Chronic Respiratory Flashcards
Definition, r/t, pathology
COPD
- Common, preventable + tx disease
- Pts have persistent respiratory symptoms + airflow limitation d/t airway +/or alveolar abnormalities from exposure to noxious particles or gases
- R/t chronic airway irritation, mucus production, pulmonary scarring
- Cigarette smoke/ genetic disposition → airway inflamm → INC mucus prod → ↓ mucus function
- Leads to airway obstruction + dyspnea
- ↑ predisposition to respiratory infxns
Can you have asthma, emphysema, and chronic bronchitis?
YES
asthma + chronic bronchitis
Emphysema + chronic bronchitis
Common COPD s/s
- SOB
- Chronic cough
- May be intermittent and may be unrpoductive
- Recurrent wheeze
- Chronic Sputum production
- Any pattern of chronic sputum may indicate COPD
- Dyspnea
- Progressive over time
- Progressively worse with exercise
- Persistent
- Recurrent lower respiratory tract infections
Chronic bronchitis s/s
- ↑ swelling + mucus (phlegm or sputum) prod in airways
- Mucusy/Smokers cough
- Results in chronic productive cough for 3 mos in each of 2 successive years
- Wet, chronic cough
Emphysema s/s
- Destruction/ damage to lung parenchyma/alveol to air trapping in lungs
- Reduces SA for gas exchange
- Dry cough
- SOB
Intra + extrathoracic
COPD differentials
Intrathoracic
* Asthma (if condition improves with fast acting bronchodilator)
* CHF
* Malignancy (smokers)
* TB
* Post-infectious process
* Interstitial lung disease
Extrathoracic
* Chronic rhinitis – feel like I have to clear my throat all time (chronic cough)
* GERD (chronic cough)
* Post-nasal drip syndromes
* Medications (ACEi)
COPD diagnostics
GOLD standard
categories FEV1
- Spirometry required to establish dx
- FEV1:FVC ratio must be < 0.7 in post bronchodilator test (in asthma, breathing improves after this test)
- Classification of severity determined by FEV1 (for tx)
Look at severity + s/s assessment
COPD diagnostics excluding spirometry
- O2 saturation (esp in chronic)
- CXR (not dx but helpful to r/o diffs)
- Chest CT – only if dx is in doubt
- CBC, BMP, ABG, EKG
- ↑ Hgb + HCT to compensate (extra RBCs to tissues) polycythemia (end stage)
- Alpha-1 antitrypsin deficiency screening: 1x screening 4 all pts
- Screen pts who develop COPD < 45 y.o. or strong FMHx of COPD
- Can see in elev, liver disease
- Usually dx ppl w/COPD >50yo
Stable COPD pharm txs
- Bronchodilators: mainstay tx
- Short-acting
+ SABA: albuterol (PRN)
+ SAMA: Ipratropum (PRN/4x a day)
+ Both effective in improving lung fx - Long-acting (can be used independently)
+ LABA: Salmeterol/form (BID)
+ LAMA: Triotropium (QD)
+ Both sx control, LAMAs > on reducing exacerbations
+ think about pt preference, cost, SEs - Theophylline
+ Rarely used d/t narrow therapeutic index + SEs
Antimuscarinics: think anticholinergic SEs
COPD pharm txs 3rd line/other tx options
INH corticosteroids 3rd line tx in COPD
* Not monotherapy (INC PNA risk)
- Use these in pts w/serum eosinophils elevated
- Hx of hospitalizations for COPD
- >/= 2 mod exacerbations of COPD/yr
- Hx of, or concomitant asthma
* Triple therapy (OCS + LAMA + LABA)
- Dose: 1 puff daily
- HIGH COST for each, this is cost alternative
Additional options
* Phosphodiesterase inhibitos
- Roflumilast – once daily PO therapy for bronchitis associated COPD
- Reduce inflammation
- Not recommded as monotherapy
* PO glucocorticoids
- Used to tx acute exacerbations
- Long term O2 therapy
ONLY therapy for COPD shown to ↓ mortality
+ Goal: correct hypoxemia (PaO2 > 60 or SpO2 > 90)
+ Increased survival, prevent progression of pulm HTN, improves alertness, motor speed, + hand grip
COPD nonpharm tx #1?
smoking cessation
COPD nonpharm txs (other)
- Lifestyle modifications, ID + avoiding RFs, advanced directives
- Education
- Disease course, prognosis
- Preventative measures avoiding URI, flu, + PNA vaccines
- Importance of physical activity
- Breathing exercises
- Med use: when + how
- When to seek tx
(↑ color/amt sputum; ↓ fx ability; ↑ SOB; fever) - Nutrition
COPD when to refer
- Stage IV
- Disease onset < 40yrs
- Frequent exacerbations (2+) despite optimal tx
- Need for O2
- Onset of co-morbid illness
- Possible indication for surgery
COPD risk factors
- Host factors
- Tobacco
- Occupation
- Indoor/outdoor pollution
- AAT deficiency raises your risk for lung + other diseases (dx at early age)
- FMHx of COPD: low birthweight, childhood respiratory infxns etc.
Overall COPD Maangement algorithm
- Confirm DX w/ spirometry
- Evaluate severity based on GOLD category (FEV1)
- Evaluate sx + risk for exacerbation
- Various tools available
- Determine GOLD group (A, B, C, D)
- Make pharm tx
Goals of COPD therapy
- Inhaler teaching
- Intervention shown t improve QOL
- Components
- Upper + lower ext conditioning
- Exercise/endurance training
- Breathing retraining + adaptive mechanisms
- Nutrition
- Med adherence
- Psychological support
Acute COPD exacerbations
Triggers
- Respiraotry infxns trigger ~70% of exacerbations
- viral or bacterial
- Environmental pollution
- allergies
- PE (pulm effusion)
- Unknown etiology
Acute COPD clinical s/s
- Acute onset or worsening of respiratory sx (over several hrs – days)
- Dyspnea
- Cough
- Sputum prod
Acute COPD objective findings
- Wheezing
- Tachypnea
SEVERE - Difficulty speaking d/t respiratory effort
- Use of acc. Mm
- Paradoxical chest wall/abd movements
When to consider alternative dx from acute COPD exacerbation?
- Constitution sx (fever, malaise)
- Chest pain/ pressure
- Edema
- Crackles on exam
- Risk for embolic disease/ coronary event
Acute COPD exacerbation differentials
- PNA
- PTX (COPD RF)
- CHF (Pleural effusion)
- Cardiac arrhythmia
- PE (pulm embolism)
Acute COPD exacerbations diagnostics
- Mild: Clinical assessment + SpO2
- Mod-severe
- Consider ED referral depending on setting + severity
- CXR
- CBC/BMP
ABG (if in ED w/resp failure)
- Labs to r/o other dxs
- EKG, BNP, troponin, D-dimer, influenza/ covid/infxn etiology
Acute COPD pharm txs
- Bronchodilator therapy – ↑ dose/ frequency of existing therapy
- Add anticholinergic if not already used
- Nebulizer can be helpful
- Albuterol, atrovent
- Steroids – consider in mod/severe exacerbation – breathlessness interfering w/daily activities
- PO prednisone 40mg x 5days
- ABXs – recommended in outpts w/mod cough or severe exacerbation of COPD who have ↑ cough + sputum purulence (GOLD guidelines)
- Target likely pathogens (H. influenzae, M. catarrhalis, + S. PNA)
When to consider hospitalization for acute COPD
- Marked ↑ in tensity of s/s such as sudden resting dyspnea
- Severe underlying COPD
- New physical signs (cyanosis, peripheral edema)
- Failure to respond to initial management
- Significant co-morbidities
- Hx of frequent exacerbations/ hospitalizations
- DX uncertainty
- Frailty
- Insufficient home support
Acute COPD RFs
- Adv age
- Prod cough
- Duration of COPD
- Hx of abx therapy
- COPD related hospitalization w/in last yr
- Serum eosinophil count > 300
- Theophylline therapy
- Chronic mucus hypersecretion
- Co-morbidities (ischemic heart disease, chronic heart failure, DM)
- Severity of COPD + hx prior exacerbations
Post-hospitalization F/U post-acute COPD
- Ability to cope in usual environment
- Measure FEV1 (check after exacerbation for baseline)
- Understanding of tx regimen
- INH technique
- Need for LTOT for pts w/severe COPD
- Consider Pulm rehab
- Think about palliative care in severe disease
Assess Readiness to change (5 As)
- Ask – ID all tobacco users
- Advise patient to quit, using clear, strong, and personalized messages
- Assess patient’s willingness to make a quit attempt in next 30 days
- Assist in developing quit plan (date to quit, meds, behavioral changes)
- Arrange a F/U contact
- F/U on or after quit date
Meds for smoking cessation
-
Bupropion (welbutrin/Zyban)
- Contraind. for ppl who had seizure in their life
- Also antidepressant
- Appetite suppressant
- ↑ anxiety (not for smokers triggered by anxiety)
-
Varenicline (Chantix)
- Better for quitting smoking
- Nausea common SE, vivid dreams, ↑ SI/depression
- Nicotine replacement therapy
- Gum, patch, lozenge, nasal spray
- Electronic nicotine delivery services – vaping (not the best option)
- Supportive resources
- Quitline, apps, etcs
Smoking cessation quit plan
- Set quit date (can be significant holiday/date)
- Tell family + friends to gain support
- Around ppl who smoke (influence)
- Pt dependent
- Remove all cigarettes + related objects out of house
- Review past quit attempts + anticipate challenges
- Anticipate triggers
- Provide support
- Recommend pharm therapy
Common smoking habit triggers
- Can be a/w a social event or routine thing
- Coffee in AM
- Get together with friends
- Stress induced
- Instead of using cigarette/ put something else in hand (healthy food)
Popcorn lung
- Bronchiolitis obliterans
- Damage + inflamm of bronchioles → scarring
- Vapes contain diacetyl (same ingredient in microwave popcorn but INH)
Why are vapes not a good thing?
What if person is hesitant to quit smoking d/t weight?
- Hesitant to quit b/c of weight gain
- Snack on something while quitting
ENDS – vaps
- Snack on something while quitting
- Thought to be safer d/t lack of tobacco + tar
- Still contains volatile substances
- Nicotine levels are variable (could be more)
- Often used as method to quit or cut down on cigarette smoking
- Not approved, Limited evidence, Harm reduction, Dual use issue
- Youth use e-cigs more
- Screen this separately
- May not consider vaping smoking – be specific
Etiology, Transmission, active/dormancy
Tuberculosis
- Caused by mycobacterium TB
- Transmissible by airborne droplets from pts w/active respiratory disease
- Disease can be active any time
Latent TB
Latent
* Initially controlled by host defenses + remains latent
* Pt not infectious when disease is latent
* Has potential to become active infxn at any time
* Immune system able to keep TB at bay
Active TB
Clinical findings
- 80% of active TB infxns initially latent
- Cough
- Hemoptysis
- Weight loss
- Fever
- Night sweats
(+) Tb + has these = active
Would you give someone w/ previously (+) TB a TST test?
Why?
NO
Pt will get a reaction
What? Purpose to detect positive
Tuberculin Skin Test (TST)
Test has greater risk of exposure, ↑ positive predictive value (likelihood of true +)
- (+) IF ≥ 5mm
- PPD (Purified Protein Derivative)
- Mantoux technique (Intradermal INJ in inner forearm)
- Causes a hypersens rxn in persons previously exposed to M. TB
- Must be read 48-72hrs after placement
+ Measure indurated area
If TST (-) → repeat testing indications
-
If (-), repeat testing is indicated if:
+ Exposure to active Tb within the last 8 weeks
+ Continued occupational exposure-annual testing
+ Two Step testing/ “booster phenomenon”
(initial test reignites response to TB → another test 6wks later (+) b/c exposed long ago)
TB screening: IGRA
Confirm (+) TST
* Interferon gamma release assay (IGRA)
- Indicates a cellular immune response
- Blood test – 2 different assays available
+ QuantiFERON + T. SPOT
- Can be used in place of TST
* Conversion generally occurs w/in 4-7wks of exposure
* Lower false (+) rate than TST
- > 95% specific (low false +); sensitivity (high false negative) diminished by HIV infxn
Persons w/BCG vaccine
Which test to detect that they have it?
Time estimate for person to be (+) w/this
- Those vaccinated in last 10yrs will most likely have a (+) TST after 10yrs, rxn typically < 10mm
- Use of IGRA testing can help determine a true positive in those w/hx of BCG vaccination
Indication for BCG vaccine
- In countries where prevalence of TB is moderate to high, neonatal vaccination is recommended
- With low prevalence, not recommended
Preferred treatment for TB
Rifampin
* Better adherence + less hepatotoxic than INH (4 mos tx)
INH tx TB
- INH can cause hepatitis + peripheral neuropathy
- Check LFTS regularly
- Consider pyridoxine supplementation to help prevent neuropathy
Active TB pharm txs
- 4 regimens available + complex
- DOT (directly observed therapy)
- Someone observes them taking meds every time
- Do this to be compliant
- Long duration
- Drug resistant TB
- Need to finish full tx
- DOT (directly observed therapy)
- Tx done by ID or TB clinic
- Pts should minimize contacts + use surgical mask recommended until non-infections
Multi-drug resistant TB pharm tx
if TX fails?
- DOT recommended/required
- Susceptibility testing should guide tx
- Surgery considered for tx failure
Tx goal for TB
catch ppl w/latent TB + tx early on preventing spread of TB in community
Who should be screened for TB?
- Persons at ↑ risk of new infxn – all should be screened
- Close/casual contacts of persons w/untreated active tB
- Illicit drug users
- Residents or employees of homeless shelter/correctional facility
- Healthcare workers in some situations
Latent TB infection screening (who?)
Aka risk for disease progression
High, moderate, low risk
- High risk (test all)
- HIV/immunocompromised
- head/neck cancer
- lymphoma
- leukemia
- renal failure on dialysis
- evidence of healed TB on CXR
- Moderate risk (test patients in groups with increased prevalence)*
- DM
- chronic systemic glucocorticoids
- Slightly increased risk (test patients in groups with increased prevalence):
- underweight
- smoker
- CXR with solitary granuloma
- Groups with increased prevalence
- homeless
- IVDU
- contact with active TB
- those born in countries with increased TB incidence (>100/100,000)
* Screening of low-risk persons is discouraged due to risk of false positive results
* Routine screening of all HCP is no longer recommended
Interpretation of TST
TB test (+), now what
- +/- order confirmatory testing
- Must rule out active TB prior to initiating treatment
- Clinical history and physical exam for any s/s of TB
- Order a CXR
- If any abnormalities patient will require sputum acid fast bacillus smears
* Tx is different in active vs latent disease
- If any abnormalities patient will require sputum acid fast bacillus smears
- Refer to ID for management
- Consider HIV testing
TST vs. IGRA
preference?
- If low-intermediate risk of progression to active disease: IGRA preferred (fewer false positives)
- If** high risk **of progression: either is acceptable
- IGRA especially useful if pt unlikely to return for reading of TST and for those with a hx of BCG vaccine
- If IGRA unavailable or too costly then TST is acceptable
Refined ABCD assessment tool stable COPD
USPSTF lung cancer screening recommendation
- Annual screening for lung cancer with **low-dose CT **in adults aged 50 to 80 years who have a 20 PPY smoking Hx + currently smoke or have quit w/in past 15 yrs.
- Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery
Harms of lung cancer screening
- Risk for false(+) results +
- Risk forincidental findings → cascade of testing + tx → more harms, including anxiety of living w/lesion that may be cancer
- Overdx of cancer + risk of radiation
