Copd Flashcards
The most characteristic symptom of COPD
Chronic and progressive DYSNEA
The FIRST SYMPTOM OF COPD
Chronic Cough
Test required to establish diagnosis of COPD
Spirometry
Consider COPD In px with dyspnea that is
PROGRESSIVE OVER TIME
Characteristically worse with exercise
Persistent
COPD chest X-ray findings:
Diaphragmatic flattening
Increase in retrosternal air space
Attenuation of vascular markings (hyperinflation)
Genetic factors that have
also been related to a decline in lung function or risk of COPD
- alpha-1 antitrypsin (AATD) 15 ;
- metalloproteinase 12 (MMP-12)
- glutathione S-transferase
How to diagnose COPD?
Spirometry is required to make the diagnosis; the presence of a post-bronchodilator FEV1/FVC < 0.70 confirms the presence of persistent airflow limitation.
The World Health Organization recommends that all patients with a diagnosis of COPD should be screened once especially in areas with high AATD diagnostic test because of its weak specificity.
Alpha-1 antitrypsin deficiency (AATD) screening
Classification of airflow limitation severity post bronchodilator:
What is the classification if FEV1> or = 80%
MILD
Classification of airflow limitation severity post bronchodilator:
What is the classification if FEV1 is 50-80%
Moderate
Classification of airflow limitation severity post bronchodilator:
What is the classification if FEV1 is 30-50%
Severe
Classification of airflow limitation severity post bronchodilator:
What is the classification if FEV1 is <30%
Very severe
What is the MMRC scale:
I only get breathless with strenuous activity
MMRC 0
What is the MMRC scale:
I get short of breath when “hurrying” on the level
Or
Walking up a slight hill
MMRC 1
What is the MMRC scale:
I walk slower than other people of the same age on the same level because of breathlessness
Or
I have to stop for breath when walking on my own pace on the level
MMRC 2
What is the MMRC scale:
I stop for breath after walking 100 meters or after a few minutes on the level
MMRC 3
What is the MMRC scale:
I am too breathless to leave the house or I am breathless when dressing or undressing
MMRC 4
is a once daily LABA that improves breathlessness, health status and exacerbation rate
Indacaterol
are additional once daily LABAs that improve lung function and symptoms
Oladaterol and vilanterol
OV
have prolonged binding to M3 muscarinic receptors, with faster dissociation from M2 muscarinic receptors, thus prolonging the duration of bronchodilator effect.
Long-acting antimuscarinic antagonists (LAMAs), such as tiotropium
aclidinium
glycopyrronium bromide
umeclidinium
also block the inhibitory neuronal receptor M2, which potentially can cause vagally induced bronchoconstriction
Short-acting antimuscarinics (SAMAs),
namely ipratropium and oxitropium
systematic review of randomized controlled trials concluded that this SAMA/ short acting muscarinic antagonist, used alone provided small benefits over short-acting beta2-agonist in terms of lung function, health status and requirement for oral steroids
ipratropium
improve symptoms and health status. They also improve the effectiveness of pulmonary rehabilitation and reduce exacerbations and related hospitalizations
LAMA treatments (tiotropium)
Main side effect of anticholinergic drugs
Dry mouth
The most commonly used methylxanthine, is metabolized by cytochrome P450 mixed function oxidases. Clearance of the drug declines with age.
Theophylline
an anatomically defined condition characterizedby destruction of the lung alveoli with air space enlargement
emphysema
a clinically defined condition with chronic cough andphlegm;
Chronic bronchitis
a condition in which small bronchiolesare narrowed and reduced in number.
small airway disease
has been demonstratedto be a hallmark of advanced COPD.
extensive small airway destruction
The major site of increased resistance in most individuals with COPDis in airways ≤2 mm diameter.
The small airways
undergo squamous metaplasia, predisposing to carcinogenesis and disrupting mucociliary clearance.
Large airways
the type most frequently associated with cigarette smoking,is characterized by enlarged air spaces found (initially) in association with respiratory bronchioles.
Centrilobular emphysema
Centrilobular emphysema is usually most prominent in what part and-is often quite focal
upper lobes and superior segments of lower lobes
refers to abnormally large airspaces evenly distributed within and across acinar units.
Panlobular emphysema
Panlobular emphysema is commonly observed in patients with α1AT deficiency,which has a predilection for the
lower lobes
occurs in 10–15% of cases and is distributed along the pleural margins with relative sparing of the lung core or central regions
Paraseptal emphysema
is the most typical finding in COPD.
Persistent reduction in forced expiratory flow rates FEV1
the total volume of air exhaled during the entire spirometric maneuver
forced vital capacity [FVC]
In contrast to asthma, the reduced FEV1 in COPD seldom shows largeresponses to inhaled bronchodilators, although improvements up to% are common.
15%
The partial pressure of oxygen in arterialblood Pao2 usually remains near normal until the FEV1 is decreased to~% of predicted, and even much lower FEV1 values can be associatedwith a normal Pao2, at least at rest.
50%
An elevation of arterial level of carbon dioxide (Paco2) is not expected until the FEV1 is _% of predicted and even then may not occur
<25%
Pulmonary hypertension severe enough to cause cor pulmonale and right ventricular failure due to COPD typically occurs in individuals who have marked decreases in FEV1 __% of predicted) and chronic hypoxemia (Pao2 __ mmHg);
FEV1 (<25% of predicted) and chronic hypoxemia (Pao2 <55 mmHg);
accounts for essentially all of the reduction in Pao2 that occurs in COPD; shunting is minimal.
Ventilation-perfusion mismatching
often described as increased effort to breathe, heaviness, air hunger, or gasping, can be insidious.
The development of exertional dyspnea
are thin and noncyanotic at rest and have prominent use of accessory muscles, pursed lip breathing, decreased breath sounds thru out the lungs
pink puffers
Predominantly emphysema
are more likely to be heavy and cyanotic , fluid retention
patients with chronic bronchitis
blue bloaters
Some patients with advanced disease have paradoxical inward movement of the rib cage with inspiration, the result of alteration of the vector of diaphragmatic contraction on the rib cage as a result of chronic hyperinflation.
Hoover’s sign
Increased hematocrit and signs of RVH on ECG
Chronic hypoxemia
Obvious bullae, paucity of parenchymal markings, or hyperlucency on chest x-ray suggests the presence of
emphysema
Increased lung volumes and flattening of the diaphragm suggest
hyperinflation
is the current definitive test for establishing the presence or absence of emphysema, the pattern of emphysema, and the presence of significant disease involving medium and Large airways
Chest computed tomography (CT) scan
subjects with low α1AT levels, the definitive diagnosis of α1AT deficiency requires
PI type determination
Only three interventions——have been demonstrated to improve survival of patients with COPD
smoking cessation, oxygen therapy in chronically hypoxemic patients, and lung volume reduction-surgery (LVRS) in selected patients with emphysema
There are principal pharmacologic approaches to quitting smoking:
- nicotine replacement therapy
- bupropion
- varenicline -a nicotinic-acid receptor agonist/antagonist.
Short-acting anticholinergic that improves symptoms with acute improvement in FEV1.
ipratropium bromide
Long acting anticholinergic there was a trend toward reduced mortality rate in-treated patients that approached statistical significance
tiotropium
Main role of ICS in COPD
Reduce exacerbation
selective phosphodiesterase 4 (PDE4) inhibitor that has been demonstrated to reduce exacerbation frequency in patients with severe COPD, chronic bronchitis, and a prior history of exacerbations; its effects on airflow obstruction and symptoms are modest.
roflumilast
administered daily to subjects with a history of exacerbation in the past 6 months demonstrated a reduced exacerbation frequency and longer time to first exacerbation
Azithromycin
is the only pharmacologic therapy Demonstrated to unequivocally decrease mortality rates in patients with COPD.
Supplemental O2
Indication for O2 supplementation
For patients with “RESTING” hypoxemia
(resting O2 saturation ≤88% in any patient
or
≤89% with signs of pulmonary hypertension or right heart failure)
Vaccines for COPD
ANNUAL INFLUENZA VACCINATION
Pneumococcal vaccination
Bordetella pertussis vaccination
Patients that are not candidates for LVRS due to increased post procedure mortality
- FEV1 <20% of predicted
- diffusely distributed emphysema on CT scan
- diffusing capacity of lung for Carbon monoxide (DLCO) <20% of predicted
are episodic acute worsening of respiratory symptoms, including increased dyspnea, cough, wheezing, and/or change in the amount and character of sputum.
Exacerbations
Strongest predictor of Exacerbations
Previous Exacerbations
Bacteria frequently implicated in COPD exacerbations include
Streptococcus pneumoniae,
Haemophilus influenzae
Moraxella catarrhalis
Mycoplasma pneumoniae
Chlamydia pneumoniae are found in 5–10% of exacerbations.
In patients admitted to the hospital, the use of systemic glucocorticoids reduces the length of stay, hastens recovery, and reduces the chances of subsequent exacerbation or relapse.
2 weeks of OCS glucocorticoid therapy produced benefit indistinguishable from 8 weeks of therapy.
Gold recommendation for OCS
Current recommendations suggest 30–40 mg of oral PREDNISOLONE or its equivalent typically for a period of 5–10 days in outpatients
Supplemental O2 should be supplied to maintain oxygen saturation of.
≥90%
The initiation of noninvasivepositive-pressure ventilation (NIPPV) in patients with respiratory failure, defined as, results in a significantreduction in mortality rate, need for intubation, complications oftherapy, and hospital length of stay.
Paco2 >45 mmHg
The mortality rate of patients requiring mechanical ventilatory support is ___ for that particular hospitalization
17–30%
For patients aged >65 admitted to the intensive care unitfor treatment, the mortality rate doubles over the next year to __%,regardless of whether mechanical ventilation was required.
60%
Following a hospitalization for COPD, about of __ % patients are re-hospitalized in the subsequent 30 days and __% are hospitalized in the next year.
20%
45%
Mortality following hospital discharge is about ___ %in the following year
20%
