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PTHER 544 - Cardiorespiratory > 19. COPD > Flashcards

19. COPD Flashcards

1
Q

What is COPD

A

Respiratory disorder largely caused by smoking.

Characterized by progressive partially reversible airway obstruction and lung hyperinflation, alveolar collapse, systemic manifestations (e.g. schema, cardiac failure, osteoporosis, diabetes, depression),

persistent inflammation and repeated injury of airways results in increasing frequency and severity of exacerbation

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2
Q

Risk factors

A
  • smoking (main inflammatory trigger)
  • Alpha 1-antitrypsin deficiency
  • Genetics, gender, socioeconomic factors, occupational/environmental factors
  • Bronchial hyper-responsiveness
  • Environmental exposure to tobaccco smoke
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3
Q

Pathophysiology: Why is there airway limitation

A
  1. Persistent inflammation
  2. repeated injury of small and large airways, lung parenchyma, and vasculature
  • Highly variable from patient to patient
  • Evidence of airway inflammation evident in early disease
  • Inflammation persisted (but decreased) after stimulus removed
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4
Q

Pathophysiology - Hyperinflation

A
  1. Expiratory flow limitation
  2. Dynamic collapse of small airways = airway trapping
  3. Destruction of elastin (recoil) results in increased compliance
  4. Volume of air in lungs at end of tidal volume expiration increases
  5. When BR increases (exertion), there is further air trappings and hyper ventilation resulting in SOBOE
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5
Q

COPD complications

A
  1. Respiratory failure - oxygenation and carbon dioxide elimination compromised = hypoxia and hypercapnia
  2. Pulmonary Hypertension
    - destruction of vasculature from emphysema, vasoconstriction effects of chronic hypoxia leads to pulmonary hypertension and for pulmonale
  3. Mucus hypersecrtion and chronic cough
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6
Q

MRC dyspnea scale (severity of breathlessness)

COPD classification? (mild, mod, severe)

A
  1. Not troubled by breathing except on strenuous exercise
  2. SOB when hurrying or walking up hill (mild stage)
  3. Walks slower than people at same level; stop for breath when walking at own pace (mod)
  4. Stops for breath after about 100m or a few minutes on level ground (mod)
  5. Too breathless to leave house and dressing/undressing (severe)
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7
Q

COPD Assessment: History & Questions

A

1. Early diagnosis and access to treatment #2. Smoking cessation

  • Exposure (occupation, usage)
  • Tobacco use in pack years = (# cigarettes per day/20 x number of years smoking)
  • dyspnea, chronic cough, sputum production

Questions to ask:

  • frequency of exacerbation: do you cough regularly? phlegm? wheeze?
  • SOB with chores?
  • Frequent colds that persist longer than others?
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8
Q

COPD Assessment: Skeletal muscles

A
  • higher percentage of Type 2 (fatigue faster with exercise)
  • skinny (swallow air when they eat)
  • lower capillary density = decreased blood flow

Why?
COPD: malnutrition, inflammation, hypercapnia, hypoxia
Co-morbid: decondition, Cv decondition, age related changes

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9
Q

COPD: appearance

A
  • pink puffer: very skinny, muscle wasting

- Blue bloaters: cyanosis, air trapping

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10
Q

COPD Malnutrition

A
  1. Systemic Inflammation
    - protein breaks down
  2. Altered metabolism
    - increased TDEE, inadequate hormonal stimulation, side effects
  3. Inadequate caloric intake
    - decreased appetite/early satiety/swallow air making them feel full/fatigue while eating
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11
Q

COPD Ax: Physical Appearance (cannot be used as diagnostic)

A
  • may have barrel chest
  • signs of dyspnea (nasal flaring, increased RR, cyanosis)
  • nutritional status/peripheral muscle wasting
  • O/A: decreased BS, crackles, wheezing (bronchoconstriction)
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12
Q

When is spirometry recommended? (Identifying patients with COPD)

A
  • Cough regularity
  • Cough up phlegm
  • SOBOE (simple chords)
  • wheeze on exertion
  • frequent colds that persistent longer than those of other people
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13
Q

Classification by impairment of lung function (FEV1, FEV1/FVC)

A

Mild
- FEV1 > 80% prediction (FEV1/FVC < 0.7)

Moderate
FEV1 50-79% prediction (FEV1/FVC < 0.7)

Severe
FEV1 30-49% prediction (FEV1/FVC < 0.7)

Very Severe
FEV1 < 30% prediction (FEV1/FVC < 0.7)

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14
Q

Diagnosing COPD

A

Demonstration of airflow obstruction by spirometry is essential for the diagnosis of COPD

airflow obstruction = post-bronchodilation FEV1/FVC < 0l70

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15
Q

Airflow obstruction post-bronchodilation

A

FEV1/FVC < 70 indicates airflow obstruction, and is necessary to establish the diagnosis of COPD

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16
Q

Assessment Investigation:

  • Exercise
  • ABG for FEV1
  • CXR
  • cytology
A

Exercise:
- establishes prognostic info/baseline for rehab (6MWT, treadmill)

ABG:
for FEV1 < 40% predicted (supplemental O2 required)

CXR:
not diagnostic but may rule out co-morbidities (features: barrel chest, hyperinflation, bullae, skinny mediastinum)

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17
Q

What is bullae

A

Lung pulps (define)

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18
Q

CXR

A

Not diagnostic

  • typically scooped pattern in the loops (expiratory airflow)
  • dark lungs typical in COP X-ray with relatively flat diaphragm
  • hyperinflation/barrel chest
  • bullae
  • skinny mediastinum
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19
Q

5 year survival in COPD based on peak VO2

A

> 995mL/min 99% survival rate after 5 years

< 650mL/min 40% survival rate after 5 years

20
Q

Management of COPD

A
  1. MRC Dyspnea
  2. Lung function impairment
  3. Education (smoking cessation, exercise, self-mange)
  4. PRN SABD
  5. LABD
  6. Pulmbonary rehab
  7. IBC/LABA
  8. Oxygen
  9. Surgery
21
Q

Management of symptomatic, mild COPD

A
  • education (smoking cessation)
  • prevent exacerbation
  • get yearly vaccination
  • invitation of bronchodilator therapy
  • encourage regular PA (encourage to maintain active lifestyle)
  • Close follow-up and disease monitoring
22
Q

Smoking Cessation - why is it important?

A

single most effective intervention to reduce risk of developing COPD and is the only intervention to slow progression

  • FEV1 can improve drastically
23
Q

Smoking cessation: Counscelling

A
  • should speak to every smoker about quitting (BUT ask permission to talk about it)

Motivational interviewing

  • patient centred style of counselling to elicit behaviour change
  • emphasize personal choice control
  • non-confrontational
  • suggest strategies dependent on pt readiness to change
24
Q

COPD: pharmacological management

A

BRONCHODILATORS:

reduce air trapping and dyspnea, improves quality of life (even if there is no improvement in spirometry)

25
Q

Pharmacology: COPD vs asthma

** THIS IS WHERE YOU LEFT OFF, SLIDE 35

A

COPD: bronchodilators (beta-2 agnoist)

asthma: corticosteroids

26
Q

COPD exercise

  • what does exercise primarily improve?
A
  • encourage to maintain active lifestyle
  • promotes social contact
  • improves cardiac function: dyspnea, exercise endurance, QOL; no improvement to lung function
27
Q

Optimal Pharmacology: Mild

A

= pulmonary rehab

  • SABD

If persistent dyspnea:
LAAC + SABD
Or
LABA + SABD

28
Q

Exercise dosage

A

Frequency: 3-5x/week
Intensity: moderate SOB
timing: 30-45 mins per session
Type of exercise: walking, cycling, swimming…

29
Q

Pulmonary Rehabilitation

A
  1. Improves: dyspnea, exercise endurance, and quality of life
  2. Due to training effect/improved cardiac function (no lung function improvement)
  3. Psychological support in PR programs
30
Q

Oxygen therapy: achieve SpO2 90%

A

LTOT is dose dependent (** the longer the exposure, the larger the benefits for survival)

Long term oxygen therapy (LTOT) = +15h/day to acheive SpO2 92% (or greater)

31
Q

Oxygen therapy: SpO2 90% - who is this offered to?

A

patient with stable COPD with:

  1. severe hypoxemia (PaO2 < 55mmHg)
  2. presence of bilateral ankle edema
  3. Cor pulmonale
  4. Haematocrit > 56%
32
Q

Ambulatory oxygen

A
  • Typically impact is not clinically significant, but Pt with 10% improvement in distance or SOB should continue with ambulatory O2

oxygen and hyperopia should be administered solely during sub maximal exercise to:

  • increase exercise time
  • reduce minute ventilation and hyperinflation
  • delay respiratory ms. dysfunction
33
Q

Symptoms

A
  • Dyspnea
  • Cough +/- sputum production
  • intervals of acute deterioration in symptoms
34
Q

COPD pharmacology: mild, mod., severe

A

mild: SABD; LAAC + SABD
mod: LAAC + LABA + SABA
severe: LAAC + ICS/LABA + SABA

35
Q

COPD: exercise guidelines

  1. frequency
  2. intensity
  3. timing
  4. type of exercise
A
  1. 3-5x/week
  2. moderate shortness of breath
  3. 30-45mins/session
  4. walking, cycling, swimming, etc.
36
Q

COPD exercise recommendations

A 
mild = pulmonary rehab
mod = exercise 
severe = oxygen therapy
37
Q

Inspiratory muscle training: training effect

A
  • resistance and endurance training improves muscle function in COPD population
38
Q

IMT: outcome

A
  • maximal inspiratory muscle strength,
  • endurance time
  • endurance capacity (but not max. exercise capacity)
  • 6/12MWT,
  • QOL; reduction in dyspnea (via Borg)
39
Q

AECOPD: what is it?

A

sustained worsening (>48 hours) of dyspnea, cough, or sputum production die to viral infection

  • increase us of medication
  • results in hospital admissions and death
  • accelerate decline of lung function
40
Q

AECOPD: clinical findings

A

lower FEV1 = more frequent exacerbations

41
Q

AECOPD: prevention strategies

A
  • smoking cessation
  • vaccinations
  • self-management education
  • regular LABD, ICS/LABA
42
Q

COPD: surgery options - (bullectomy)

A

Lung volume reduction surgery (LVRS) - bullectomy (clips and removes bullae to prevent pressure build up/closing of airway) improves:

  • QOL
  • maximal exercise
  • survival
43
Q

COPD: surgery (lung transplant)

A

advanced COPD - 50% its have 5 year survival

criteria:
- FEV 1 < 25%
- PACO2 > 55mmHg
- elevated pulmonary artery pressure

44
Q

End of life (EOL) issues

A
  • prevent it from happening too late: pt with features of advanced disease should discuss EOL issues (e.g. advanced directive DNR)

EOL: anxiety, fear, panic depression

45
Q

EOL patient profile

A
  1. severe airflow obstruction (FEV1 < 30%)
  2. severe hyperinflation (IC/TLC < 25%)
  3. poor functional status (MRC 4-5)
  4. Poor nutritional status (BMI< 19kg/m2)
  5. Older age
  6. Recurrent AECOPD = frequent hospitalization
  7. pulmonary HT
46
Q

EOL management:

  • respiratory failure
  • Cough
  • Dyspnea/air hunger
A
  1. RF: non-invasive ventilation
  2. cough: opioids/anaesthetics
  3. dyspnea: opioids: morphine, benzodiazepines

PTHER 544 - Cardiorespiratory (12 decks)

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