9/21- COPD Flashcards

1
Q

Spectrum of Obstructive Lung Diseases (picture)

A
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2
Q

What is COPD (definition)

  • Onset
A

Preventable and treatable disorder of the airways characterized by airflow limitation that is not fully reversible

  • Onset in midlife
  • Airflow limitation usually progressive and associated with abnormal inflammatory response to particles or gases primarily caused by cigarette smoking
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3
Q

Epidemiology of COPD

  • Affected
  • Diagnosed
  • Deaths
  • Disability
A
  • 24 million affected in US
  • Only 50% diagnosed (12 million)
  • Estimated 130,000 deaths, being the #3 COD in the US (2012)
  • #2 cause of disability (prob most common by 2020)
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4
Q

Affected populations in COPD

  • Age
  • Gender
A

Age: 70% are under 65 yo

  • COPD > diabetes and asthma in pts 45-64

Gender: women > men (5x)

  • Deaths in women > men as well
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5
Q

What is chronic bronchitis?

A

A clinical disorder

  • Chronic cough on most days for at least 3 mo/year
  • At least two consecutive years
  • Cough and sputum production not due to any other specific causes
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6
Q

What is emphysema?

A

A disease in which airspaces distal to the terminal bronchioles are enlarged with destruction of alveolar walls.

(defined in anatomic-pathologic terms)

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7
Q

What are risk factors for COPD?

  • Host factors
  • Exposures
  • Other
A

Host factors:

  • Genetics (not all smokers get COPD)
  • Gender
  • Airway hyperreactivity

Exposures:

  • Smoking
  • Environmental pollution
  • Perinatal events and childhood infection
  • Recurrent infections
  • Occupational and environmental exposure (e.g. coal dust, silica)
  • Socio-economic status and (poor) diet

Others:

  • Preexisting bronchial hyperreactivity (Dutch hypothesis)
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8
Q

What is the relationship between smoking and COPD?

A
  • Smoking is the predominant risk factor for development of COPD (>90% of pts with COPD)
  • Dose-response relationship of FEV1 to the intensity of cigarette smoking
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9
Q

What is the most important genetic risk factor for COPD?

  • Mechanism (chrom)
  • Alleles
  • Inheritance
  • Normal function
A

Alpha-1 anti-trypsin deficiency

  • Deficiency of the protein from deficiency alleles of the AAT gene on chrom 14

Alleles:

  • Normal = M, causes production of normal AAT
  • S allele: slightly reduced levels
  • Z allele: markedly reduced levels
  • Null alleles may rarely be present

Inheritance:

  • Autosomal recessive
  • 1/3000 inherit, but only minority recognized - Not all pts with PiZZ develop COPD
  • AAT def accounts for under 1% of COPD in US

Function:

  • AAT-protein has potent protease inhibitor activity; protects normal lung tissue from proteolytic attack during inflammation
  • Normal levels are 120-200 mg/dL
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10
Q

When should you screen for AAT deficiency?

A
  • COPD in a never-smoker
  • Premature onset of COPD (moderate to severe impairment, by/before age 50)
  • A predominance of basilar (lower lobe) emphysema
  • Family Hx of AAT def or COPD onset before age 50
  • Cirrhosis without apparent risk factors
  • Bronchiectasis, esp. w/o risk factors for the disease
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11
Q

What is the pathophysiology of COPD?

  • What are the 2 main components of COPD?
A
  • Environment/occupational exposures and childhood respiratory infections (and other risk factors) act on genetic susceptibility
  • CD8 lymphocyte and neutrophil activation (MCP-1) and release of proteases
  • Protease activation and tissue destruction (protease inhibitors knocked out)
  • Airway inflammation and remodeling

Overall result = airflow limitation

2 main components of COPD:

  • Airway wall thickening and inflammation (presentation = chronic bronchitis)
  • Destruction of lung tissue (presentation = emphysema)
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12
Q

How many COPD patients have never smoked?

A

~10%

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13
Q

What cell types play a big role in COPD? Asthma?

A

COPD

  • Macrophages
  • Neutrophils
  • CD8 lymphocytes

(elevated inflammatory mediators: IL-8, TNF-a, LTB-4, oxidants and imbalance in protease/anti-proteases)

Asthma

  • CD4 lymphocytes
  • Eosinophils
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14
Q

How does cigarette smoking predispose people to COPD?

A
  • Smooth muscle hypertrophy
  • Replacement of Clara cells with mucus-secreting cells; less surfactant and more mucus
  • Small airway, goblet cell metaplasia
  • Neutrophil activation; elastases destroy walls of terminal bronchioles and alveolar ducts

All result in airway narrowing -> dyspnea

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15
Q

What are the structural changes in COPD (histological/micro-anatomical)?

A
  • Goblet cell hyperplasia/metaplasia
  • Mucus gland hypertrophy
  • Increased smooth muscle mass
  • Airway fibrosis
  • Alveolar destruction

Mucociliary dysfunction:

  • Mucus hypersecretion
  • Reduced mucociliary transport
  • Mucosal damage
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16
Q

Airflow limitation in COPD is caused by what?

A
  • Loss of alveolar attachments
  • Loss of elastic recoil
  • Increased smooth muscle contraction
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17
Q

What are the end results of the pathologic changes seen in COPD?

A
  • Airflow obstruction
  • Hyperinflation
  • Impaired gas exchange
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18
Q

What factor of COPD correlates more directly with patient-reported outcomes?

A

Hyperinflation (increased airway resistance)

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19
Q

What are the clinical features expected in a COPD patient’s history?

A
  • Smoking history
  • Cough with sputum production
  • Exertional dyspnea: usually gradual and progressive, constant
  • RV failure (cor pulmonale) symptoms like pedal edema
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20
Q

What is expected upon inspection of COPD patient? Palpation? Percussion?

A

Inspection

  • Thin, asthenic (more in emphysema)
  • Tachypnea
  • Use of accessory muscles
  • Tripod position
  • Barrel chest
  • Cyanosis rare
  • Nicotine stained fingernails
  • Hoover’s sign-inward movement of rib cage with inspiration
  • Elevated JVD (if RHF)

Palpation:

  • Barrel chest

Percussion:

  • Enlarged lung volumes
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21
Q

T/F: Clubbing is a common sign in COPD

A

False!

  • Clubbing is not seen in pure COPD and it’s presence should alert you to look for alternate/additional diagnosis
22
Q

What is Hoover’s sign?

A

Sign of inspiratory muscle fatigue

  • Inward movement of rib cage with inspiration
23
Q

What is expected upon auscultation of COPD patient?

A
  • Decreased breath sounds,
  • Prolonged expiration
  • Wheezing, usually during exacerbations
24
Q

What is seen here?

A

Left: pink puffer

  • Muscle wasting
  • Use of intercostals/accessory neck muscles
  • Pursed lips

Right: blue bloater

  • Cyanosis seen in lips
25
Q

Various patterns of disease seen in COPD?

A
26
Q

What do flow volume loops look like in COPD?

A
  • Scooped/spooned expiratory portion (obstructive disease)
  • Hyperinflation indicated by increased RV and TLC
  • Lower peak and slower flow
27
Q

What x-ray view is best to diagnose COPD? What will be seen?

A

Lateral

  • Can see air trapping and flattened diaphragm
28
Q

Differences between COPD/asthma

  • Onset
  • Symptom progression
  • Reversibility
  • Smoking hx
  • Cells involved
  • Cytokines involved
A
  • Onset: midlife for COPD; early in asthma
  • Progressive sx in COPD but varied in asthma
  • COPD is irreversible/poorly reversible airflow limitation while asthma is largely reversible
  • COPD involves smoking Hx commonly (asthma hx could include allergic rhinitis and eczema)
  • Cells: macrophages/neutrophils in COPD vs. eosinophils/mast cells in asthma
  • CD8 T cells (COPD) vs. CD4 T cells (asthma)
  • LTB4 (COPD) vs. LTD4 (asthma)
  • Cytokines: COPD has IL-8, TNF while asthma has IL-4, 5, and 13
29
Q

What is seen here?

A

Asthma

30
Q

What is seen here?

A

Chronic bronchitis

31
Q

What is seen here?

A

Emphysema

32
Q

What is the global strategy for diagnosis, mgmt, and prevention of COPD?

A

Assessment:

  • Assess symptoms
  • Assess degree of airflow limitation using spirometry
  • Assess risk of exacerbations
  • Assess co-morbidities
33
Q

How is COPD assessed?

A
  • Description of breathlessness
  • Lung function (mild to very severe on GOLD scale)
34
Q

What are the treatment goals for COPD?

A

Reduce symptoms

  • Relieve Sx
  • Improve exercise tolerance
  • Improve health status

Reduce risk:

  • Prevent disease progression
  • Prevent and treat exacerbations
  • Reduce mortality
35
Q

What are nonpharmacologic approaches to COPD management?

A

All stages of disease

  • Smoking cessation
  • Avoidance of indoor and outdoor occupational exposures

Vaccinations

  • Influenza
  • Pneumococcal – no documented evidence

Optimizing nutrition

Oxygen Pulmonary rehabilitation

Surgical interventions (LVRS, transplantation)

36
Q

What is the most effective way to improve clinical outcomes in pts at all stages of COPD?

A

Smoking cessation

37
Q

What effects does smoking cessation have in COPD patients?

A
  • Rate of FEV1 decline can return to that seen in nonsmokers (with early smoking cessation)
  • Decreased smoking slows the decline in FEV1
38
Q

What are smoking cessation strategies?

A

Advice from MD (most imp motivator)

Pharmacologic interventions:

  • Antidepressants (Buproprion), Chantix
  • Nicotine replacement therapy
  • Combo pharmacotherapy
  • Clonidine patch

Behavior modification + pharmacologic intervention is better than either alone

39
Q

What are the criteria for long-term Oxygen therapy?

A
  • PaO2 under 55 mmHg or SaO2 under 885
  • PaO2 under 59 mmHg and evidence of at least one of the following:
  • Pulmonary HTN (P wave > 3mm in LII, III or avF)
  • Cor pulmonale (dependent edema)
  • Erythrocytosis (Hct > 56%)
40
Q

What are common indications for pulmonary rehabilitation?

A
  • Anxiety with activity
  • Breathlessness
  • Limitations with activity
  • Loss of independence
41
Q

What are essential components of pulmonary rehab?

A

Education

Exercise training

  • upper-extremity
  • lower-extremity
  • strength
  • respiratory-muscle

Psychosocial/behavioral

42
Q

What are the main classes of bronchodilators available for the treatment of obstructive lung diseases?

A
  • Anticholinergics
  • Beta-2 agonists
  • Methyl-xanthines
43
Q

What are surgical therapies for COPD?

A

Bullectomy

  • For patients with bulla >1/3 of hemithorax

Lung volume reduction surgery

  • LVRS offers a mortality and symptomatic benefit in selected patients with emphysema (upper lobe predominant and low post rehab. exercise capacity)

Lung transplantation

  • Currently COPD is leading indication for transplant
44
Q

What are novel treatment options for COPD?

A

Non-surgical bronchoscopic lung volume reduction (still under investigation)

45
Q

What is COPD exacerbation? What should be done in these cases?

A

Marked worsening of symptoms from baseline

  • Need to assess severity and try to identify precipitant
  • May need CXR to rule out pneumonia and ABG to assess severity of hypoxemia and hypercarbia
46
Q

How to treat COPD exacerbation?

A
  • Aggressive bronchodilators
  • Antibiotics
  • Systemic corticosteroids
  • Oxygen if needed
  • Non-invasive mechanical ventilation
  • Mechanical ventilation
47
Q

What can cause bronchiectasis?

A
  • Infection-most common
  • Virulent bacterial, influenza, Pertussis childhood infection and Tuberculosis
  • ABPA
  • Slow growing endobronchial tumors, foreign body aspiration, stenosis
  • Impaired pulmonary defense: immunoglobulin deficiency, primary ciliary disorder, cystic fibrosis
  • Toxic inhalation, yellow-nail syndrome
48
Q

What is the inheritance pattern of cystic fibrosis?

A

Autosomal recessive

49
Q

What systems are affected in cystic fibrosis?

A
  • Respiratory (bronchiectasis)
  • Gastrointestinal
  • GU symptoms
50
Q

What are clinical findings in cystic fibrosis?

A
  • Abnormal sweat chloride test (increased Na and Cl)
  • Obstructive disorder symptoms
51
Q

What is seen here?

A

Classic for bronchiectasis

  • Signet ring” sign
  • Can see thickening of airway wall (not here)