COPD — structured viva

Structured oral on COPD: defending spirometric case-finding over screening, the cessation-first consultation, the ICS decision framework built on IMPACT/ETHOS/WISDOM/FLAME, exacerbation stewardship (REDUCE and Anthonisen), NIV thresholds, and long-term oxygen assessment.

Prompt

The examiner opens: 'Your practice hands every breathless smoker a puffer. Walk me through what you do differently.' The viva branches through diagnosis, cessation pharmacotherapy, inhaled therapy escalation with trial evidence, exacerbation management, oxygen assessment and referral thresholds.

Stem

You are supervising a GP registrar who has just prescribed a salbutamol inhaler to an undiagnosed 60-year-old smoker with exertional dyspnoea. ^[1]

References18Show

[1]Agustí A, Celli BR, Criner GJ, Halpin D, Anzueto A, et al. Global Initiative for Chronic Obstructive Lung Disease 2023 Report: GOLD Executive Summary. Eur Respir J, 2023.PMID 36858443
[2]US Preventive Services Task Force, Mangione CM, Barry MJ, Nicholson WK, Cabana M, et al. Screening for Chronic Obstructive Pulmonary Disease: US Preventive Services Task Force Reaffirmation Recommendation Statement. JAMA, 2022.PMID 35536260
[3]Fletcher C, Peto R The natural history of chronic airflow obstruction. Br Med J, 1977.PMID 871704
[5]Wang Z, Qiu Y, Ji X, Dong L Effects of smoking cessation on individuals with COPD: a systematic review and meta-analysis. Front Public Health, 2024.PMID 39722704
[6]Cahill K, Lindson-Hawley N, Thomas KH, Fanshawe TR, Lancaster T Nicotine receptor partial agonists for smoking cessation. Cochrane Database Syst Rev, 2016.PMID 27158893
[7]Anthenelli RM, Benowitz NL, West R, St Aubin L, McRae T, et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, placebo-controlled clinical trial. Lancet, 2016.PMID 27116918
[9]Cahill K, Stevens S, Perera R, Lancaster T Pharmacological interventions for smoking cessation: an overview and network meta-analysis. Cochrane Database Syst Rev, 2013.PMID 23728690
[10]Lipson DA, Barnhart F, Brealey N, Brooks J, Criner GJ, et al. Once-Daily Single-Inhaler Triple versus Dual Therapy in Patients with COPD. N Engl J Med, 2018.PMID 29668352
[11]Rabe KF, Martinez FJ, Ferguson GT, Wang C, Singh D, et al. Triple Inhaled Therapy at Two Glucocorticoid Doses in Moderate-to-Very-Severe COPD. N Engl J Med, 2020.PMID 32579807
[12]Wedzicha JA, Banerji D, Chapman KR, Vestbo J, Roche N, et al. Indacaterol-Glycopyrronium versus Salmeterol-Fluticasone for COPD. N Engl J Med, 2016.PMID 27181606
[13]Magnussen H, Disse B, Rodriguez-Roisin R, Kirsten A, Watz H, et al. Withdrawal of inhaled glucocorticoids and exacerbations of COPD. N Engl J Med, 2014.PMID 25196117
[14]Watz H, Tetzlaff K, Wouters EF, Kirsten A, Magnussen H, et al. Blood eosinophil count and exacerbations in severe chronic obstructive pulmonary disease after withdrawal of inhaled corticosteroids: a post-hoc analysis of the WISDOM trial. Lancet Respir Med, 2016.PMID 27066739
[16]Anthonisen NR, Manfreda J, Warren CP, Hershfield ES, Harding GK, Nelson NA Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease. Ann Intern Med, 1987.PMID 3492164
[17]Leuppi JD, Schuetz P, Bingisser R, Bodmer M, Briel M, et al. Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE randomized clinical trial. JAMA, 2013.PMID 23695200
[18]Osadnik CR, Tee VS, Carson-Chahhoud KV, Picot J, Wedzicha JA, Smith BJ Non-invasive ventilation for the management of acute hypercapnic respiratory failure due to exacerbation of chronic obstructive pulmonary disease. Cochrane Database Syst Rev, 2017.PMID 28702957
[24]Fishman A, Martinez F, Naunheim K, Piantadosi S, Wise R, et al. A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema. N Engl J Med, 2003.PMID 12759479
[25]Sehdai YR, Awan H, Roy P, Chowdhury F, Siddiq A, et al. Endobronchial Zephyr valves for bronchoscopic lung volume reduction for severe emphysema: a systematic review and meta-analysis. Ann Med Surg (Lond), 2025.PMID 40851937
[27]McDonald CF, Crockett AJ, Young IH Adult domiciliary oxygen therapy. Position statement of the Thoracic Society of Australia and New Zealand. Med J Aust, 2005.PMID 15963018

COPD — structured viva

Stem

You are supervising a GP registrar who has just prescribed a salbutamol inhaler to an undiagnosed 60-year-old smoker with exertional dyspnoea. ^[1]

References18Show

[1]Agustí A, Celli BR, Criner GJ, Halpin D, Anzueto A, et al. Global Initiative for Chronic Obstructive Lung Disease 2023 Report: GOLD Executive Summary. Eur Respir J, 2023.PMID 36858443
[2]US Preventive Services Task Force, Mangione CM, Barry MJ, Nicholson WK, Cabana M, et al. Screening for Chronic Obstructive Pulmonary Disease: US Preventive Services Task Force Reaffirmation Recommendation Statement. JAMA, 2022.PMID 35536260
[3]Fletcher C, Peto R The natural history of chronic airflow obstruction. Br Med J, 1977.PMID 871704
[5]Wang Z, Qiu Y, Ji X, Dong L Effects of smoking cessation on individuals with COPD: a systematic review and meta-analysis. Front Public Health, 2024.PMID 39722704
[6]Cahill K, Lindson-Hawley N, Thomas KH, Fanshawe TR, Lancaster T Nicotine receptor partial agonists for smoking cessation. Cochrane Database Syst Rev, 2016.PMID 27158893
[7]Anthenelli RM, Benowitz NL, West R, St Aubin L, McRae T, et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, placebo-controlled clinical trial. Lancet, 2016.PMID 27116918
[9]Cahill K, Stevens S, Perera R, Lancaster T Pharmacological interventions for smoking cessation: an overview and network meta-analysis. Cochrane Database Syst Rev, 2013.PMID 23728690
[10]Lipson DA, Barnhart F, Brealey N, Brooks J, Criner GJ, et al. Once-Daily Single-Inhaler Triple versus Dual Therapy in Patients with COPD. N Engl J Med, 2018.PMID 29668352
[11]Rabe KF, Martinez FJ, Ferguson GT, Wang C, Singh D, et al. Triple Inhaled Therapy at Two Glucocorticoid Doses in Moderate-to-Very-Severe COPD. N Engl J Med, 2020.PMID 32579807
[12]Wedzicha JA, Banerji D, Chapman KR, Vestbo J, Roche N, et al. Indacaterol-Glycopyrronium versus Salmeterol-Fluticasone for COPD. N Engl J Med, 2016.PMID 27181606
[13]Magnussen H, Disse B, Rodriguez-Roisin R, Kirsten A, Watz H, et al. Withdrawal of inhaled glucocorticoids and exacerbations of COPD. N Engl J Med, 2014.PMID 25196117
[14]Watz H, Tetzlaff K, Wouters EF, Kirsten A, Magnussen H, et al. Blood eosinophil count and exacerbations in severe chronic obstructive pulmonary disease after withdrawal of inhaled corticosteroids: a post-hoc analysis of the WISDOM trial. Lancet Respir Med, 2016.PMID 27066739
[16]Anthonisen NR, Manfreda J, Warren CP, Hershfield ES, Harding GK, Nelson NA Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease. Ann Intern Med, 1987.PMID 3492164
[17]Leuppi JD, Schuetz P, Bingisser R, Bodmer M, Briel M, et al. Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE randomized clinical trial. JAMA, 2013.PMID 23695200
[18]Osadnik CR, Tee VS, Carson-Chahhoud KV, Picot J, Wedzicha JA, Smith BJ Non-invasive ventilation for the management of acute hypercapnic respiratory failure due to exacerbation of chronic obstructive pulmonary disease. Cochrane Database Syst Rev, 2017.PMID 28702957
[24]Fishman A, Martinez F, Naunheim K, Piantadosi S, Wise R, et al. A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema. N Engl J Med, 2003.PMID 12759479
[25]Sehdai YR, Awan H, Roy P, Chowdhury F, Siddiq A, et al. Endobronchial Zephyr valves for bronchoscopic lung volume reduction for severe emphysema: a systematic review and meta-analysis. Ann Med Surg (Lond), 2025.PMID 40851937
[27]McDonald CF, Crockett AJ, Young IH Adult domiciliary oxygen therapy. Position statement of the Thoracic Society of Australia and New Zealand. Med J Aust, 2005.PMID 15963018