Chronic Obstructive Pulmonary Disease Flashcards
What can be defined as a disease state characterized by the presence of airflow obstruction due to chronic bronchitis or emphysema
Chronic Obstructive Pulmonary Disease
Is airflow obstruction associated with COPD progressive
yes
What is airflow obstruction associated with?
airway hyperactivity
How many Americans have been diagnosed with COPD?
14 million (an equal number are believed to be undiagnosed)
COPD and asthma are the ___ leading cause of death in the US, with over _____ deaths annually
4th
12,000
The death rate from COPD is increasing rapidly, especially among what patient population?
elderly men
Most patients with COPD have features of what 2 diseases?
emphysema and chronic bronchitis
What can be defined as a clinical diagnosis defined by excessive secretion of bronchial mucus and is manifested by daily productive cough for 3 months or more in at least 2 consecutive years?
chronic bronchitis
What can be defined as a pathologic diagnosis that denotes abnormal permanent enlargement of air spaces distal to the terminal bronchiole, with destruction of their walls and without obvious fibrosis?
emphysema
What is the most significant cause of COPD?
cigarette smoking
__% of COPD patients have siginificant exposure to tobacco smoke. The remaining __% have a combination of exposures to environmental tobacco smoke, occupational dusts and chemicals, and indoor air pollution from biomass fuel used for cooking and heating in poorly ventilated buildings
80
20
What are a few other causes of COPD?
- outdoor air pollution
- airway infection
- familial factors
- allergy
What hereditary factor is implicated in chronic bronchitis?
A deficiency of alpha-1-antiprotease [alpha-1-antitrypsin]
What are 2 important risks for COPD?
Atopy and the tendency for bronchioconstriction to develop in response to nonspecific airway stimulation
What does the pathogenesis of emphysema involve?
Excessive lysis of elastin and other structural proteins in the lung matrix by elastase and other proteases derived from lung neutrophils, macrophages, and mononuclear cells
Patients with COPD characteristically present in which decade of life?
the 5th or 6th
What are 3 characteristic symptoms that these patients complain of?
- excessive cough
- sputum production
- shortness of breath
Symptoms of COPD have typically been present for how long?
10 years or more
What symptoms is noted initially only on heavy exertion, with mild activity as the condition progresses, and quite possibly at rest in advanced stages?
dyspnea
As this disease progresses, what are the 2 symptom patterns that tend to emerge?
- pink puffers
- blue bloaters
What is the major complaint among pink puffers?
Dyspnea, often severe, usually presenting after age 50
What symptoms are rare in pink puffers?
Cough, with scant clear mucoid sputum
Describe the appearance of pink puffers
They are thin, with recent weight loss and appear uncomfortable, with evident use of accessory muscles of respiration.
When examining chest sounds in pink puffers what will you hear?
Typically nothing, chest is very quiet without adventitious sounds
What do pink puffer chest radiographs reveal?
Hyperinflation with fattened diaphragms
What is the major complaint among blue bloaters?
Chronic cough, productive mucopurulent sputum, with frequent exacerbations due to chest infections
Blue bloaters are typically around the ages of __ to __
30-40
Describe the appearance of blue bloaters
They are typically overweight and cyanotic, but seem comfortable at rest
What is also common in blue bloaters?
peripheral edema
When examining chest sounds in blue bloaters what will you hear?
Noisy chest, with rhonchi invariably present, wheezes are also common
Blue bloaters typically have _____ hemoglobin, ______ PaO2, and ______ PaCO2
elevated
reduced
elevated
What do blue bloater chest radiographs reveal?
Increased interstitial markings (“dirty lungs”), especially at the bases, with non-flattened diaphragm
Which pattern of COPD is associated with obstructive sleep apnea?
blue bloaters
During exercise minute ventilation is _____ in pink puffers and ____ in blue bloaters
increased
decreased
What 4 diseases characterize the late stages of COPD?
- pneumonia
- pulmonary hypertension
- cor pulmonale
- chronic respiratory failure
What is the hallmark of COPD?
the exacerbation of symptoms beyond normal day-to-day variation, often including dyspnea, an increased frequency or severity of cough, increased sputum volume or change in sputum character.
What can be used to provide objective information about pulmonary function?
spirometry
What do pulmonary function tests reveal in the early stages of COPD?
evidence of abnormal closing volume and reduced midexpiratory flow rate
Reductions in what lab values occur later on in the disease?
FEV1 and in the ratio of forced expiratory volume to vital capacity (FEV1% or FEV1/FVC ratio)
What is markedly reduced in severe cases?
forced vital capacity (FVC)
Lung volume measurements reveal a marked _____ in residual volume, a(n) ______ in total lung capacity, and a(n) ______ of the RV/TLC ratio.
increase
increase
elevation
What does an elevated RV/TLC ratio indicate?
Air trapping
What 2 blood gas abnormalities are common in late stage COPD?
- hypoxemia
- respiratory acidosis
ECG results may demonstrate what 3 things?
- sinus tachycardia
- supraventricular arrhythmias
- ventricular irritability
What do radiographs of patients with chronic bronchitis typically show?
nonspecific peribronchial and perivascular markings
What do plain radiographs show for the diagnosis of emphysema?
hyperinflation with flattening of the diaphragm or peripheral arterial deficiency in about half of cases
What imaging technique is the most sensitive and specific for the diagnosis for COPD
CT of the chest
What are 5 differential diagnoses for COPD?
- asthma
- bronchiectasis
- cystic fibrosis
- bronchopulmonary mycosis
- central airflow obstruction
How is COPD distinguished from asthma?
Asthma is characterized by complete or near-complete reversibility of airflow obstruction
How is bronchiectasis distinguished from COPD?
By recurrent pneumonia and hemoptysis, digital clubbing, and characteristic imaging abnormalities
How is cystic fibrosis distinguished from COPD?
It affects children, adolescents, and young adults
How is mechanical obstruction of the central airways distinguished from COPD?
by flow-volume loops
What 5 diseases may worsen otherwise stable COPD?
- acute bronchitis
- pneumonia
- pulmonary thromboembolism
- atrial dysrhythmias
- concomitant left ventricular failure
A spontaneous ______ occurs in a small fraction of patients with emphysema
pneumothorax
What may result from chronic bronchitis or may signal bronchogenic carcinoma?
hemoptysis
COPD is largely preventable through what?
elimination of long-term exposure to tobacco smoke
What may also help prevent COPD?
Vaccination against seasonal and epidemic influenza A (H1N1) and pneumococcal infection
What are the 7 treatment ideas for ambulatory COPD patients?
- smoking cessation
- oxygen therapy
- inhaled bronchodilators
- corticosteroids
- theophylline
- antibiotics
- pulmonary rehabilitation
What patients are particularly likely to benefit from home oxygen therapy?
Hypoxemic patients with…
- pulmonary hypertension - chronic cor pulmonale - erythrocytosis impaired cognitive function - exercise intolerance - nocturnal restlessness - morning headache
Survival of hypoxemic patients with COPD treated with supplemental oxygen is directly proportional to what?
the number of hours per day oxygen is administered
Oxygen via nasal prongs must be given for at least __ hours per day
15
For most patients a flow rate of 1-3 L/min achieves a PaO2 greater than __ mm Hg
55
Do bronchodilators alter the decline in lung function that is a hallmark of COPD? What do they do?
No, they improve symptoms, exercise tolerance, and overall health status
What are the 2 most commonly prescribed short-acting bronchodilators?
- anticholinergic ipratropium bromide
- beta-2-agonists
What are a couple examples of anticholinergic ipratropium bromide and beta-2-agonists
albuterol and metaproterenol
Which short-acting bronchodilator is typically preferred and why?
Ipratropium bromide because of its longer duration of action and absence of sympathomimetic side effects
What type of short-acting bronchodilators have a more rapid onset of action, which commonly leads to greater patient satisfaction?
beta-2-agonists
When should long-acting beta-2-agonists and anticholinergics be used?
In patients with advanced disease
What are a few examples of long-acting beta-2-agonists ?
- formoterol
- salmeterol
- indacaterol
- arformoterol
What is one example of a long-acting anticholinergic?
tiotropium
Combination therapy with an inhaled corticosteroid and what reduces the frequency of exacerbations and improves self-reported functional status in COPD patients?
a long-acting beta-2-agonist
What does theophylline do?
Improves dyspnea ratings, exercise performance, and pulmonary function in many patients with stable COPD
What do the benefits of theophylline result from?
- bronchodilation
- anti-inflammatory properties
- extrapulmonary effects on diaphragm strength, myocardial contractility, and kidney function
What is a significant concern of theophylline?
its toxicity
Antibiotics are prescribed to outpatients with COPD for what 3 indications?
1) to treat an acute exacerbation,
2) to treat acute bronchitis
3) to prevent acute exacerbations of chronic bronchitis (prophylactic antibiotics)
What are 3 pulmonary rehabilitation exercise ideas?
- Graded aerobic exercise
Training of inspiratory muscles - Pursed-lip breathing
In patients with chronic bronchitis, increased mobilization of secretions may be accomplished through the use of what?
- adequate systemic hydration
- effective cough training methods
- the use of a hand-held flutter device and postural drainage
What is available for replacement therapy in emphysema due to congenital deficiency?
Human alpha-1-antitrypsin
Severe dyspnea in spite of optimal medical management may warrant a clinical trial of what?
opioids or sedative-hypnotic drugs
What does management of a hospitalized patient with an acute exacerbation of COPD include?
- supplemental oxygen (titrated to maintain SaO2 between 90% and 94% or PaO2 between 60 mm Hg and 70 mm Hg)
- inhaled ipratropium bromide (500 mcg by nebulizer, or 36 mcg by MDI with spacer, every 4 hours as needed) plus beta-2-agonists (eg, albuterol 2.5 mg diluted with saline to a total of 3 mL by nebulizer, or MDI, 90 mcg per puff, four to eight puffs via spacer, every 1–4 hours as needed)
- broad-spectrum antibiotics
If progressive respiratory failure ensues what 2 things are necessary
tracheal intubation and mechanical ventilation
What are 3 surgery options for patients with COPD?
- Lung transplantation
- Lung volume reduction surgery
- Bullectomy
What are the 8 requirements for lung transplantation?
- severe lung disease
- limited activities of daily living
- exhaustion of medical therapy
- ambulatory status
- potential for pulmonary rehabilitation
- limited life expectancy without transplantation
- adequate function of other organ systems
- a good social support system
What is lung volume reduction surgery?
a surgical approach to relieve dyspnea and improve exercise tolerance in patients with advanced diffuse emphysema and lung hyperinflation
What is a bullectomy?
An older surgical procedure for palliation of dyspnea in patients with severe bullous emphysema
The outlook for patients with clinically significant COPD is ____.
poor
What is an important predictor of survival?
The degree of pulmonary dysfunction at the time the patient is first seen
The median survival of patients with FEV1 ≤ 1 L is about _ years
4
When should you refer a patient for hospitalization?
- COPD onset occurs before the age of 40
- 2 or more exacerbations despite optimal treatment
- Severe or rapidly progressive COPD
- Symptoms disproportionate to the severity of airflow obstruction
- Need for long-term oxygen therapy
- Onset of comorbid illnesses (such as bronchiectasis, heart failure, or lung cancer)
When should you admit a patient for hospitalization?
- Severe symptoms or acute worsening that fails to respond to outpatient management
- Acute or worsening hypoxemia, hypercapnia, peripheral edema, or change in mental status
- Inadequate home care, or inability to sleep or maintain nutrition/hydration due to symptoms
- The presence of high-risk comorbid conditions
