COPD Flashcards
What is COPD?
a preventable and treatable disease state characterized by airflow limitation that is not fully reversible; it is progressive and associated with an abnormal inflammatory response of lungs to noxious gases like cigarette smoke
What are two diseases included with COPD?
chronic bronchitis and emphysema
Why is asthma not technically included in the new definition of COPD?
because asthma can be reversible until you reach a certain point and airflow limitation becomes chronic
What is emphysema?
defined as the presence of permanent enlargement of the airspaces distal to the terminal bronchioles accompanied by destruction of the walls of the airspaces without fibrosis
What is chronic bronchitis?
an inflammatory disease of the peripheral airways and clinically defined as chronic, productive cough for more than 3 months in each of 2 consecutive years
How many Americans currently suffer from COPD, chronic bronchitis and emphysema?
10-15 million (Gary) 24 million (Egan)
What are two of the most common risk factors that cause the development of COPD?
cigarette smoking and alpha antritrypism deficiency
What are the 4 pieces of evidence that link cigarette smoking to the development of COPD?
- symptoms of COPD are more common in smokers than nonsmokers
- impaired lung function with evidence of an obstructive pattern of lung dysfunction is more common in smokers than nonsmokers
- pathologic changes of airflow obstruction and chronic bronchitis are evident in lungs of smokers
- so called susceptible smokers, who represent 15% of all cigarette smokers, experience more rapid rates of decline of lung function than nonsmokers
What is the other name for alpha one antitrypsin deficiency?
genetic emphysema
Describe the protease-antiprotease hypothesis of emphysema
it explains the pathogenesis of emphysema in AAT deficiency but there is also evidence that suggests there are individuals with COPD who have normal amounts of AAT (which is conflicting)
What is the protective threshold of alpha one antitrypsin in the serum?
11 micromol/L or 57 mg/dl
What are the mechanisms of airflow obstruction in COPD?
- inflammation and obstruction of small airways
- loss of elasticity
- active bronchospasm
What are the common symptoms and signs of COPD?
- cough
- phlegm production
- wheezing
- shortness of breath
What are the physical examination findings of a patient with COPD?
- wheezing
- diminished breath sounds
- barrel chest
- hoover sign
_____ is usually preserved until airflow obstruction is severe (i.e. FEV1 < 1L) when it may increase
PaCO2
What are the four clinical goals for managing stable COPD?
- establish the diagnosis of COPD
- optimize lung function
- maximize patient’s functional status
- simplify medical regimen
- prolong survival whenever possible
List the features that favor the diagnosis of COPD
chronic daily phlegm production
List the features that favor the diagnosis of asthma
diminished FEV1 on spirometry can be normalized after use of an inhaled bronchodilator
What is stage I of COPD?
mild; FEV1/FVC <70% and FEV1 80% predicted
What is stage II of COPD?
moderate; FEV1/FVC <70% and FEV1 50-79% predicted
What is stage III COPD?
severe; FEV1/FVC <70% and FEV1 30-49% predicted
What is stage IV COPD?
very severe; FEV1/FVC <50% predicted plus chronic respiratory failure
Is airflow obstruction resulting from emphysema considered to be reversible?
no
What fraction of patients with stable COPD demonstrate a reversible component to airflow obstruction defined as 12% rise in the postbronchodilator FEV1?
up to 2/3
Why is bronchodilator therapy recommended for patients with COPD?
it produces smooth muscle relaxation, which results in improved symptoms and airflow obstruction
Both _____ and _____ bronchodilators can improve airflow in patients with COPD
anticholinergic; adrenergic
Other treatment options to optimize lung function include administering ______ and methylxanthines
corticosteroids
Systemic corticosteroids can produce significant improvements in airflow in a minority (_____) of patients with stable COPD
6%-29%
Controlled trials do show lessened dyspnea in _____ recipients despite lack of measurable increases in airflow
methylxanthines
What are the side effects of methylxanthines?
- anxiety
- tremulousness
- nausea
- cardiac arrhythmias
- seizures
To minimize the chance of toxicity, current recommendations suggest maintaining serum theophylline levels at ______
8-10 mcg/ml
What does acute exacerbation mean?
a sudden worsening of symptoms that lasts several days
List the strategies used to improve lung function during an acute exacerbation
- inhaled bronchodilators (especially B2 agonists)
- antibiotics
- systemic corticosteroids
List the candidacy for noninvasive ventilation
- acute respiratory acidosis
- hemodynamic stability
- ability to tolerate the interface needed for noninvasive ventilation
- ability to protect airway
- copious secretions
- massive obesity
- lack of craniofacial trauma/burns
What can be done to maximize the ability of a stable COPD patient to perform the activities of daily living?
- pharmacologic treatments
- comprehensive pulmonary rehabilitation
- transcutaneous neuromuscular electrical stimulation
What can be done to prevent the progression of COPD?
cessation of smoking
What therapy has been proven to prolong the survival of COPD patients?
supplemental oxygen
What are indications for long-term oxygen therapy?
continuous: resting PaO2 < or = 55mmHg or resting PaO2 56-59mmHg or SaO2 89%
noncontinuous: O2 flow rate and number of hours per day must be specified
Why should patients receive optimal bronchodilator therapy before being assessed for supplemental long-term continuous oxygen?
only 1/3 of potential O2 candidates can experience sufficient improvement with aggressive bronchodilation to avoid the need for long term supplemental oxygen
Why are annual influenza vaccinations and pneumococcal vaccinations indicated for patients with COPD?
patients with long term illnesses are at a high risk of developing the influenza or pneumococcal diseases
What are 2 surgeries that can be used in extreme cases for patients with end stages of COPD
lung transplantation and lung volume reduction surgery (LVRS)
According to actuarial survival studies. what percentage of patients can be expected to live for five years after receiving a lung transplant surgery?
54%
What does LVRS stand for?
lung volume reduction surgery
Can all patients benefit from LVRS?
no, patients with severe COPD should not get it
What are the benefits and difficulties of IV augmentation with alpa one antitrypsin therapy?
weekly augmentation therapy may be associated with a slower rate of decline of lung function and improved survival and also slow the rate of FEV1 decline
What is the ATS’ definition for chronic bronchitis?
based on the major “clinical manifestations” associated with the disease
What is the ATS’ definition of emphysema?
based on the pathology, or the “anatomic alterations of the lung” associated with the disorder
What are the anatomic alterations of the lungs associated with chronic bronchitis?
- chronic inflammation
- excessive mucus production
- partial or total mucus plugging
- bronchospasm
- air trapping and hyperinflation of alveoli
What are the anatomic alterations of the lungs associated with emphysema?
- permanent enlargement and deterioration of the air spaces distal to the terminal bronchioles
- destruction of pulmonary capillaries
- weakening of the distal airways
- air trapping and hyperinflation of alveoli
What are the risk factors for COPD?
- tobacco smoke
- occupational dusts and chemicals
- indoor and outdoor air pollution
- conditions that affect normal lung growth
- genetic predisposition (AAT deficiency)
What are the key indications to consider for a COPD diagnosis?
- dyspnea
- chronic cough
- chronic sputum production
- history of exposure to risk factors
What are the three main spirometry tests for COPD?
- FVC
- FEV1
- FEV1/FVC ratio
How is the presence of COPD confirmed?
when both the FEV1 and FEV1/FVS ratio are decreased
What is another name for emphysema?
pink puffer
What is another name for chronic bronchitis?
blue bloater
Clinical manifestations for emphysema
- inspection: thin body build and barrel chest
- resp pattern: hyperventilation and marked dyspnea (late stage: diminished resp drive and hypoventilation)
- pursed lip breathing common
- reddish skin
- use of accessory muscles
Clinical manifestations for emphysema continued
- auscultation: decreased breath and heart sounds, prolonged expiration
- percussion: hyperresonance
- chest xray: hyperinflation, narrow mediastinum, normal or small vertical heart, low flat diaphragm, presence of blebs
- occasional infections
- DLCO(/VA): both decreased
Clinical manifestations for chronic bronchitis
- inspection: stocky, overweight
- resp pattern: diminished resp drive hypoventilation
- cough and sputum (copious amounts) classic signs
- cyanosis, peripheral edema, right heart failure, neck vein distension
Clinical manifestations for chronic bronchitis continued
- auscultation: wheezes, crackles, rhonchi, depending on severity of disease
- chest xray: congested lung fields, enlarged horizontal heart, densities, increased bronchial vascular markings
- polycythemia and infections common
- pulmonary hypertension
- cor pulmonale common in right-heart failure
What is DLCO and when is it affected?
Diffusion capacity. It is decreased in emphysema and is a classic diagnostic sign
