Chronic Respiratory Flashcards
What is COPD?
Common, preventable and treatable disease characterized by persistent respiratory symptoms and airflow limitation due to small airway/alveolar abnormalities (obstructive bronchiolitis) and parenchymal destruction (emphysema)
Caused by significant exposure to noxious particles or gases
4th leading cause of death worldwide (3rd by 2020)
May be punctuated by periods of acute worsening which are called exacerbations
Associated with significant concomitant chronic diseases which increase its morbidity and mortality
What are risk factors for developing COPD?
Main risk factor = smoking but may be other environmental exposures
Other: genetic abnormalities, abnormal lung development, accelerated agingIndoor air pollution
Occupational exposures
Genetic: Alpha 1 antitrypsin deficiency
Age
Chronic bronchitis
Childhood infectionsGender: female
Lung growth and development during gestation and childhood
Socioeconomic: exposure, crowding, poor nutrition, infections
Asthma
ROS for COPD
Assessment of symptoms
Severity of breathlessness, cough, sputum production, wheezing, chest tightness, weight loss or anorexia
Change in alertness or mental status, fatigue, confusion, anxiety, dizziness, pallor or cyanosis
COPD should be considered in any patient with a chronic cough, dyspnea or sputum production or history of exposure
Medical History Questions for COPD
Medical History Allergies Sinus problems Other respiratory disease Risk factors Exposures (occupational and environmental) Family history Co-morbidities that may affect activity Medications Prior hospitalizations or evaluation to date
COPD Evaluations
Vital Signs
Respiratory rate, pattern, effort
Pulse oximetry
Extremities
Inspection for cyanosis
Chest
Inspection to assess AP diameter (barrel chest)
Palpation and percussion of chest
Lungs
Auscultation for wheezing, crackles, and/or decreased breath sounds Note effort of breathing; signs below suggest increased effort
Use of accessory muscles - sternocleidomastoid, pectoralis minor
Arms braced on knees or table
Difficulty speaking in full sentences
Pursing of lips
Nasal flaring
Paradoxical abdominal breathing
Sweating
Assess for cyanosis
Central - look at lips, oral mucosa and tongue
Peripheral - nails, hands and feet
Chest wall deformities or asymmetries of shape or movement
Increased Anterior-Posterior (AP) diameter (barrel chest)
Intercostal, subcostal and supraclavicular indrawing
Tracheal position and presence of a downward tug
Decreased inspiratory range with hyperinflated lungs of COPD
Tactile fremitus - decreased in COPD
Percuss anterior and posterior, comparing left to right – hyper-resonance with COPD
Listen to each of the five lung lobes and compare findings between sides
Air entry - decreased in COPD
Adventitious sounds
Wheezes, crackles, other
Generalized versus localized
Volume - Loud versus soft
The differential diagnosis of COPD should be considered in patients who present with which of the following symptoms? Chronic cough Any sputum production Dyspnea Increased sputum production All of the above
Patients with COPD most commonly present with dyspnea, chronic cough or sputum production. Although none of these symptoms alone is diagnostic of COPD it should be included in the differential in any patient with these symptoms. Those patients who smoke, are over 40 yrs of age and have more than one of these clinical indicators of chronic lung disease are more likely to have COPD. By suspecting COPD in patients with undifferentiated symptoms the diagnosis may be made at an earlier stage in the disease when interventions are more likely to help.
Pulmonary DDx for COPD
Asthma Bronchogenic carcinoma Bronchiectasis Tuberculosis Cystic fibrosis Interstitial lung disease Bronchiolitis obliterans Alpha-1 antitrypsin deficiency Pleural effusion Pulmonary edema Recurrent aspiration Tracheobronchomalacia Recurrent pulmonary emboli Foreign body
Non-pulmonary DDx COPD
Congestive Heart Failure Hyperventilation syndrome/panic attacks Vocal cord dysfunction Obstructive sleep apnea – undiagnosed Aspergillosis Chronic Fatigue Syndrome
Asthma as DDx for COPD
Asthma is the most common alternative diagnosis that mimics COPD is asthma. Others can mimic COPD due to the overlap in symptoms and physical findings.
By taking into account the clinical characteristics and epidemiological factors the differential may be narrowed down.
Studies that may help in Dx COPD
Chest X-ray (SOR: C) Spirometry (SOR: C) Arterial blood gas (SOR: C) Alpha-1 antitrypsin levels (SOR: C) High resolution CAT scan of chest (SOR: C)
How does spirometry assist with dx COPD?
Gold standard for diagnosis
Standard to establish severity and stage
Perform both pre- and post-bronchodilator
Irreversible airflow limitation is the hallmark of COPDGold standard for diagnosis
Standard to establish severity and stage
Perform both pre- and post-bronchodilator
Airflow limitation that is not fully reversible is a hallmark of the disease
In severe persistent asthma airflow limitation may not be fully reversible as well but most other diagnoses have characteristic spirometry features that distinguish them from COPD.
All patients should be evaluated with spirometry to establish the diagnosis per international guidelines.
Without spirometry it is very difficult to distinguish older adults with asthma from those with COPD.
Home lung function tests are marketed on the internet but are not established to make the diagnosis of COPD, but rather are useful for monitoring asthma condition.
GOLD Criteria for diagnosis COPD
diagnosis of COPD is based on symptoms and spirometry:
Symptoms and exposure to risk factors are not diagnostic in themselves but should prompt spirometry in pts >40 yrs of age
Diagnosis should be confirmed by pre- and post-bronchodilator spirometry
Key factors in the report are age and the need for spirometry, younger patients should be considered for other diagnoses that occur more often in their age groups – but they are not necessarily excluded from having COPD
What is the appropriate technique for spirometry?
Acceptable spirometry testing needs to be conducted three times by an acceptable and reproducible method for determining forced vital capacity (FVC).
The bronchodilator test is a method for measuring the changes in lung capacity after inhaling a short-acting bronchodilator drug that dilates the airway.
When an obstructive ventilatory defect is observed, this test helps to diagnose and evaluate asthma and COPD by measuring reversibility induced by the bronchodilator drug.
A positive response is defined as an increase of ≥12% and ≥200 mL as an absolute value compared with baseline in either FEV1or FVC.
Dyspnea in COPD
Dyspnea Progressive (worsens over time) Usually worse with exercise Persistent (present everyday) Described by the patient as an “increased effort to breathe,” heaviness,” “air hunger,” or “gasping.”Progressive, usually worse with exercise, persistent, described as increased effort to breathe
Chronic cough in COPD
May be intermittent and may be unproductive
Chronic Sputum production in COPD
Any pattern of chronic sputum production may indicate COPD
History of exposure to risk factors in COPD
Tobacco smoke, occupational dust, chemicals, fumes or smoke from cooking or heating fuels
Key indicators for COPD
Dyspnea
Chronic cough
Chronic sputum production
History of exposure to risk factors
Spirometry classifications for COPD GOLD 1 (mild)
FEV1 >80% of predicted
Spirometry classifications for COPD GOLD 1 (moderate)
FEV1 50-<80% of predicted
Spirometry classifications for COPD GOLD 1 (severe)
FEV1 30-<50% of predicted
Spirometry classifications for COPD GOLD 1 (very severe)
FEV1 <30% of predicted
What are some questionnaires that assist with dx COPD and what do they assess for?
Utilized to assess the severity of individual symptoms.
The Modified British Medical Research Council (mMRC) questionnaire is used to determine the health status of a patient by assessing physical limitations due to shortness of breath.
The COPD Assessment Test (CAT) questionnaire is utilized to assess a patient’s quality of life with COPD.
Current guidelines recommend the mMRC or CAT questionnaire as a tool to assess symptoms.
COPD Staging assessment tool “A”
Low RIsk, less symptoms, mMRC 0-1, CAT <10, 1-2 exacerbations per year
COPD Staging assessment tool “B”
Low risk, more symptoms
CAT >10, mMRC >2 exacerbation history 0-1 per year
COPD Staging assessment tool “C”
High risk, less symptoms 3-4 exacerbations per year
COPD Staging assessment tool “D”
High risk, more symptoms > 2 exacerbations per year
CAT >10, mMRC >2
treatment hallmarks for COPD
Smoking cessation is key
Effectiveness of e-cigarettes uncertain
Meds can reduce symptoms, exacerbations, improve exercise tolerance
Meds should be individualized
Inhaler technique- check frequently
Influenza and pneumococcal vaccines decrease lower respiratory tract infections (PCV13 and PPSV23 >65 or younger with co-morbid)
Pulmonary rehab improves symptoms and QOL
Oxygen improves survival for those with severe resting hypoxemia
Long-term oxygen treatment should NOT be prescribed for those with stable COPD and resting or exercise-induced moderate desaturation
In patients with advanced emphysema refractory to optimized medical care, surgical interventions nay be helpful
Palliative approaches are effective in controlling symptoms
Pharm treatment for COPD
Select depending on patient’s individual response, tolerability, and availability
GOLD- stepwise approach
Options: bronchodilators or anti-inflammatory agents
Bronchodilators for COPD
Mainstay of treatment
Short-acting or long-acting anticholinergics/antimuscarinics (SAMAs or LAMAs)
Short or long-acting beta2 agonists (SABAs or LABAs)
Beta2 agonists relax smooth muscle to promote bronchodilation
LABAs and and anti-cholinergics preferred over short-acting formulations (reduce exacerbations)
Dual therapy common and shown to improve symptims
Methylxanthines for COPD
Controversy regarding effectiveness
Theophylline clearance declines with age
Risk versus benefit as small therapeutic window
anti-inflammatory therapy for COPD
Inhaled corticosteroids (ICS) used to treat moderate-severe disease
Used in combination with long-acting bronchodilator (LABA)
Many RCTs that ICS use associated with higher prevalence of oral candidiasis, hoarse voice, skin bruising, and pneumonia
Oral glucocorticoids play a role only in acute management of exacerbations
Oral glucocorticoids for acute management for COPD
acute management
60 mg taper down
burst of 20 mg
Other medications for management of COPD
PDE-4 inhibitors (Rofluminast) oral- shown to reduce exacerbations but high side effect profile including mood disturbance, weight loss, and suicidal ideation
Mucolytics help with reducing exacerbations and improve QOL
Stage A COPD Pharm tx
1st line: SABA/SAMA PRN
2nd line: LAMA or LABA or SABA + SAMA
Stage B COPD Pharm tx
1st line: LAMA or LABA
2nd line: LAMA + LABA
Stage C COPD Pharm tx
1st line: ICS + LABA or LAMA
2nd line: LAMA + LABA or
LAMA + PDEi or
LABA + PDE4i
Stage D COPD Pharm tx
1st line: ICS+ LABA and/or LAMA 2nd line: ICS + LABA and LAMA or ICS + LABA and PDE4i or LAMA + PDE4i
what are COPD exacerbations and how should they be treated?
Acute worsening of symptoms that requires additional therapy
Most common cause: respiratory infections
SABAs recommended as initial with LABA before hospital discharge
Systemic steroids and oxygen can improve FEV1 (5-7 days)
Antibiotics can shorten recovery time
Non-invasive mechanical ventilation should be 1st mode
Review exacerbation prevention measure
what is asthma
Definition: A disease with many variations, usually characterized by chronic airway inflammation.
Two key features: 1) A history of respiratory symptoms such as wheeze, shortness of breath, chest tightness, and cough that vary over time AND
2) Variable expiratory airflow limitation.
If well-treated airflow limitation should be completely reversible
Long-standing, inadequately controlled may lead to permanent airflow obstruction indistiunguishable from COPD
name some variable respiratory symptoms associated with asthma
Wheeze, SOB, chest tightness, cough Generally more than 1 of these symptoms Vary in frequency and intensity Worse at night or on waking Triggered by exercise, laughter, allergens, or cold air Worsen with viral infections
what are spirometry findings with asthma?
At least once during diagnostic process when the FEV1 is low, document that the FEV1/FEV ratio is normally more than 0.75-0.80 in adults and more than 0.90 in children.
The greater the variation, or the more times excess variation is seen, the more confident you can be of diagnosis.
Testing may need to be repeated when patient symptomatic, such as early morning or after withholding bronchodilators
what are key indicators/diagnostic criteria of asthma?
Cough, worse particularly at night
Recurrent wheezing, chest tightness or difficulty breathing
Wheezing on physical examination
Symptoms that occur or worsen in presence of known triggers
Symptoms that occur/worsen at night
what does obstruction reversibility mean in terms of spirometry?
Reversibility is defined as >12% increase in FEV1 from baseline
(after using SABA)
what should be included in the physical exam when assessing for asthma?
Gen: vital signs, HR and RR, use of accessory muscles, nasal flaring, diaphoresis, cyanosis, hyperexpansion of the thorax – hunched shoulders
HENT: Increased nasal secretions or nasal polyps, allergic shiners
Resp: wheezing sounds during normal breathing – may be absent between attacks
Skin: Atopic dermatitis, eczema, or other allergic skin conditions
Perform cardiac exam and note mood (anxiety), GI upsets
Do: Incentive spirometry - demonstration and good coaching is essential!
http://www.youtube.com/watch?v=lWHx31BquBA
Record height/weight/race
Need 6 seconds exhalation minimally
what might you include in your differentials for asthma?
cardiac, sarcoidosis, GERD, airway obstructions/tumors
what are 5 things to assess alongside spirometry results?
Is the flow volume curve a sailboat?
Is the FEV1(second)/ FVC ratio > 70% - normal (< = obstructive)
Is the FEV1 more or less than 80% predicted? FEV1 = severity of disease
Is there reversibility? Reversibility of FEV1 (if 20% suggests a diagnosis of asthma and with COPD there is not reversibility).
Of note: restrictive lung disease is either intrapulmonary (sarcoidosis or extrapulmonary – kyphosis)
what is spirometry used for in asthma management, and when should you do it?
Recommend at time of diagnosis to determine baseline and reversibility, after treatment started, with
exacerbations, to determine treatment effectiveness, and
every 1 – 2 years to monitor airway function
what is “Peak Flow” how do you perform it, and what is it used for?
Used to monitor lung function/ personal best not to confirm diagnosis
Instructions: Standing, take deep breath, close lips around mouth piece and exhale hard & fast
Perform 3 times and record the best of the three blows
how are asthma and COPD similar?
COPD & Asthma both are major epidemiologic causes of chronic obstructive airway disease.
Both involve underlying airway inflammation.
Both can cause similar chronic respiratory symptoms and fixed airflow limitation.
Both can co-exist with the other making diagnosis more difficult.
how does using a peak flow meter at home help manage asthma?
Provides objective data to assist management
Documents “personal best” and variability
Detects impending exacerbation
Guides stepping up and down asthma action plan
Helps to identify triggers
peak flow is 80-100% personal best, what does that mean?
All clear – no symptoms and routine treatment plan
peak flow is 50-80% personal best, what does that mean?
Caution: could be acute exacerbation or overall asthma not under good control, probable need to increase medication
peak flow below 50% personal best, what does that mean?
Medical Alert take bronchodilator immediately and seek help
step 1 asthma, what is it, how to manage?
Mild intermittent
As needed SABA
Indicated only if symptoms are rare, there is no night waking due to asthma, no exacerbations ion last year, and normal FEV1
Other options: regular low dose ICS for patients with exacerbation risks
Examples: Albuterol MDI, Ventolin, Proventil
Side effects: Tachycardia
Can be used before exercise
step 2 asthma, what is it, how to manage?
Mild persistent
Regular low dose ICS plus PRN SABA
Leukotriene tabs: Singulair
For purely seasonal allergic asthma, start ICS immediately and cease 4 weeks after exposure
step 3 asthma, what is it, how to manage?
Moderate persistent
Refer to specialist
Low dose ICS/LABA either as maintenance treatment plus PRN SABA
Examples: Advair low dose 100/45
step 4 asthma, what is it, how to manage?
Severe persistent Should be referred to specialist Medium dose ICS/LABA SABA PRN May add oral corticosteroid
when should you follow up with a patient with asthma?
1-3 months after starting treatment
After exacerbation: 1 week
Variable condition that may warrant stepping-up or stepping-down therapy
what is a spacer and how does it work?
MDIs
10-20% of MDI dose reaches the lungs
80-90% of dose is swallowed
Majority of systemic side effects, i.e. shakiness, irritability (reducing medication compliance) comes from medication entering the GI tract
Spacer device increases the amount that reaches the lungs, which results in less systemic SE
what are the differences between asthma and COPD?
Asthma – Differences from COPD
Underlying immune mechanism of chronicinflammation different
Age of onset
Earlier in life with asthma
Usually > age 40 in COPD
Symptoms in asthma vary; COPD slowly progressive
Smoking associated with COPD
Asthma with reversible airflow limitation; irreversible airflow limitation in COPD
*The immune mechanisms are complex and can only be seen on lung/bronchial biopsies. However, they are crucial to the understanding of the two conditions and play a significant role in the clinical picture and response to therapy so they must be emphasized along with the other less specific historical/clinical findings.
Asthma vs COPD spirometry findings
Using spirometry to differentiate from COPD
Post-bronchodilator FEV1 <80% predicted together with FEV1/FVC <0.70 confirms airflow limitation that is not fully reversible
Asthma may show similar changes in chronic and more severe cases; PFT’s may be needed to distinguish it from COPD
What are the potential reasons for a positive PPD?
+PPD means you have sensitized lymphocytes, infection, but not necessarily disease
Latent TB: +PPD, absent physical findings of disease and normal chest x-ray or not active disease
TB disease: person w/ infection w/ signs, symptoms and x-ray findings appearing to be caused by M. tuberculosis
what is the cause of TB?
Mycobacterium tuberculosis vs atypical mycobacterium
Most commonly infects lungs
when assessing for TB, what should you ask about?
History: country of origin, HIV, substance use; TB exposure; dates/results PPD
signs/symptoms of TB?
Signs/symptoms: sputum (purulent or some hemoptysis), night sweats, afternoon fevers, chest pn
physical findings of TB?
Physical findings: Apical rales, May have positive nodes w/ hilar lymphadenopathy, pleural effusion may be only abnormality
TB DDx
Malignancy Pneumonia Bronchiectasis Asthma COPD Silicosis
Diagnostic tests for TB
Screening Tuberculin skin test (TST) Readings positive or negative OR Interferon-gamma release assays (IGRAs) When to test after exposure to TB HIV + many false negative readings
are pulmonary function tests useful in assessing TB?
Nope!
what could be seen on a chest radiograph with TB infection?
infiltrate nodular lesions hilar adenopathy cavitary lesions granulomas
what are some recommended testing with TB diagnosis?
chest radiography
sputum AFB (acid fast bacillus) culture
PPD
sputum cultures confirm diagnosis
how do you read a PPD
induration, not erythema
depends on risk factors
15mm general population
10mm higher risk –> from country with higher risk, nurse, nursing home
5mm –> immune compromise, HIV+, recent exposure to active TB
what causes false positive PPD
BCG vaccine
Repeated tests
After exposure to “atypical” mycobacteria (i.e. HIV)
What could cause false negative PPD
A person recently infected with TB
Elderly
Debilitated
Immunocompromised (e.g., AIDS) patients
what is treatment for TB
Multiple oral medications - managed by infectious disease
Rifampin
INH
Ethambutol
Duration of combined therapy = 9 months
Incubation ends after 2-3 weeks of Rx
MDR – TB – may need additional drugs and Rx for 1 year
Liver toxicity – most serious side effect of drugs
Other side effects:
Hearing loss
Vision loss
