chronic obstructive diseases Flashcards
When does lung function decline in COPD?
after age 40 with presence in the 50s and 60s and progressing
What do these symptoms characterize: cough, sputum production, SOB that starts w/ exertion, common to see blue bloaters and pink puffers?
COPD
What are risk factors for COPD?
History of smoking or biomass fuel cooking, air pollution, airway infection, environmental factors, allergy, hereditary factors, reactive airway disease
Exposures early in life → poor lung growth in childhood + expiratory flow limitation (may not manifest clinically until mid-life)
Is COPD reversible?
no
How are COPD exacerbations precipitated?
infection or exposure
What do late stages of COPD look like?
pneumonia, pulmonary HTN, RHF, chronic respiratory failure
What deficiency can predispose someone to emphysemic dysfunction and COPD and is common in 20yo with early unexplained disease that may be misdiagnosed as asthma with no improvement upon treatment + unexplained pannicultis + antiproteinase-3 vasculitis?
alpha 1 antitrypsin deficiency
What is the treatment for alpha 1 antitrypsin deficiency?
augmentation therapy
What would this PE indicate:
barrel chest -> lungs fill w/ air + unable to fully breathe out
- use of resp muscles
- pursed lip breathing
- reduced chest expansion
- reduced breath sounds
- wheezing
- hyperresonance
- expiratory time >4s
- reduced expiratory flow, airflow obstruction, air trapping + hyperinflation?
COPD
What is the basis of COPD diagnosis?
spirometry
What on an early PFT would indicate COPD?
abnormal closing volume
What on FEV1 and FEV1/vital capacity indicate COPD?
reduced –> airflow obstruction
severe = significant FVC reduction
What does an increase in residual volume + total lung capacity or elevation of RV/TLC ratio mean?
COPD – air trapping + hyperinflation
What tests do you need to indicate COPD?
DLCO (effectiveness), 6 minute walk test, ABGs (w/ hypoxemia or hypercapnia), FEV1 or DLCO <40% of predicted for severe COPD and <70% meaning obstruction
early sign could be increased alveolar-arterial gradient
respiratory acidosis
sinus tachy
chest xray to differentiate chronic bronchitis and emphyema
What’s the first line for COPD?
smoking cessation and vaccination
How do you identify a high risk patient?
1) FEV1<50% of predicted
2) 2+ exacerbations in past year
3) 1+ hospitalizations for COPD exacerbations in the past year
What’s the gold criteria?
FEV1 measurement
Gold 1 - >80 - mild
Gold 2 - 50-79 - moderate
Gold 3 - 30-49 - severe
Gold 4 - <30 - very severe
<70 needs treatment
Group A/B- 1 or 2
Group E - 3 or 4
What group of medications do you give for a patient with more than 2 moderate exacerbations or more than 1 leading to a hospitalization?
Group E- (LAMA + LABA for highly symptomatic or ICS + LABA + LAMA for eos >300) + SAMA or SABA
What group of medications do you give for 0-1 exacerbations with no hospital admission?
Group A (bronchodilator) or B (long acting bronchodilator)
Group A
bronchodilator (SAMA or SABA) short acting
Group B
LABA AND LAMA
Group E
LAMA+LABA (highly symptomatic) or ICS + LABA + LAMA (eos>300) + SABA/SAMA
How do you treat COPD outpatient?
O2 for at least 15 hours a day and only treatment to lengthen life
What medications can you use to improve symptoms in COPD?
inhaled bronchodilators but stop if doesn’t help
What helps COPD in severe exacerbations with eos>300?
corticosteroids
stable for 2 years = discontinue
What med is used in COPD for patients who don’t improve with anything else and require monitoring?
theophylline
What COPD med is used only for
1) acute exacerbation (increased sputum, purulence, dyspnea)
2) acute bronchitis
3) prophylaxis for bronchitis?
abx
What med is for COPD for moderate/severe + chronic bronchitis and frequent exacerbations with taking LABA/ICS and/or LAMA?
roflumilast (phosphodiesterase type 4 inhibitor)
What are these symptoms indicative of: cough and sputum production for >3 months/year for >2 years w/ absence of other conditions?
chronic bronchitis
blue bloaters
high BMI, metabolic comorbidity, increased exacerbation
pink puffer
lower BMI, low muscle mass, hyperinflation, dyspnea, decreased exercise capacity, worse health status from smoking
How do you differentiate from chronic bronchitis and emphysema?
Chest XR and CT
emphyesma has a dry cough and is a structural change — chronic bronchitis has a productive cough
When do you admit a COPD patient?
severe symptoms, worsening, hypoxemia, hypercapnia, edema, AMS, inadequate home care, inability to sleep or maintain nutrition, high risk comorbid conditions
How do you manage an inpatient COPD patient?
O2 90-94%, inhaled beta 2 agonists w/ or w/o ipatropium (SAMA), steroids, broad spectrum antibiotics
What is characterized by a chronic cough, purulent sputum, dyspnea, hemoptysis, chest pain, wheezing, rhinosinusitis, fatigue, weight loss, and failure to thrive?
bronchiectasis
What can predispose you to bronchiectasis?
CF!
severe infections, immunodef, autoimmune, inhaling objects, idiopathic, radiation
middle age
What is bronchiectasis?
widening + scarring of airways –> progressive, suppurative lung disease
What would you see on a CT for bronchiectasis?
dilation >.8 children, >1-1.5 in adults, mucus impaction
xray = bronchi dilation
How can you diagnose bronchiectasis?
PFTs or respiratory status testing, sputum culture, XR with tram track markings, dilated bronchi
How do you treat bronchiectasis?
airway clearance techniques w/ pretreatment of bronchodilators, expectorants, humidifiers
How do you treat severe bronchiectasis?
long term abx for 3+ exacerbations/year.. may need lung resection/transplant
What do these xray findings indicate:
-enlarged lung fields, flattened diaphragms, trapped air, decreased vascular markings, and bullae?
emphysema
What do these xray findings indicate:
increased vascular markings, normal diaphragms, pulmonary HTN, right heart enlargement?
chronic bronchitis
How would a patient differ whether they have emphysema or chronic bronchitis?
emphysema – hyperresonance on percussion, low breath sounds, LOW fremitus (air trapping) barrel chest, and generally would be breathing through pursed lips and not displaying signs of cyanosis
chronic bronchitis – may be obese, cyanotic, and have crackles, rales, rhonci, wheezing upon auscultation
Which COPD med is considered the strongest long acting and thus is the recommendation of Group C?
LAMA - tiotropium
LAMA
tiotropium
LABA
salmeterol
SABA
albuterol
SAMA
ipatropium
Could you add on a long acting on top of short acting muscarinic antagonist/beta agonist in Group B to make it stronger?
yes
What are the new guidelines for COPD Group A?
LABA or LAMA if cost permits unless in very mild cases, SABA/SAMA are an option otherwise and recommended for mild disease on a PRN basis
What are the new guidelines for COPD Group B?
LAMA+LABA +/- SABA/SAMA
What are the new guidelines for COPD Group E?
LAMA + LABA
LAMA + LABA + ICS w/ eos>300, +/- SABA
