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?
IV pooled alpha 1 antitrypsin
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 and dec mid expiratory flow rates
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?
Spirometry: FEV1/FVC postbronchodilator <70% predicted, dec or normal FEV1 and FVC.
DLCO: normal (chronic bronchitis) or dec (emphysema).
6 min walking test.
May also evaluate:
ABGs
EKG - sinus tach
CXR
Chest CT
What’s the first line for COPD?
smoking cessation and vaccination
How do you identify a high risk COPD patient?
1) FEV1<50% of predicted (gold grade 3 or 4)
2) 2+ moderate exacerbations in past year (group E)
3) 1+ hospitalizations for COPD exacerbations in the past year (group E)
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
What group of medications do you give for a COPD patient with 2+ moderate exacerbations or 1+ leading to a hospitalization in the past year?
Group E- LAMA + LABA or ICS + LABA + LAMA for eos 300+
What group of medications do you give for COPD pt with 0-1 exacerbations with no hospital admissions in past year?
Group A (LABA OR LAMA) or B (LABA AND LAMA)
COPD Group A tx
LABA OR LAMA
COPD Group B tx
LABA AND LAMA
COPD Group E tx
LAMA+LABA (highly symptomatic) or ICS + LABA + LAMA (eos>300)
How do you treat COPD outpatient?
O2 for at least 15 hours a day is only treatment to lengthen life.
Smoking cessation.
Vaccinations.
Bronchodilators.
Pulmonary rehabilitation.
May do sx
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?
Inhaled corticosteroids
Consider de-escalation of ICS if pneumonia or other considerable side effects. More likely to develop exacerbations if blood eos still 300+
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 those taking LABA and LAMA w or w/o ICS w exacerbations, FEV <50%, and chronic bronchitis?
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 reminds us of what characteristics?
Obesity, cyanosis, peripheral edema
Chronic bronchitis
pink puffer reminds us of what characteristics?
cachectic (wasting and weakness due to chronic illness), non cyanotic
Emphysema
How do you differentiate from chronic bronchitis and emphysema?
Symptoms - emphysema dry cough vs chronic bronchitis productive cough
DLCO - emphysema dec vs chronic bronchitis normal
Chest XR and CT - emphysema hyperinflation vs chronic bronchitis inc vascular markings
When do you admit a COPD patient?
severe symptoms that fail to respond to outpatient tx.
worsening hypoxemia, hypercapnia, edema, or AMS.
inadequate home care.
inability to sleep or maintain nutrition.
high risk comorbid conditions.
How do you manage an inpatient COPD exacerbation patient?
O2 90-94%, SABA 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 (50% of bronchiectasis!)
severe especially recurrent infections, immunodef, autoimmune, inhaling objects, idiopathic, radiation
middle age
What is bronchiectasis?
widening + scarring of airways + dysfunction of mucociliary transport mechanism –> progressive, suppurative lung disease
What would you see on a CT for bronchiectasis?
dilation >.8 bronchoarterial dilation ratio in children, >1-1.5 bronchoarterial dilation ratio in adults, mucus impaction
xray = bronchi dilation
How can you diagnose bronchiectasis?
CT scan showing bronchoarterial dilation ratio high
May also assess: bronchoscopy, PFTs, sputum cultures (for their frequent and unusual infx)
How do you treat bronchiectasis?
airway clearance techniques w/ pretreatment of bronchodilators, expectorants, humidifiers.
Antibiotics for frequent exacerbations.
Resection or transplantation of lung
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 PE 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, wheezing, accessory muscle use, dyspnea, chronic cough w or w/o sputum, weight loss
chronic bronchitis – may be obese, cyanotic, and have crackles, rales, rhonci, wheezing, chronic cough w sputum, dyspnea
name a LAMA
tiotropium
name a LABA
salmeterol, formoterol
name a SABA
albuterol, levalbuterol
name a SAMA
ipatropium
name an ICS
budesonide, fluticasone
What are the new guidelines for COPD Group A?
LABA or LAMA
What are the new guidelines for COPD Group B?
LAMA+LABA
What are the new guidelines for COPD Group E?
LAMA + LABA
LAMA + LABA + ICS w/ eos>300
