Ep #165: COPD Review: What You Need to Know for Boards

Anna: Welcome to the Real Deal Nurse Practitioner Club, the podcast for nurses who are ready to pass their boards and thrive in their careers as real deal nurse practitioners. I’m Anna and I’m the Director of Nursing Content at Blueprint Test Prep. Whether you’re deep in exam prep or stepping into practice, I’ve got you. It is time to become the confident, knowledgeable NP that you’re meant to be. Let’s dive in. 

Hey, hey friends. Welcome back to the Real Deal Nurse Practitioner Club Podcast. I’m Anna, and today, we are going to do a high-yield review of what you need to know for boards about chronic obstructive pulmonary disease, or COPD. And as usual, I have my friend here.

Alex: Hey everyone. Alex here. And a quick note before we jump in. This is not going to be a full, deep dive into COPD. We are not going to cover every nuance, every PFT interpretation, or every possible inhaler combination on the market. We will focus on what you actually need to know for your exam. But this info is definitely so so important when you take the leap into clinical practice, too.

Anna: So, let’s start with the basics here. And I am going to say, if you need a little bit more practice, our courses are going to go a little bit more in depth. But we’re just giving a basic overview today in this podcast.

So starting with our very very basics, we know that COPD is a progressive condition where changes in the airway and the alveoli lead to airflow obstruction or limitation. And that’s why it’s called chronic obstructive pulmonary disease. And this is most commonly caused by what? What do you think? This is a gimme answer: smoking. And there are other exposures and genetic factors that can play into this, but smoking is the big one to know for boards.

Alex: Yes, and COPD is actually an umbrella term. So the two classic subtypes you’ll see are chronic bronchitis and emphysema. So in clinical practice, patients may present with features of both of these, but for boards, it’s important to know those classic textbook presentations.

Anna: Yeah, absolutely. I know the exams love those textbook cases, and I wish it was like that in clinical practice. It would make our lives so much easier. But of course, we know it’s not. But we are going to focus on that because we are focusing on the boards right now.

So remember that chronic bronchitis, it involves inflammation with cilia destruction and excess mucus production. And that’s what leads to that chronic productive cough, whereas emphysema results from destruction of the alveoli, which reduces the elastic recoil. And so it causes that air trapping and progressive shortness of breath.

Alex: Yes, and a key exam point here: Is COPD reversible? Nope. It is typically progressive and not reversible. If a patient is diagnosed with COPD, our goal is not to cure it. It’s to reduce symptoms, reduce exacerbations, and improve quality of life.

So bonus question here: What’s a common reversible obstructive lung disease? That’s going to be asthma. 

Anna: Yeah, absolutely. Do not let asthma versus COPD trip you up. Again, we go into all of those nuances and easy ways to remember and all of the key things you need to know in our courses. But remember, asthma is reversible, COPD is not.

And I want to dive a little bit more into that clinical presentation. So remember, a patient with COPD might present to the clinic with a cough, sputum production, dyspnea, wheezing. And what do you think would show up on the physical exam?

Well, early on, we might not see many changes actually. But as the disease progresses, that’s where we could see decreased or abnormal breath sounds, like crackles, generalized hyperresonance, or an increased AP diameter of the chest, also known as a barrel chest.

Alex: Yes, all good things to know for boards there. So do you know how we formally diagnose COPD? That’s going to be spirometry, which is a type of pulmonary function test. This simply measures airflow limitation, and we’re looking at something called the FEV1/FVC ratio.

So FEV1, or forced expiratory volume in one second, basically just measures how much air a patient can exhale in one second. FVC is the forced vital capacity, or the total amount of air someone can blow out with exhalation. So a reduced FEV1/FVC ratio after receiving a bronchodilator signals COPD.

Anna: Yeah, and keyword there: after receiving a bronchodilator. Because what’s going to happen in asthma after they receive a bronchodilator? Well, their numbers are going to get better, right? And do you all know what the diagnostic cutoff for COPD is for that FEV1/FVC ratio? That is going to be a ratio less than 70% or 0.7.

And the key point here is that this is measured after the bronchodilator, and remember, that means the airway obstruction is not reversible. If you haven’t picked up on it yet, this is a key testing point. All right, let’s move on to treatment. Alex, you want to start us off here?

Alex: Absolutely. So students often report feeling overwhelmed with COPD treatment principles, so let’s simplify it. The go-to guidelines are provided by the Global Initiative for COPD, or GOLD Report. So once COPD is diagnosed, GOLD helps categorize patients into treatment groups based on symptom burden, or how much it affects the patient’s daily life, and exacerbation risk, or basically a history of COPD flare ups or related hospitalizations. And the latest report stratifies patients into three different treatment groups: A, B, or E.

Anna: And as always, keep an eye on your clinical practice guidelines. We know that evidence is always changing. Right? We used to have groups A, B, C, D, and in the last few years, we now have A, B, and E. So we’re going to give you the most current guidelines, but as always, make sure you are keeping up to date in practice.

But essentially, patients in group A, it just means they have fewer symptoms and a lower exacerbation risk. Patients in group B, they have more day-to-day symptoms, but still a low exacerbation risk. And then we have group E, which is where they have a higher exacerbation risk and often a higher symptom burden, but it doesn’t matter. It is really on that exacerbation risk. So I really like to pair group E with the E in exacerbation to remember this.

And on boards, group E tends to represent the patient who’s had exacerbations, they’ve had ED visits, they’ve had hospitalizations. And now, let’s move on to the part that everyone frets about, everyone wants to know: what do we actually prescribe?

Alex: Yes, so for patients in group A, we start with a bronchodilator. Now, a long-acting bronchodilator, like a long-acting beta agonist, or LABA, or a long-acting muscarinic antagonist, or LAMA, is generally preferred. Short-acting beta agonists, or SABAs, like albuterol, are typically only recommended as monotherapy for just very occasional breathlessness.

Anna: Yep, so A, think of those long-acting ones. And then as for group B, well, remember, I said that patients in this group, they are more symptomatic day-to-day, so we just want to step up that daily regimen to dual bronchodilator therapy, typically with a LABA and a LAMA.

And then group E, remember, represents those with a higher exacerbation risk. So the initial treatment often starts with a LABA and a LAMA, and then we consider adding an inhaled corticosteroid, or ICS, depending on the patient picture and if they have an elevated eosinophil count. And patients in group E definitely need to be seeing a pulmonary specialist. And what should all patients with COPD have on hand as a rescue inhaler? That is going to be that SABA, like albuterol.

Alex: Yes. And here’s a quick exam tip. The board might not say LABA or LAMA. Do not let this trip you up. It might just actually list actual meds that you do need to know for clinical practice. But it’s not worth memorizing everything on the market. It’s worth memorizing a couple very very common examples.

So for example, SABAs, albuterol is going to be the go-to there. LABAs, formoterol is an example that you’ll hear. LAMAs, tiotropium. And then ICS, budesonide is the one that you will see most often. You’ll see this in asthma, too, but remember, budesonide is a gold standard in asthma from the get-go, but for COPD, it’s typically reserved for treatment later down the line towards group E.

Anna: All right, let’s do like a little quick case scenario here just to help put this all together. All right, let’s say you have a patient with confirmed COPD. Remember that FEV1/FVC ratio is less than 70%. They report feeling short of breath most days, and they also report using their rescue inhaler most days. Now, they haven’t had any ED visits. They haven’t had any hospitalizations in the past year. And so what treatment group do you think fits best here? Alex, I’m going to let you answer this.

Alex: So that sounds like a higher symptom burden. However, still a low exacerbation risk since they’ve had no ED visits or COPD-related hospitalizations. So I’m going with group B.

Anna: Exactly. And that’s exactly how you want to think through this if you get a question like this on boards. So we’ve determined group B. Next, we need to think, what is the recommended initial treatment for group B? Alex, again, take it away.

Alex: So remember, that’s going to be that dual long-acting bronchodilator, so the LABA plus the LAMA.

Anna: Exactly. And it can really be as simple as that, right? You don’t need to memorize really long lists of inhalers for boards. You just really need to know the basics. You have to have a good understanding of how symptom burden and how exacerbation history play into these treatment plans, and then you just need to know how to critically think through the case scenario and be able to analyze the answer choices and see which one fits best.

Alex: Absolutely. And remember, COPD management can be personalized in real life. There are multiple valid options depending on patient preferences, inhaler technique, cost, comorbidities, response to treatment. But the exams aren’t trying to reflect every single real-world nuance. They will typically give you one clear, best answer based on the clinical scenario. 

Anna: Absolutely. And I will say, sometimes you get into that exam, right, and your anxiety is a little higher and your adrenaline’s going. And you’re reading through the question, and sometimes it doesn’t feel like there’s one clear answer, right? I hear all the time students say, “I could narrow it down to two, but then I got stuck.”

So if you feel like two answers could work, go back to the question and look for things like an exacerbation clue, an allergy or a contraindication, an incorrect medication class for the goal, or maybe even just a small detail about symptom frequency. Again, we’re going to put on our clinician hats. We’re going to critically think through these. 

Alex: Yeah, and really, that tip applies to all pharmacology questions across all diagnoses, not just COPD.

Anna: Absolutely. Sometimes you think you know the answer, and you go down, and that first-line main drug is not listed there. And so that is when we just pause, and we take a deep breath, and we think, “What else could work? What’s a good second line? What’s another option that we could do?” And a lot of times, if you go back and you close your eyes and you just reset, then it becomes really obvious later what the answer actually is.

But this is going to be the end of your high-yield, very basic COPD review. We talked about what it is, how it presents, how to think through our GOLD groups, A, B, and E, and the treatment for each.

Alex: Yeah, and if you want a deeper dive in the COPD and other really important respiratory conditions to know for your boards, that’s exactly what we cover inside our courses in our QBank.

Anna: Absolutely. Now, if you want to tune in to our next mini episode next week, Kaitlyn is going to be doing one all about medication dosages, which is really good. And then we will be back in two weeks for another episode kind of similar to this one, but it’s all about diabetes and what to know for your NP boards. We’ll see you next time.