10-9 DSA - COPD by Kinder

Question 1

What is COPD?

Answer 1

Disease characterized by progressive, mostly irreversible airflow obstruction.

Question 2

When is the onset of COPD?

Answer 2

middle age or elderly 20-30 years after exposure

Question 3

What is the burden of COPD?

Answer 3

4^th leading cause of mortality in the United States with mortality in women now exceeding mortality in men.

Question 4

What role does cigarette smoking play in COPD?

Answer 4

Cigarette smoking is by far the leading cause of COPD. Lung function decline is related to both the duration and intensity of cigarette smoking.

Question 5

What decreases in lung function can smokers expect?

Answer 5

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.

Question 6

What does exposure to smoke or second hand smoke do to children?

Answer 6

Lung growth can be impaired from maternal smoking in pregnancy, 2^nd hand exposure during childhood, and smoking during adolescence.

This reduced lung growth increases risk of COPD later in life.

Question 7

What other exposures can cause COPD?

Answer 7

workplace dusts from mining, cotton mills, and grain-handling facilities

Question 8

What is alpha-1 antitrypsin deficiency?

Answer 8

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.

Question 9

What are people with alpha 1 antitrypsin deficiency at risk for?

Answer 9

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.

Question 10

What is emphysema?

Answer 10

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

Question 11

What is centriacinar emphysema?

Answer 11

affects respiratory bronchioles distal to the terminal bronchiole, remainder of acinus spared.

Occurs with smoking

Question 12

What is panacinar emphysema?

Answer 12

alveolar ducts, adjacent alveoli, coalescence and bullae formation.
Common in alpha 1 antitrypsin deficiency.

Occurs with smoking

Question 13

What type of emphysema is common with people with COPD?

Answer 13

Most severe COPD patients have a combination of centriacinar and panacinar emphysema.

Question 14

What is chronic bronchitis and bronchiolitis?

Answer 14

enlargement of bronchial mucous glands and increased epithelial goblet cell production leads to cough and increased mucous production

Question 15

What is pulmonary HTN (PHTN)?

Answer 15

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.

Question 16

What are the lung mechanics in COPD?

Answer 16

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.

Question 17

What is hypoxemia in COPD? When does it present?

Answer 17

mild hypoxemia can be detected in early COPD.

Hypercapnea presents only in severe COPD.

Ventilation perfusion mismatching is common secondary to uneven ventilation.

Question 18

What are some questions regarding HPI to ask patients with suspected COPD?

Answer 18

History: current or past cigarette use, dyspnea with slow progression, history of acute bronchitis, chronic cough, sputum production, and wheezing

Question 19

What physical findings do you expect to find with COPD?

Answer 19

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”

Question 20

What are the PFTs consistent with mild COPD?

Answer 20

Mild FEV1/FVC < 70%, FEV1 ≥ 80% of predicted

Question 21

What are the PFTs consistent with moderate COPD?

Answer 21

Moderate FEV1/FVC < 70%, 50% ≤ FEV1 < 80% of predicted

Question 22

What are the PFTs consistent with severe COPD?

Answer 22

Severe FEV1/FVC < 70%, 30% ≤ FEV1 < 50% of predicted

Question 23

What are the PFTs consistent with very severe COPD?

Answer 23

Very Severe FEV1/FVC <70% < 30% of predicted

or FEV1 < 50% of predicted plus chronic respiratory failure

Question 24

What would you see on CXR with someone with COPD?

Answer 24

hyperinflation,

flattened diaphragms,

increased retrosternal space,

bullae,

can be normal in mild to moderate COPD

Question 25

What are some diff Dx’s for someone with COPD?

Answer 25

asthma, bronchiectasis, bronchiolitis obliterans

Question 26

What are the treatments for COPD?

Answer 26

Smoking cessation

Bronchodilators

Oxygen

Immunizations

Pulm rehab

Surgery

Question 27

What types of medications are helpful in treating COPD?

Answer 27

beta 2 adrenergic agonists

anticholinergics

methyxanthines

PDE-4 inhibitor

corticosteroids

Question 28

Which beta 2 adrenergic agonists are helpful in treating COPD?

Answer 28

B2-adrenergic agonists - inhaled

Short Acting: albuterol, levalbuterol

Long Acting: salmeterol, formoterol

Question 29

Which anticholinergics are helpful in treating COPD?

Answer 29

Anticholinergics - inhaled

Short Acting: ipatroprium bromide

Long Acting: tiotropium

Question 30

Why are methylxanthines useful in treating COPD?

Answer 30

Theophylline oral

antagonizes adenosine receptors, increases cAMP, weak bronchodilator,

requires close monitoring,

narrow therapeutic window,

numerous side effects,

numerous drug interactions

Question 31

What is a PDE-4 inhibitor? What can it help with in COPD?

Answer 31

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

Question 32

What are the corticosteroids that are helpful in treating COPD?

Answer 32

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

Question 33

In long vs. short acting bronchodilators, which are more effective in treating COPD?

Answer 33

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%.

Question 34

Why is oxygen helpful in treating COPD?

Answer 34

chronic hypoxemia can lead to pulmonary hypertension and cor pulmonale. Long term oxygen extends life in patients with chronic hypoxemia

Question 35

Which immunizations should people with COPD get?

Answer 35

influenza and pneumococcus

Question 36

What is pulmonary rehab?

Answer 36

exercise endurance training, will improve walking distance

Question 37

What are the surgical options for treating COPD?

Answer 37

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.

Question 38

What is COPD exacerbation?

Answer 38

combination of dyspnea, cough, and productive sputum that is worse than usual stable state

Question 39

What causes most COPD exacerbations?

Answer 39

respiratory infections

Question 40

What are the common bacterial infections that cause COPD exacerbation?

Answer 40

Bacterial:

Haemophilus influenzae,

Streptococcus pneumoniae,

Moraxella catarrhalis

Question 41

What are the less common bacteria that cause COPD exacerbations?

Answer 41

Pseudomonas aeruginosa and enteric bacilli are less common, but are present in more severe disease and recently hospitalized or intubated patients

Question 42

What viruses and other factors can cause COPD exacerbation?

Answer 42

Viral:

rhinoviruses,

influenza,

parainfluenza, and

respiratory syncytial virus

Airborne pollution

Question 43

What should be assessed to see if a COPD patient with exacerbation needs to be hospitalized?

Answer 43

Dyspnea, accessory muscle use, ABG, hemodynamic stability, and mental alertness

Question 44

What drugs should a COPD patient with exacerbation be given while hospitalized?

Answer 44

Antibiotics when cough and purulent sputum present

Systemic corticosteroids

Increase short acting bronchodilator frequency

Oxygen to maintain saturation greater than 90%

Question 45

What interventions should be done with the patient hospitalized with COPD exacerbation?

Answer 45

Noninvasive positive-pressure ventilation

Intubation, mechanical ventilation

Question 46

What is the prognosis of a COPD patient?

Answer 46

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