CPC Respiratory Assessment and Management 2 — Questions and Answers

Question 1: Which of the following is the CORRECT interpretation of peak expiratory flow rate (PEFR) results in asthma management using the traffic light system?

Green ≥80% predicted, Yellow 50–79%, Red <50% (Correct answer)
Green ≥90% predicted, Yellow 70–89%, Red <70%
Green ≥70% predicted, Yellow 40–69%, Red <40%
Green ≥60% predicted, Yellow 40–59%, Red <40%

Correct answer: Green ≥80% predicted, Yellow 50–79%, Red <50%

The NAEPP/GINA asthma action plan traffic light system: Green zone (≥80% personal best or predicted) = good control; Yellow zone (50–79%) = caution, step up treatment; Red zone (<50%) = emergency action needed.

Peak expiratory flow (PEF) monitoring is a key self-management tool in asthma. The traffic light system divides the patient's personal best PEF (measured during a period of optimal control) into three zones: Green (≥80%): maintain current treatment; Yellow (50–79%): exacerbation warning zone — increase rescue inhaler use, begin oral corticosteroids per action plan, contact provider; Red (<50%): severe exacerbation — immediate bronchodilator use, activate emergency medical services. Community paramedics measure PEFR during home visits using a peak flow meter and compare to the patient's personal best, assessing whether the patient has an individualized asthma action plan and understands zone-specific responses.

Question 2: A community paramedic visits a patient with CHF who has developed progressive dyspnea over 3 days. On auscultation, fine crackles are heard bilaterally at the bases. These crackles MOST likely represent:

Pneumonia consolidation in both lower lobes
Pulmonary edema from fluid accumulation in the alveoli (Correct answer)
Bronchospasm from concurrent asthma
Normal breath sounds in an elderly patient

Correct answer: Pulmonary edema from fluid accumulation in the alveoli

Bilateral fine crackles at the lung bases in a CHF patient with worsening dyspnea are the classic auscultatory finding of pulmonary edema — fluid transudating into the alveoli from elevated left-heart filling pressures.

In decompensated CHF, elevated left ventricular end-diastolic pressure raises pulmonary capillary wedge pressure (PCWP), driving fluid into the pulmonary interstitium and alveoli. Fine bibasilar crackles result from the reopening of fluid-filled alveoli during inspiration — they are gravity-dependent, so they occur at the bases in ambulatory patients and throughout the lungs in severe cases. Associated findings: jugular venous distension, peripheral edema, S3 gallop, and orthopnea. Community paramedics assess crackle distribution (bases only vs. mid-lung vs. full field), severity of dyspnea, SpO2, and weight change to determine if the patient requires urgent escalation or home-based diuretic adjustment.

Question 3: Which respiratory pattern is characterized by cycles of gradually increasing tidal volume followed by gradually decreasing tidal volume with periods of apnea?

Kussmaul breathing
Cheyne-Stokes respiration (Correct answer)
Biot's respiration
Apneustic breathing

Correct answer: Cheyne-Stokes respiration

Cheyne-Stokes respiration is a cyclical pattern of crescendo-decrescendo tidal volumes with intervening apnea periods. It is associated with severe CHF, stroke, TBI, and altitude sickness.

Respiratory pattern abnormalities: Cheyne-Stokes (cyclical waxing-waning depth with apnea — CHF, brainstem lesions, altitude), Kussmaul (deep, labored, regular — compensatory for metabolic acidosis, classically in DKA), Biot's/Ataxic (irregular depth and rate with apnea — severe brainstem damage, meningitis), Apneustic (prolonged inspiratory pause — pontine lesions), Tachypnea (fast, shallow), Bradypnea (slow). In CHF, Cheyne-Stokes results from oscillating hypercapnia/hypocapnia due to circulatory delay in CO2 chemoreceptor feedback. Community paramedics document respiratory pattern type, rate, depth, and regularity as part of a comprehensive respiratory assessment.

Question 4: Which medication class is the CORNERSTONE of maintenance pharmacotherapy for moderate-to-severe COPD?

Short-acting beta-2 agonists (SABAs)
Long-acting muscarinic antagonists (LAMAs) (Correct answer)
Inhaled corticosteroids (ICS) alone
Oral theophylline

Correct answer: Long-acting muscarinic antagonists (LAMAs)

Long-acting muscarinic antagonists (LAMAs, e.g., tiotropium, umeclidinium) are the cornerstone of maintenance therapy for COPD with GOLD Grade 2 or higher, providing superior bronchodilation, fewer exacerbations, and better QOL than SABAs or ICS alone.

GOLD COPD pharmacotherapy guidelines recommend: Group A (low symptom burden, low exacerbation risk): bronchodilator PRN; Group B (high symptom burden, low risk): LAMA or LABA; Group E (high exacerbation risk): LAMA + LABA, with ICS added if eosinophil count ≥300 cells/µL. LAMAs (anticholinergics) — tiotropium (Spiriva), umeclidinium (Incruse), glycopyrronium (Seebri) — reduce airway hyperresponsiveness, dynamic hyperinflation, and exacerbation frequency. ICS monotherapy is NOT recommended in COPD; it is added only in combination inhalers. Theophylline is a last-line option with a narrow therapeutic window and significant drug interactions. Community paramedics review inhaler class and technique at every COPD visit.

Question 5: A community paramedic is assessing a patient for sleep apnea using the STOP-BANG screening tool. A STOP-BANG score of 5 indicates:

Low risk for obstructive sleep apnea
Intermediate risk for obstructive sleep apnea
High risk for obstructive sleep apnea (Correct answer)
The patient has already been diagnosed with sleep apnea

Correct answer: High risk for obstructive sleep apnea

STOP-BANG score interpretation: 0–2 = low risk, 3–4 = intermediate risk, 5–8 = high risk for moderate-to-severe obstructive sleep apnea. A score of 5 indicates HIGH risk and warrants referral for polysomnography.

The STOP-BANG questionnaire is an 8-item validated screening tool for obstructive sleep apnea: Snoring, Tiredness, Observed apneas, Pressure (hypertension), BMI >35, Age >50, Neck circumference >40 cm, Gender (male). Each 'yes' scores 1 point. STOP-BANG score ≥3 has 93% sensitivity for moderate-to-severe OSA. Score 5–8 carries the highest risk and should prompt urgent referral for polysomnography. Community paramedics screen for undiagnosed OSA during home visits for patients with HTN, type 2 diabetes, CHF, stroke, or excessive daytime sleepiness — all conditions associated with untreated OSA.

Question 6: Which of the following is the PRIMARY long-term oxygen therapy (LTOT) criterion for a patient with COPD?

SpO2 <94% on any occasion
PaO2 ≤55 mmHg (or SaO2 ≤88%) at rest on room air, confirmed on two measurements at least 3 weeks apart (Correct answer)
SpO2 <92% only during exercise
Physician preference regardless of objective measurements

Correct answer: PaO2 ≤55 mmHg (or SaO2 ≤88%) at rest on room air, confirmed on two measurements at least 3 weeks apart

LTOT is indicated when resting PaO2 ≤55 mmHg or SaO2 ≤88%, confirmed on two measurements 3+ weeks apart, or PaO2 56–59 mmHg with evidence of cor pulmonale, polycythemia, or right heart failure.

Long-term oxygen therapy (LTOT) for COPD is prescribed based on CMS criteria: Resting hypoxemia: PaO2 ≤55 mmHg or SaO2 ≤88% on room air, confirmed on 2 ABG or oximetry measurements at least 3 weeks apart during a stable period. Borderline resting hypoxemia: PaO2 56–59 mmHg or SaO2 89% with evidence of cor pulmonale (P pulmonale on ECG, peripheral edema suggesting RHF) or erythrocytosis (hematocrit >55%). LTOT prescribed for ≥15 hours/day improves survival in severe COPD by reducing pulmonary hypertension. Community paramedics assess oxygen equipment compliance, flow rate, and hours of use per day during home visits, and verify that the patient is not using oxygen around open flames.

CPC Respiratory Assessment and Management 2

Which of the following is the CORRECT interpretation of peak expiratory flow rate (PEFR) results in asthma management using the traffic light system?