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
