COPD Flashcards
2 main ways COPD affects the lungs
Bronchitis and Emphysema
what do we call the two main presentations of COPD? What do they correspond with?
Blue Bloaters vs Pink Puffers
<1% of COPD cases are caused by _______
Alpha-1-antitrypsin deficiency
Why are Blue Bloaters hypoxic and Pink Puffers not?
Blue bloaters have bronchitis, the mucus impedes O2 perfusion
Pink Puffers have emphysema, the don’t have as much mucus but the walls of their alveoli are being broken down. Part of their lungs start to collapse. The healthy areas can still perfuse
Thin 65yo man, dyspnea, pursed-lip breathing with accessory muscle use, not cyanotic
Pink Puffer
Large 65yo woman, dyspnea, constantly spitting up sputum, chronic cough, skin is slightly blue-tinged, smiling today upon exam
Blue Bloater
Why is hemoptysis sometimes a symptom of COPD?
blebs can rupture or alveolar capillaries may leak.
Assume cancer until proven otherwise
Do COPD pts have tachycardia or bradycardia?
Tachycardia in hopes to maintain CO for oxygenation
Why would COPD cause osteoporosis?
smoking reduces blood supply to bones. Nicotine slows prod of osteoblasts. It also decreases the body’s absorption of Ca++
PE findings?
Barrel chest, distant heart sounds, rhonchi, wheezes, cyanosis, accessory muscle use
Would a barrel chest cause high or low voltage on ECG?
low bc there’s more space in b/w heart and leads
Symp of both types of COPD?
Chronic cough, dyspnea (persistent, progressive), wheezing, cyanosis, tachypnea, tachycardia
Poss complications of COPD
MI, arrhythmias, CHF, aortic aneurysm, pulm HTN, CVA, PE, DVT (due to hypercoagulability), lung cancer
WU for COPD
#1 PFT Pulm Function Testing (spirometry)
CXR if trying to r/o others
O2 sat
ABG
Which COPD pt’s get screened for alpha-1-antitrypsin deficiency?
ALL of them (only one time req)
elevated eosinophils >300 indicates ___ in COPD pts
a good response to steroid treatment &
higher risk for exacerbations
Image screening criteria for poss lung cancer due to smoking?
Must have all to get annual CT Scans:
55-80yo
Current or former smokers (within 15 yrs)
at least a 30pk/yr hx
Once you stop smoking for ____ yrs, You hit the “reset button” for risk of lung cancer
15
You have to be at least ____yo to do a PFT
5
What does FEV1/FVC tell you? what should it be?
amnt of air you can exhale in 1 sec after a max inhale effort
norm adult ratio: FEV1/FVC >70%
How to differentiate b/w COPD and Asthma?
Asthma has a weird bronchoconstriction response to methacholine/other stimuli. COPD doesn’t
COPD doesn’t respond as well to SABA (as seen by their FEV1 <200mL and <12% change)
COPD CXR findings
hyperinflation, flattened diaphragm, incr retrosternal space
Decr vasculature and bullae in pts with emphysema bc alveoli are being destroyed)
_____ is the ONLY trmnt that REDUCES MORTALITY
Supplemental O2 to keep sats >90%
give if O2 <55mHg or sats<88%
Qs to ask pt to classify COPD symptoms
Productive cough?
Chest tightness?
shortness of breath?
affect your activity?
affect your sleep?
affect your energy?
Trmnt for Group A COPD?
SABA +/- SAMA
Trmnt for Group B COPD?
SABA + LABA or LAMA
Trmnt for Group C COPD?
SABA + LAMA
Trmnt for Group D COPD?
SABA + LAMA + LABA or
SABA + LABA + ICS or
worst case ss + eosinophils = SABA + LABA + LAMA + ICS
Which ICS is once a day instead of BID?
Fluticasone(Flovent, Arnuity), Mometasone(Asmanex), Budesonide(Pulmicort), Beclomethasone(Qvar), Ciclesonide(Alvesco)
Arnuity
ICS + LAMA + LABA combos
Brextri (Budesonide/Glycopyrrolate/Formoterol)
Trelegy (Fluticasone furoate/Umeclidinium/Vilanterol)
When to consider Roflumilast (PDE-4 inhibitor)?
if in group D and eosinophils <100
What are most common pathogens causing acute bronchitis in COPD pts?
H/ flu, Strep pneumoniae
WU of COPD exacerbation
Labs: ABG, CBC, CRP, BNP, CMP, sputum culture
O2 if spO2 <88%
CXR
EKG for dyspnea
What steroid should you Rx to pt being discharged from ER for COPD exacerbation?
Oral prednisone
Oral ABX for COPD related acute bronchitis infection
H. flu, S. pneumo. Still gotta treat like pneumonia: G +/-, atypicals coverage
Best opts: Azithromycin (Macrolide/Zpak), Levofloxacin
Others: Augmentin (amoxicillin-clavulanate), Bactrim (Trimethoprim-sulfamethoxazole), doxycycline
Inpatient ABX for COPD related infection
1) Ampicillin, Ceftriaxone (Rocephin)
2) Azithromycin (macrolide/zpak) or Levaquin (fluoroquinolone)
Indications for Assisted Ventilation (Noninvasive Positive Pressure Ventilation)
_Respiratory Acidosis_
Severe dyspnea
acidosis (pH <7.35)
Hypercapnia (pCO2 45-60mmHg)
RR 25-35 bpm
Contraindications to assisted ventilation for COPD
Mask contraindications
respiratory arrest
unstable
impaired mental status
copious bronchial secretions
extreme obesity
When to intubate during COPD exacerbation
if contraindication to assisted ventilation (noninvasive positive pressure ventilation = NPPV)
NPPV fails (worsening ABG)
Inheritance pattern of Alpha-1-antitrypsin deficiency
Autosomal, codominant
What does alpha-1-antitrypsin deficiency lead to?
Panacinar emphysema - enlarged air spaces in lower lobes due to destruction of alveolar septums (without fibrosis)
Alpha-1-Antitrypsin deficiency presentation
<45 yo, non-smoker, COPD ss (dyspnea, cough, sputum)
Liver: child w/liver failure, liver cancer, cirrhosis
Panniculitis (bumps under skin, seen in obese)
Alpha-1-Antitrypsin deficiency WU
CXR, PFT, Serum Alpha-1-antitrypsin level
Alpha-1-Antitrypsin deficiency Trmnt
treat like COPD for ss and exacerbations
Goal: serum > 50mg/dL
Rx: Zemaira IV
Alpha-1-Antitrypsin Deficiency CXR findings
green (air bronchograms from bronchiectasis)
red (Pacainar Emphysema)
