4 - COPD Flashcards
What is COPD?
Progressive airflow obstruction secondary to:
- chronic bronchitis
- emphysema
Most COPD have both
What is chronic bronchitis?
Excessive secretion of bronchial mucus; daily productive cough x 3 months to 2 yrs
What is emphysema?
Abnormal permanent enlargement of airspace distal to terminal bronchiole with wall destruction
Is COPD common?
Yeah
15 million in us with another approx 15 million as of yet undiagnosed COPD
COPD + asthma = 4th leading cause of death
What is the most common cause of COPD?
Smoking
80% have smoking in hx
20% environmental hx
What is the genetic cause of COPD?
Alpha-1 antitripsin deficiency
Smoking effects on airways?
Hypertrophy and hyperproliferation of mucus glands
Paralysis of cilia
Bronchioles are most affected
-always leads to bronchitis
What effect does smoking have on the lung parenchyma?
Destruction of connective tissue matrix making up alveolar walls
A1-antitrypsin imbalance
Leads to parenchyma
What does a1-antirypsin do in the lungs?
It inhibits destruction by inhibiting enzymes of inflammatory cells
What is the life expectancy of 1.5 pack/day smoker?
65yrs
What are the hereditary factors of COPD?
A1-antitrypsin deficiency (AAT) - allows elastin degradation
1% of COPD
Heterozygous (MZ) and Homozygous (ZZ) affects severity
When does COPD develop in those with a1-antitrypsin deficiency?
3rd or 4th decade
Check anyone with a fam hx
AAT + tobacco 32-40yrs
AAT w/o tobacco 48-54 yrs
Chronic bronchitis?
Enlargement of mucus glands and proliferation of goblet cells
+
Fibrosis = decreased luminal diameber
All Chronic bronchitis is considered what?
Considered Mild COPD
Pathology of emyphsema?
Destruction of alveolar walls and enlargement of terminal spaces (air trapping)
Loss of elastic recoil -> driving pressure during exhalation
Panacinar emphysema
Diffuse involvement of acinus (bronchiole, alveolar ducts, sacs and alveoli)
Lower lung more than upper
Centrilobular emphysema
Proximal acinus (bronchiole)
Destruction more irregular with areas of sparred tissue
SS Of COPD?
Typically 5th or 6th decade
Early: SOB, cough, sputum production
— 10 yrs
-pink puffer/blue bloater ss emerge
Late: pneumonia, pulm HTN, cor pulmonale, chronic respiratory failure
Hallmark of COPD?
Periodic exacerbations
Often precipitated by infection or environment
Bronchitis CC?
Chronic productive cough
Daily for 3+ months - 2+ years
Bronchitis PE?
Cyanotic at rest w no distress Wheezes, rhonchi Peripheral edema Multiple lung infections/yr Mild dypsnea or exercise limitation Overweight (frequently) Blue bloaters (hypoxemia)
Emphysema CC?
Severe dypsnea
- slow developing w widespread by the time they come in
Emphysema PE?
Rare cough, non-productive Thin pt w wt loss Apparent respiratory distress Lung sounds quiet Nonperipheral edema
Pink puffers - hyperventilation
Chronic bronchitis vs emphysema buzz words
Bronchitis:
- cyanosis
- obesity
- high Hb (hypoxemia)
- cough/lung sounds
Emphysema
- rubor
- cachexia
- Older
- Quiet lungs
PFTs spirometery?
Early, mid, late
Early: decreased mid/small airway flow decreased
Mild: decreased FEV1 and FEV1/FVC ration
Late: very decreased FVC, increased TLC
Increased TLC and RV
Low DLCO
COPD staging
GOLD 1: mild: FEV1 >80%
GOLD 2: moderate: FEV1 50-79%
GOLD 3: severe: FEV1 30-49%
GOLD 4: very severe: FEV1<30%
What does the GOLD guidelines assume?
They only look at FEV1 and assume that FEV1/FVC is <70%
Do we need areterial blood gas (ABG)study in COPD?
Not routinely needed
AVG results for COPD?
If severe chronic broncitis show respiratory acidosis
Sputum analysis/culture in COPD?
S. Pneumonia,
H. influenzae,
M. Catarrhalis
Doesnt correlate w exacerbations
ECG for COPD?
Sinus tach Chronic pulmonary HTN/cor pulmonale Arrhythmias -MAT -A flutter -A fib
CXR for COPD?
Not for diagnosis only to r/o alternatives/comorbidities
Chronic bronchitis x ray results?
Nonspecific peribronchial/perivascular markings
Cardiomegaly
Increased AP diameter
Emphysema CXR results?
Flattening of diaphragms
Bullae
Peripheral vascular deficiency
Relatively small cardiac silhouette
Increased AP diameter
HRCT for COPD?
High resolution CT
Not routinely used
Can characterize extent of damage in pts - considered in lobectomy
DDx of COPD?
Asthma
Bronchiectasis
CF
Alpha 1 antitrypsin deficiency
Complications of stable COPD?
Acute bronchitis Pneumonia Pulmonary thromboembolism Atrial dysrhythmias LV failure
Complications of advanced COPD?
Pulmonary HTN
Cor pulmonale
rare COPD complications?
Spontaneous pneumothroax
Hemoptysis?
Can be copd (chronic bronchitis)
Also may be bronchogenic carcinoma
What do COPD pts need to do?
Tobacco cessation
Vaccination
- influenza
- pneumococcal
Single most important intervention for COPD?
Smoking
Slows the decline in FEV1
Resting hypoxemia <90%?
-only therapy w evidence of improvement in natural progression of COPD
Longer survival
Reduced hospitalizations
Improved QOL
O2 distribution and rate?
Nasal cannula x 15hrs/day
Typically 1-3L/min
O2 for COPD with normal/low-normal resting O2 but low O2 w exertion
O2 improves exercise intolerance
Shortens recovery from dypsnea
NO evidence of mortality benefit
What will improve s/s, excercise tolerance and overal health but not the inevitable decline into lung death?
Bronchodilators
What inhaled bronchodilators are used?
Short acting:
- ipratropium (anticholinergic)
- albuterol, metaproterenol (SABAs)
Long acting:
- tiotropium (LAMA)
- Formoterol, salmeterol (LABA)
—often combined with ICS
What other meds do COPDers get?
corticosteroids
- ICS daily for moderate - severe COPD, often combined w LABA
- systemic for acute
Phosphodiesterase 4 inhibitors
- roflumilast - decreased inflammation and increased bronchodilation
Who gets ABX?
Most benefit with:
-increasted sputum purulence or quantity + dypsnea (think bacterial infection)
Pt hx of: Age > 65 FEV1 <50% 3+ exacerbations/yr Comorbitdities (cardiac/DM)
ABX for COPD exacerbations?
Doxycycline 100mg Trimethoprium-sulfamethozazole 160/800mg Cephpodoximine 200mg Azithromycin 500mg Ciprofolaxacin or levofloxacin 500mg Amoxicillin-clavulanate 875/125mg
What else can help COPD?
Exercise rehab
Chest physiotherapy chest wall percussion and drainiage)
Supplemental a1-antitrypsin
What meds are not helpful for COPD?
Cough suppressants and sedatives
Expectorants/mucolytics
When to admit COPD pts?
Acute or worsening symptoms
Inadequate home care
Inability to sleep/maintain nutrition
High risk comorbid conditions
Meds the hospital will give to COPD inpatient?
O2 titrated 90-94% Ipatropium + SABA Corticosteroids (prednisone 7-10 days) Broad-spectrum abx Chest physiotherapy in selected cases
Surgical options for COPD?
Lung transplant
Lung volume reduction
Bullectomy (severe bullous emphysema)
Opiates for COPD?
Small amount of opiates can reduce symptoms of air hunger
How is the BODE index calculated?
Points accumulated from the following categories:
BMI
FEV1
Exercise
Dypsnea with ___
BODE index 4 yr survival rate?
0-2 pts 80%
3-4 pts 67%
5-6 pts 57%
7-10 pts 18%
Who gets referred?
COPD before age 40 >2 exacerbations/yr on max therapy Severe/rapidly progression S/s disproportionate to severity of airflow obstruction Need for long-term O2 therapy Onset of comorbidities
Does surgery for COPD extend life?
Nope only palliative, doesnt extend life only improve symptoms
