10-9 DSA - COPD by Kinder Flashcards
What is COPD?
Disease characterized by progressive, mostly irreversible airflow obstruction.
When is the onset of COPD?
middle age or elderly 20-30 years after exposure
What is the burden of COPD?
4th leading cause of mortality in the United States with mortality in women now exceeding mortality in men.
What role does cigarette smoking play in COPD?
Cigarette smoking is by far the leading cause of COPD. Lung function decline is related to both the duration and intensity of cigarette smoking.
What decreases in lung function can smokers expect?
Non-smokers after the age of 30 have approximately a 25ml per year reduction of their FEV1.
Smokers have a 40ml per year reduction of FEV1.
A small percentage of smokers develop FEV1 reduction of a 100ml per year and may develop COPD in their 4th or 5th decades of life.
What does exposure to smoke or second hand smoke do to children?
Lung growth can be impaired from maternal smoking in pregnancy, 2nd hand exposure during childhood, and smoking during adolescence.
This reduced lung growth increases risk of COPD later in life.
What other exposures can cause COPD?
workplace dusts from mining, cotton mills, and grain-handling facilities
What is alpha-1 antitrypsin deficiency?
Genetic risk factor for COPD. 1-2 % of COPD.
A serine protease inhibitor secreted by the liver that protects the lung tissue against the action of neutrophil elastase and serine proteases.
What are people with alpha 1 antitrypsin deficiency at risk for?
These patients are very susceptible to damage caused by cigarette smoking. Consider this in patients that are young at onset.
Also leads to LFT abnormalities and cirrhosis.
What is emphysema?
enlargement of the air spaces distal to the terminal bronchiole with destruction of the alveolar walls
Emphysema is caused by an imbalance of elastase-antielastase in the lung
What is centriacinar emphysema?
affects respiratory bronchioles distal to the terminal bronchiole, remainder of acinus spared.
Occurs with smoking
What is panacinar emphysema?
alveolar ducts, adjacent alveoli, coalescence and bullae formation.
Common in alpha 1 antitrypsin deficiency.
Occurs with smoking
What type of emphysema is common with people with COPD?
Most severe COPD patients have a combination of centriacinar and panacinar emphysema.
What is chronic bronchitis and bronchiolitis?
enlargement of bronchial mucous glands and increased epithelial goblet cell production leads to cough and increased mucous production
What is pulmonary HTN (PHTN)?
hypoxemia leads to vasoconstriction and increased pulmonary vascular resistance in small pulmonary arteries. This leads to vascular remodeling including medial smooth muscle enlargement and intimal fibrosis.
What are the lung mechanics in COPD?
Elastic recoil is the lungs innate ability to deflate following inflation.
Elastic fibers in the lung parenchyma, along with surface tension at the alveolar air-liquid interface are responsible for this elastic recoil.
Elastic recoil maintains the patency of small airways.
1) This elastic recoil is markedly decreased in COPD.
2) Airway resistance is increased in COPD. The sites of airflow obstruction in COPD are the distal airways of less than 2mm diameter.
What is hypoxemia in COPD? When does it present?
mild hypoxemia can be detected in early COPD.
Hypercapnea presents only in severe COPD.
Ventilation perfusion mismatching is common secondary to uneven ventilation.
What are some questions regarding HPI to ask patients with suspected COPD?
History: current or past cigarette use, dyspnea with slow progression, history of acute bronchitis, chronic cough, sputum production, and wheezing
What physical findings do you expect to find with COPD?
barrel chest,
prolonged expiratory phase,
accessory muscle use,
low diaphragm,
distant heart sounds,
diminished breath sounds,
rhonchi,
wheezing,
cyanosis,
pedal edema,
distended jugular veins,
hepatic congestion, and
cachexia.
“blue bloaters” “pink puffers”
What are the PFTs consistent with mild COPD?
Mild FEV1/FVC < 70%, FEV1 ≥ 80% of predicted
What are the PFTs consistent with moderate COPD?
Moderate FEV1/FVC < 70%, 50% ≤ FEV1 < 80% of predicted
What are the PFTs consistent with severe COPD?
Severe FEV1/FVC < 70%, 30% ≤ FEV1 < 50% of predicted
What are the PFTs consistent with very severe COPD?
Very Severe FEV1/FVC <70% < 30% of predicted
or FEV1 < 50% of predicted plus chronic respiratory failure
What would you see on CXR with someone with COPD?
hyperinflation,
flattened diaphragms,
increased retrosternal space,
bullae,
can be normal in mild to moderate COPD
What are some diff Dx’s for someone with COPD?
asthma, bronchiectasis, bronchiolitis obliterans
What are the treatments for COPD?
Smoking cessation
Bronchodilators
Oxygen
Immunizations
Pulm rehab
Surgery
What types of medications are helpful in treating COPD?
beta 2 adrenergic agonists
anticholinergics
methyxanthines
PDE-4 inhibitor
corticosteroids
Which beta 2 adrenergic agonists are helpful in treating COPD?
B2-adrenergic agonists - inhaled
Short Acting: albuterol, levalbuterol
Long Acting: salmeterol, formoterol
Which anticholinergics are helpful in treating COPD?
Anticholinergics - inhaled
Short Acting: ipatroprium bromide
Long Acting: tiotropium
Why are methylxanthines useful in treating COPD?
Theophylline oral
antagonizes adenosine receptors, increases cAMP, weak bronchodilator,
requires close monitoring,
narrow therapeutic window,
numerous side effects,
numerous drug interactions
What is a PDE-4 inhibitor? What can it help with in COPD?
Phosphodiesterase-4 Inhibitor
Roflumilast: can increase FEV1 by 50 ml
reduce exacerbations in moderate to severe exacerbations of COPD,
- even in patients already treated with tiotropium
What are the corticosteroids that are helpful in treating COPD?
Inhaled: Reduces COPD exacerbations by 15-20%. Added benefit when combined with long acting beta agonist
Systemic: Prednisone – no proven benefits of chronic, low dose prednisone, many adverse effects
In long vs. short acting bronchodilators, which are more effective in treating COPD?
Generally, long acting
Long acting bronchodilators provide improvement in 10-15% of patients.
Tiotropium once daily superior to salmeterol twice daily.
Long acting bronchodilators reduce exacerbations by 15-20%.
Why is oxygen helpful in treating COPD?
chronic hypoxemia can lead to pulmonary hypertension and cor pulmonale. Long term oxygen extends life in patients with chronic hypoxemia
Which immunizations should people with COPD get?
influenza and pneumococcus
What is pulmonary rehab?
exercise endurance training, will improve walking distance
What are the surgical options for treating COPD?
Lung volume reduction surgery: used in severe emphysema involving the upper lobes
Lung transplantation: used for severe incapacitation, no other major comorbities, median survival of about 5 years.
What is COPD exacerbation?
combination of dyspnea, cough, and productive sputum that is worse than usual stable state
What causes most COPD exacerbations?
respiratory infections
What are the common bacterial infections that cause COPD exacerbation?
Bacterial:
Haemophilus influenzae,
Streptococcus pneumoniae,
Moraxella catarrhalis
What are the less common bacteria that cause COPD exacerbations?
Pseudomonas aeruginosa and enteric bacilli are less common, but are present in more severe disease and recently hospitalized or intubated patients
What viruses and other factors can cause COPD exacerbation?
Viral:
rhinoviruses,
influenza,
parainfluenza, and
respiratory syncytial virus
Airborne pollution
What should be assessed to see if a COPD patient with exacerbation needs to be hospitalized?
Dyspnea, accessory muscle use, ABG, hemodynamic stability, and mental alertness
What drugs should a COPD patient with exacerbation be given while hospitalized?
Antibiotics when cough and purulent sputum present
Systemic corticosteroids
Increase short acting bronchodilator frequency
Oxygen to maintain saturation greater than 90%
What interventions should be done with the patient hospitalized with COPD exacerbation?
Noninvasive positive-pressure ventilation
Intubation, mechanical ventilation
What is the prognosis of a COPD patient?
Only ½ of patients with FEV1 that is 40% will survive 5 years
Smoking cessation reduces mortality in patients with mild to moderate COPD
Oxygen reduces mortality in subset with chronic hypoxemia
