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Senior - EMED 2 > 9 - COPD > Flashcards

9 - COPD Flashcards

1
Q

COPD definition?

A

Persistent airflow limitation that is generally progressive and associated w an abnormal inflammatory response to noxious particles or gases

Emphysemia and chronic bronchitis

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2
Q

Asthma vs COPD?

A

Asthma is an acute exacerbation

COPD is a CHRONIC disorder

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3
Q

Bronchitis vs emphysemia?

A

Bronchitis is productive cough x 3 months in 2 yrs

Emphysema is destruction of the bronchioles and alveoli

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4
Q

COPD and women?

A

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!!
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5
Q

Tobacco causes 100% of COPD, if you look at a cigarette you will die

A

I cant make any promises, but only 15% of smokers develop COPD

Any of the lung irritants up your likelihood though

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6
Q

What happens with chronic compensation of COPD?

A

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

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7
Q

Stages of COPD severity?

A

Mild - FEV1 >80%

Moderate - FEV1 50-79%

Severe - FEV1 30-49%

Very severe - FEV1 <30%

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8
Q

Hallmark symptoms of COPD?

A

PROGRESSIVE:

  • dypsnea
  • cough
  • sputum

These may vary day to day

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9
Q

Feeling of impending doom?

A

Not with COPD, thats asthma

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10
Q

PE for COPD?

A

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
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11
Q

ABG with COPD?

A

Early:

- mild - moderate hypoxemia w/o hypercapnia

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12
Q

As COPD advances and FEV1 falls below 1L?

A

Hypoxemia becomes more severe

hypercapnea develops

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13
Q

Clinical signs of COPD?

A

Facial vascular engorgment
- secondary polycythemia

Hypercabia

  • Tremor
  • Somnolence
  • Confusion
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14
Q

WTF if hypercarbia?

A

Aka:

  • hypercapnia
  • CO2 retention

A condition of elevated CO2 in blood

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15
Q

If concomitant L HF exists?

A

The cardiac auscultatory findings may be overshadowed by the pulmonary inflation abnormalities of COPD

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16
Q

The diagnosis of chronic compensasated COPD is confirmed by?

A

Spirometry:
- postbronchodilator FEV1 of <80% predicted
FEV1 <0.7

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17
Q

What is the best measure of disease progression once the diagnoses is established?

A

The % of FEV1

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18
Q

CXR?

A

Chronic bronchitis nothing unless:
- bronchiectasis is present

Emphysema shows hyperaeration

  • anteroposterior chest diameter
  • flattened diaphragms
  • increased parenchymal lucency
  • attenuation of pul arterial vascular shadows
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19
Q

How to distinguish acute HF from COPD?

A

Difficult but:

COPD
- BNP <100 pg/mL

HF

  • BNP >500 pg/mL
  • ECG shows dysrhythmias or ischemia
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20
Q

What reduces COPD mortality?

A

Long-term O2 therapy

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21
Q

Goal of long term O2 therapy?

A

Increase baseline PaO2 >/= 60
Or
Arterial SaO2 to >/= 90 (94 for his test)

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22
Q

Criteria for long term O2 therapy are

A 
PaO2 = 55mmHg
SaO2 = 88%

Or

PaO2 56-59mmHg when
- pulm HTN or cor pulmonale(sustained RVF) or polycythemia is present

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23
Q

Pharmacotherapy provides?

A

Symptomatic relief
Controls exacerbation
Improves QOL
Improves exercise performance

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24
Q

Chronic COPD meds?

A

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
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25
Q

Experts dont recommend ___ for all COPD pts because only 20-30% improve

A

Long-term systemic corticosteroids

  • they need inhaled corticosteroids
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26
Q

What is the only intervention that can reduce the rate of decline in lung function and the mortality from respiratory causes?

A

These guys need Jesus,

JK, well maybe that too (i’m no theologist) but they need to quit smoking

27
Q

Define acute exacerbations of COPD?

A

Worsening of respiratory symptoms beyone normal day-day variations and are usually triggered by an infection or respiratory irritant

28
Q

What causes acute exacerbations?

A

75% of the time
- viral/bacterial infection

triggered

  • Hypoxia
  • Cold
  • B-blockers
  • Narcotics
  • Sedative-hypnotics
29
Q

B Blocker vs B agonist?

A

B blocker - bronchial constriction

B agonist - bronchial dilation

30
Q

Why does supplemental O2 help?

A

Increases blood O2 concentration and can help reverse pulmonary vasoconstriction

31
Q

How do you test for hypoxemia?

A

ABG

Not the SpO2

32
Q

How does the ED manage COPD exacerbations?

A
  • 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
33
Q

Consider abx for COPD exacerbation if?

A

Increased sputum volume
Change sputum color
Fever
Suspicion of infection

34
Q

Basic ED eval for COPD exacerbation should include?

A

Chest radiograph
CBC w differential
BMP
ECG

35
Q

What is the most life-threatening feature of an acute exacerbation?

A

Hypoxemia (arterial sat <90)

36
Q

Signs of hypoxemia?

A 
Tachypnea
Tachycardia
Systemic HTN
Cyanosis
Change in mental status
37
Q

Increased work of breathing can cause?

A

CO2 production increase— > Alveolar hypoventilation —> CO2 retention and respiratory acidosis

38
Q

Diagnosis of acute exacerbation of COPD?

A

Pulse oximetry IDENTIFIES
- hypoxemia
Capnography IDENTIFIES
- hypercarbia

DIAGNOSIS comes from ABG

39
Q

ABG diagnoses and…

A

Clarifies the severity of exacerbation and the probably clinical course

40
Q

respiratory failure is characterized by?

A

PaO2 <60 or arterial SaO2 <90

On room air

41
Q

Respiratory acidosis is present if?

A

Pco2 is >45

Normal is 35-45

42
Q

If pH is <7.35

A

Acute and uncompensated component of respiratory or metabolic acidosis is present

43
Q

Sputum assessment is?

A

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

44
Q

Radiographs for COPD exacerbations?

A

Radiographic abnormalities are common and can ID causes
- pneumonia
Or can id alternate diagnosis like acute HF

45
Q

ECG can show?

A

Ischemia
Acute MI
Cor pulmonale
Dysrhythmias

46
Q

Labs/imaging to consider with acute COPD exacerbation?

A

Based on clinical findings and suspicions these can be used as appropriate

  • Theophylline levels
  • CBC
  • Electrolytes
  • B-type natriuretic peptide
  • D-dimers
  • CT angiography
47
Q

Goal of tx for exacerbation of COPD?

A
  • Correct tissue oxygenation
  • Alleviate reversible bronchospasm
  • Treat underlying cause
48
Q

If they dont respond to standard therapy?

A

Reevaluation for other potentially life-threatening issues

49
Q

Your pt has low PaO2 or SaO2 so you put them on O2, how long do you wait before reassessing?

A

20-30 min for improvement to occur

50
Q

If no improvement or resp acidosis develops your pt needs?

A

Ventilation

51
Q

Meds for acute exacerbation of COPD?

A

1st line

Short acting B2 agonist
- albuterol q 30-60 min

Anticholinergic
- ipitropium

52
Q

Meds for every acute exacerbation of COPD in the ED?

A

Start:

  • Albuterol
  • Ipitropium
  • Steroids

Send home w
- z pack

Check their
- o2 script levels (make sure they are g2g at home)

53
Q

Why steroids?

A

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

54
Q

Why z-pac?

A

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

55
Q

If they arent responding to passive o2?

A

Noninvasive ventilation can be delivered by

  • nasal mask,
  • full face mask
  • mouthpiece
56
Q

Benefits of noninvasive o2?

A

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

57
Q

Selection criteria for noninvasive ventilation?

A 
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
58
Q

Exclusion criteria for noninvasive ventilation

A 
Respiratory arrest
Cardiovascular instability
Change in mental
High aspiration risk
Viscous/copious secretions
Facial surgery
Craniofacial trauma
Nasopharyngeal abnormalities
Burns
Obesity (extreme)
59
Q

Mechanical vent is indicated if?

A

Evidence of respiratory muscle fatigue
Worsening resp acidosis
Deteriorating mental
Refractory hypoxemia

60
Q

Goal of assisted vent?

A

Rest ventilatory muscles

Restore adequate gas exchange

61
Q

Adverse events of invasive vent?

A

Pneumonia
Barotrauma
Inability to wean from vent

62
Q

Indications for hospital admission

A 
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
63
Q

Indications for ICU?

A 
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
64
Q

When discharging make sure you arrange the following:

A
  1. Supply of home o2
  2. Bronchiodilation tx
  3. Short course of steroids
  4. Follow up appointments (w/in 1 week)

Teach them how to use the meds

Senior - EMED 2 (10 decks)

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