9 - COPD Flashcards
COPD definition?
Persistent airflow limitation that is generally progressive and associated w an abnormal inflammatory response to noxious particles or gases
Emphysemia and chronic bronchitis
Asthma vs COPD?
Asthma is an acute exacerbation
COPD is a CHRONIC disorder
Bronchitis vs emphysemia?
Bronchitis is productive cough x 3 months in 2 yrs
Emphysema is destruction of the bronchioles and alveoli
COPD and women?
COPD is now an equal opportunity disease
COPD in women has doubled in the past few decades and women are now >50% of COPD related deaths
- girl power!!
Tobacco causes 100% of COPD, if you look at a cigarette you will die
I cant make any promises, but only 15% of smokers develop COPD
Any of the lung irritants up your likelihood though
What happens with chronic compensation of COPD?
Loss of elastic recoil, narrowing and collapse of the smaller airways
Mucous stasis and bacterial colonization develop
There is an insidious progression so the process takes decades
Stages of COPD severity?
Mild - FEV1 >80%
Moderate - FEV1 50-79%
Severe - FEV1 30-49%
Very severe - FEV1 <30%
Hallmark symptoms of COPD?
PROGRESSIVE:
- dypsnea
- cough
- sputum
These may vary day to day
Feeling of impending doom?
Not with COPD, thats asthma
PE for COPD?
Tachypnea
Accessory muscle use
Pursed-lip exhalation
Wheezing
Prolonged expiratory time
Chronic bronchitis
- coarse crackles
Emphysemia
- expansion of thorax
- impeded diaphragmatic motion
- global diminution of breath sounds
ABG with COPD?
Early:
- mild - moderate hypoxemia w/o hypercapnia
As COPD advances and FEV1 falls below 1L?
Hypoxemia becomes more severe
hypercapnea develops
Clinical signs of COPD?
Facial vascular engorgment
- secondary polycythemia
Hypercabia
- Tremor
- Somnolence
- Confusion
WTF if hypercarbia?
Aka:
- hypercapnia
- CO2 retention
A condition of elevated CO2 in blood
If concomitant L HF exists?
The cardiac auscultatory findings may be overshadowed by the pulmonary inflation abnormalities of COPD
The diagnosis of chronic compensasated COPD is confirmed by?
Spirometry:
- postbronchodilator FEV1 of <80% predicted
FEV1 <0.7
What is the best measure of disease progression once the diagnoses is established?
The % of FEV1
CXR?
Chronic bronchitis nothing unless:
- bronchiectasis is present
Emphysema shows hyperaeration
- anteroposterior chest diameter
- flattened diaphragms
- increased parenchymal lucency
- attenuation of pul arterial vascular shadows
How to distinguish acute HF from COPD?
Difficult but:
COPD
- BNP <100 pg/mL
HF
- BNP >500 pg/mL
- ECG shows dysrhythmias or ischemia
What reduces COPD mortality?
Long-term O2 therapy
Goal of long term O2 therapy?
Increase baseline PaO2 >/= 60
Or
Arterial SaO2 to >/= 90 (94 for his test)
Criteria for long term O2 therapy are
PaO2 = 55mmHg SaO2 = 88%
Or
PaO2 56-59mmHg when
- pulm HTN or cor pulmonale(sustained RVF) or polycythemia is present
Pharmacotherapy provides?
Symptomatic relief
Controls exacerbation
Improves QOL
Improves exercise performance
Chronic COPD meds?
Inhaled LONG acting B2 agonist
Inhaled corticosteroids when FEV1<50%
Azithromycin daily
- mild global initiation for COLD staging
Respiratory secretions control
- antihistamines, antitussive, mucolytics, decongestants
- humidity
Experts dont recommend ___ for all COPD pts because only 20-30% improve
Long-term systemic corticosteroids
- they need inhaled corticosteroids
What is the only intervention that can reduce the rate of decline in lung function and the mortality from respiratory causes?
These guys need Jesus,
JK, well maybe that too (i’m no theologist) but they need to quit smoking
Define acute exacerbations of COPD?
Worsening of respiratory symptoms beyone normal day-day variations and are usually triggered by an infection or respiratory irritant
What causes acute exacerbations?
75% of the time
- viral/bacterial infection
triggered
- Hypoxia
- Cold
- B-blockers
- Narcotics
- Sedative-hypnotics
B Blocker vs B agonist?
B blocker - bronchial constriction
B agonist - bronchial dilation
Why does supplemental O2 help?
Increases blood O2 concentration and can help reverse pulmonary vasoconstriction
How do you test for hypoxemia?
ABG
Not the SpO2
How does the ED manage COPD exacerbations?
- Assess severity of symptoms
- Administer controlled O2
- continuous cardiovascular status monitoring
- ABG post 20-30 min if SpO2 <90
- or concern for symptomatic hypercapnia
- administer bronchiodilatiors
- b2 agonist or anticholingergics
- oral or IV corticosteroids
- abx (if needed)
- IV methylxanthine (if refractory)
- noninvasive mechanical vent
- assess comorbids
Consider abx for COPD exacerbation if?
Increased sputum volume
Change sputum color
Fever
Suspicion of infection
Basic ED eval for COPD exacerbation should include?
Chest radiograph
CBC w differential
BMP
ECG
What is the most life-threatening feature of an acute exacerbation?
Hypoxemia (arterial sat <90)
Signs of hypoxemia?
Tachypnea Tachycardia Systemic HTN Cyanosis Change in mental status
Increased work of breathing can cause?
CO2 production increase— > Alveolar hypoventilation —> CO2 retention and respiratory acidosis
Diagnosis of acute exacerbation of COPD?
Pulse oximetry IDENTIFIES
- hypoxemia
Capnography IDENTIFIES
- hypercarbia
DIAGNOSIS comes from ABG
ABG diagnoses and…
Clarifies the severity of exacerbation and the probably clinical course
respiratory failure is characterized by?
PaO2 <60 or arterial SaO2 <90
On room air
Respiratory acidosis is present if?
Pco2 is >45
Normal is 35-45
If pH is <7.35
Acute and uncompensated component of respiratory or metabolic acidosis is present
Sputum assessment is?
Basically useless
- cultures usually contain a mixed flora and dont guide ED abx selection
Basically your mouth is a dirty dirty hole and anything that comes out of it cannot be trusted
Radiographs for COPD exacerbations?
Radiographic abnormalities are common and can ID causes
- pneumonia
Or can id alternate diagnosis like acute HF
ECG can show?
Ischemia
Acute MI
Cor pulmonale
Dysrhythmias
Labs/imaging to consider with acute COPD exacerbation?
Based on clinical findings and suspicions these can be used as appropriate
- Theophylline levels
- CBC
- Electrolytes
- B-type natriuretic peptide
- D-dimers
- CT angiography
Goal of tx for exacerbation of COPD?
- Correct tissue oxygenation
- Alleviate reversible bronchospasm
- Treat underlying cause
If they dont respond to standard therapy?
Reevaluation for other potentially life-threatening issues
Your pt has low PaO2 or SaO2 so you put them on O2, how long do you wait before reassessing?
20-30 min for improvement to occur
If no improvement or resp acidosis develops your pt needs?
Ventilation
Meds for acute exacerbation of COPD?
1st line
Short acting B2 agonist
- albuterol q 30-60 min
Anticholinergic
- ipitropium
Meds for every acute exacerbation of COPD in the ED?
Start:
- Albuterol
- Ipitropium
- Steroids
Send home w
- z pack
Check their
- o2 script levels (make sure they are g2g at home)
Why steroids?
The use of short course (5-7 days) of systemic steroids improves lung function and hypoxemia and shortens recover time
Doesnt affect rate of hospitalizations but does decrease rate or return visits
Why z-pac?
The WHO says so
Actually it can be azithromycin, doxycycline, amoxicillin
- whatever
Little evidence regarding the duration of tx, it ranges from 3-14 days
If they arent responding to passive o2?
Noninvasive ventilation can be delivered by
- nasal mask,
- full face mask
- mouthpiece
Benefits of noninvasive o2?
Patients with respiratory failure who receive noninvasive ventilation have better outcomes in terms of intubation rates, short-term mortality rates, symptomatic improvement, and length of hospitalization
Selection criteria for noninvasive ventilation?
Acidosis (pH <7.36) Hypercapnea (pco2 >50) O2 deficit (Pao2 <60.Sao2<90) Sever dypsenea w clinical signs like - respiratory muscle fatigue - increased work of breathing
Exclusion criteria for noninvasive ventilation
Respiratory arrest Cardiovascular instability Change in mental High aspiration risk Viscous/copious secretions Facial surgery Craniofacial trauma Nasopharyngeal abnormalities Burns Obesity (extreme)
Mechanical vent is indicated if?
Evidence of respiratory muscle fatigue
Worsening resp acidosis
Deteriorating mental
Refractory hypoxemia
Goal of assisted vent?
Rest ventilatory muscles
Restore adequate gas exchange
Adverse events of invasive vent?
Pneumonia
Barotrauma
Inability to wean from vent
Indications for hospital admission
Marked increase in intensity - sudden resting dyspnea - inability to walk room - room Significant comorbids Failure to respond to medical management Freq relapse after ED tx Older age Bad home support
Indications for ICU?
Sever dyspnea that fails to respond Respiratory vent failure despite - supp o2 - noninvasive positive pressure Decreasing LOC Hemodynamic instability Presence of comorbids - end organ failure
When discharging make sure you arrange the following:
- Supply of home o2
- Bronchiodilation tx
- Short course of steroids
- Follow up appointments (w/in 1 week)
Teach them how to use the meds
