COPD are caused by worsening of underlying inflammation and are most often triggered by viral or bacterial respiratory infections (70%-80%). Air pollution and pulmonary embolism are common but less frequent causes (Choices A and D). Viral infections account for slightly less than half of all COPD exacerbations. The most common viral causes are rhinovirus and influenza virus, but parainfluenza virus, coronavirus, and adenovirus also contribute to the burden of disease. (Choice B) Although allergic responses such as those seen in patients with seasonal allergies can lead to exacerbations of asthma, they are not a common trigger for COPD exacerbations. (Choice C) Patients with gastroesophageal reflux disease (GERD) appear to be at increased risk for COPD exacerbations; however, it remains unclear if GERD is a trigger of disease exacerbations. (Choice F) Bacterial infections are somewhat less common than viral infections as a trigger for COPD exacerbation. Common offending pathogens include Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pneumoniae; staphylococci are not a common trigger. Green sputum is caused by release of myeloperoxidase from neutrophils and can be present in either viral or bacterial respiratory infection. Educational objective: Most chronic obstructive pulmonary disease exacerbations are triggered by viral or bacterial upper respiratory infections, with rhinovirus, influenza virus, Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pneumoniae being among the most common causes. __________ References: COPD exacerbations. 2: aetiology. (http://www.ncbi.nlm.nih.gov/pubmed/16517585) Pathogens in COPD exacerbations identified by comprehensive real-time PCR plus older methods. (http://www.ncbi.nlm.nih.gov/pubmed/26451098) Chronic obstructive pulmonary disease exacerbations: latest evidence and clinical implications. (http://www.ncbi.nlm.nih.gov/pubmed/25177479)

A 63-Year-Old Woman Comes to the Office During the Winter