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Chronic obstructive pulmonary disease — SCE Respiratory MCQ

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HardICS-LABA CombinationChronic obstructive pulmonary diseaseSCE Respiratory

A 67-year-old man with spirometrically confirmed COPD is reviewed because exertional breathlessness continues to restrict shopping and household activities. His CAT score is 21 and MRC dyspnoea grade is 3. Post-bronchodilator FEV1 is 46% predicted, with 3% reversibility. He has a 45-pack-year smoking history but stopped smoking 2 years ago. He has taken fluticasone propionate/salmeterol for 6 years, initiated under a previous treatment pathway. Adherence and inhaler technique are good. He has completed pulmonary rehabilitation and received relevant vaccinations. He has had no moderate or severe exacerbations during the past 2 years. There is no previous asthma diagnosis, atopy or substantial peak-flow variability, and stable blood eosinophil counts are 70–110 cells/µL. Haemoglobin, ECG and echocardiography are normal. CT shows emphysema without bronchiectasis or another cause of his symptoms. Following clinical review, his day-to-day limitation is attributed to COPD. Which long-term inhaled treatment strategy is most appropriate?

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Correct answer: E — Add a LAMA to establish LAMA/LABA/ICS triple therapy

Explanation lettering: E = shown as A · A = shown as C · C = shown as E

NICE distinguishes the initial choice of dual therapy from escalation in someone already taking LABA/ICS. Absence of asthmatic features would favour LAMA/LABA when initiating long-acting combination therapy, but this patient is already receiving LABA/ICS and remains limited by COPD symptoms despite adherence, correct technique and optimised non-pharmacological management. Alternative causes of breathlessness have also been addressed. NICE therefore recommends offering LAMA/LABA/ICS when day-to-day symptoms continue to adversely affect quality of life in a person taking LABA/ICS; qualifying exacerbations are an alternative, not an additional, requirement. A is inappropriate because symptoms remain materially uncontrolled. B is attractive because LAMA/LABA is the preferred initial combination in COPD without steroid-responsive features, but it does not follow NICE's specific escalation pathway for symptomatic patients already taking LABA/ICS. C is therefore correct. D increases corticosteroid exposure without adding the mechanistically indicated long-acting muscarinic bronchodilator. E provides less bronchodilation than dual or triple therapy and is unsuitable for persistent symptom limitation. The 3-month trial-and-revert approach applies specifically when triple therapy is considered for persistent symptoms in someone currently taking LAMA/LABA. NICE states that triple therapy should be offered, rather than merely trialled under that pathway, when the patient is already taking LABA/ICS.

Reference: Chronic obstructive pulmonary disease in over 16s: diagnosis and management — Recommendations (Published 5 December 2018; updated 26 July 2019; checked 18 August 2026) — https://www.nice.org.uk/guidance/ng115/chapter/Recommendations Chronic obstructive pulmonary disease in over 16s: diagnosis and management — Rationale and impact (Published 5 December 2018; updated 26 July 2019; checked 18 August 2026) — https://www.nice.org.uk/guidance/ng115/chapter/Rationale-and-impact