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1. The following patient CASE pertains to questions 1–5.
Patient Case: TG is a 67-year-old man with a past medical history significant for hypertension and hyperlipidemia who presents to his annual physical with his primary care provider (PCP) with new complaints of dyspnea that has worsened over the last 6 months. TG also complains of a chronic cough that is sometimes productive. TG denies any treatment within the last year with antibiotics or oral steroids for respiratory infection. He reports a 35 pack–year history of smoking but quit approximately 3 years ago. TG underwent initial spirometry and was determined to have an FEV1/FVC of 0.58. His FEV1 was 67% predicted. His mMRC score was 2, and his CAT score was 11. TG is now diagnosed with COPD in group B using the Redefined ABCD Assessment Tool.

Based on the GOLD classification system of airflow limitation severity, Into what group would TG fall?

A. GOLD 1 B. GOLD 2 C. GOLD 3 D. GOLD 4 E. Unsure

2. Which of the following would be the most appropriate initial treatment plan for managing TG's COPD?

A. Long-acting beta-2 agonist alone B. Long-acting beta-2 agonist + inhaled corticosteroid C. Short-acting beta-2 agonist alone D. Long-acting muscarinic antagonist + short-acting beta-2 agonist E. Unsure

3. TG returns to his PCP 6 months after being initiated on a long-acting beta-2 agonist plus a short-acting beta-2 agonist to treat his COPD. He reports a slight increase in dyspnea and is wondering if there is anything that can be done to improve his feelings of breathlessness. What would be the most appropriate change to TG's current inhaler regimen?

A. Initiate a long-acting muscarinic antagonist B. Initiate an inhaled corticosteroid C. Discontinue long-acting beta-2 agonist and initiate a long-acting muscarinic antagonist D. Discontinue short-acting beta-2 agonist and initiate a short-acting muscarinic antagonist E. Unsure

4. Despite optimization of treatment, TG presents to the emergency department complaining of shortness of breath at rest and coughing up green phlegm. These symptoms have worsened over the previous 2 weeks. He is found to have a heart rate of 110 bpm, blood pressure of 132/72 mm Hg, respiratory rate of 34/minute, oxygen saturation 88% on room air, and temperature of 38.3° C. He is admitted to the general hospital floor with a severe COPD exacerbation associated with non-life-threatening acute respiratory failure. Which of the following therapies should be initiated?

A. Tiotropium bromide 18 mcg inhaled once daily B. Theophylline 4.6 mg/kg IV loading dose, followed by 0.3 mg/kg/hr continuous infusion C. Ipratropium bromide 0.5 mg and albuterol 2.5 mg per 3 mL nebulized every hour D. Budesonide 80 mcg and formoterol fumarate dehydrate 4.5 mcg per actuation, 2 puffs inhaled twice daily E. Unsure

5. Which of the following recommendations would be best regarding antibiotic administration for TG's COPD exacerbation?

A. Azithromycin should be ordered B. Piperacillin/tazobactam should be ordered C. Piperacillin/tazobactam and vancomycin should be ordered D. No antibiotics should be ordered E. Unsure

6. The following patient CASE pertains to questions 6–9.
Patient Case: DG is a 15-year-old boy who presents to his PCP reporting intermittent symptoms of wheezing, shortness of breath, and chest tightness. He states that symptoms worsen with exercise and are present 1–2 days a week. He has woken up twice in the last month due to shortness of breath. He completes PFTs and is diagnosed with asthma.

What is the most appropriate initial controller therapy to treat DG’s asthma?

A. Low-dose ICS + LABA scheduled daily B. Short-acting bronchodilator taken as needed C. Low-dose ICS scheduled daily D. Low-dose ICS + leukotriene receptor antagonist E. Unsure

7. DG is initiated on low-dose budesonide taken daily with low-dose budesonide-formoterol prescribed to be taken as needed for symptoms. DG has a follow-up visit with his PCP to reassess his asthma control after 3 months of therapy. DG reports that his symptoms have not improved, and he continues to have wheezing and shortness of breath several days a week, which he treats with his reliever inhaler. It is determined that DG needs a step-up in therapy. What would be the most appropriate recommendation for his step-up in therapy?

A. Add a leukotriene receptor antagonist to his current regimen B. Increase to a medium-dose ICS taken daily C. Add a LABA to his currently prescribed therapy D. Add tiotropium to his current regimen E. Unsure

8. DG presents with his father to his local community pharmacy and requests a refill of his albuterol MDI. The pharmacist notices that the prescription was filled 10 days prior, and she asks DG and his father some questions about his asthma control prior to filling the prescription. DG says he has been using his albuterol inhaler every 3–4 hours for the past 3 days. His PEF was 70% of his personal best this morning. He does not appear to be in any acute distress, nor does he appear to be using accessory muscles. His heart rate is 82 bpm, and respiratory rate is 22/minute. He has an asthma action plan at school, but he does not know what it says. The pharmacist believes that DG is having an asthma exacerbation of moderate severity. What recommendation should the pharmacist makes to DG and his father?

A. Self-manage using his asthma action plan B. Refer to primary care provider for outpatient management C. Refer to emergency department for acute management D. Refer to emergency department for admission to intensive care unit E. Unsure

9. What SABA therapy would be preferred for initial treatment of DG's asthma exacerbation?

A. Continuously nebulized albuterol for the first 4 hours B. Albuterol MDI 6 puffs every 20 minutes for the first 1 hour C. Levalbuterol MDI 2 puffs every 4–6 hours for the first 24 hours D. Albuterol 2.5 mg per 3 mL nebulized every hour for the first 4 hours E. Unsure

10. Why is SABA monotherapy no longer recommended according to the 2020 GINA guidelines?

A. Overuse of SABA is associated with increased risk of exacerbation B. Overuse of SABA is associated with increased risk of asthma-related death C. Regular SABA use increases allergic response and airway inflammation, which reduces the bronchodilator response to SABA when needed D. All of the above E. Unsure