COPD Flashcards
Difference between chronic bronchitis and emphysema
bronchitis = central areas
emphysema = terminal airway of bronchioles and alveoli
Explain how tobacco leads to COPD-Emphysema
fill in
pathophys of COPD-chronic bronchitis
inflammation stops airway d/t smooth muscle hypertrophy
How many etiologies of COPD are there?
MANY, treat differently
chronic bronchitis vs emphysema clinical presentation
Blue bloater
Male patient
Overweight
Cyanosis
Emphysema: thin patients, barral chest chest, muscle wasting, sickly
What are the three historical symptoms ESSENTIAL for dx COPD?
Coughing (often accompanied by increased effort to breathe, air hunger, gasping, and wheezing)
Dyspnea (air trapping and airflow limitation result in progressive exertional shortness of breath - ask if this limited activity)
Sputum production: excess mucus
Why can you have weight gain or loss in COPD?
Muscle wasting from COPD
Weight gain = more sedentary, activity limitation
What are the associated symptoms of COPD that are sometimes seen in COPD (but not required for dx)
Activity limitation (including intercourse)
Wheezing +/- chest tightness
Syncope
Anxiety / depressive symptoms (QOL is lower
What are the risk factors of COPD?
Family history
Smoking history
Consider age at initiation, average amount smoked per day since initiation, cessation date if applicable
Environmental history
Secondhand smoke exposure, air pollution, occupational exposure
History of childhood pulmonary infections, HIV, or TB
Asthma
How does the PE of COPD differ from mild compared to mod/severe?
Mild Disease
PE is often normal; may pick up on prolonged expiration, faint end-expiratory wheeze with forced expiration
Moderate / Severe Disease
Lung hyperinflation → ↑ resonance with percussion
Decreased breath sounds, wheezes
Crackles at lung bases
Distant heart sounds
Increased AP diameter
What lung sounds do you hear in barrel chest COPD?
Bilateral wheezing and fine crackles/rales
How does end-stage COPD present in PE?
End-stage Disease / Chronic Respiratory Failure
Tripod posturing
May have calloused forearms, swollen bursae on extensor surface of forearms
Use of accessory muscles for breathing
Expiring through pursed lips
Hoover’s sign → lower intercostal interspace retraction during inspiration
Cyanosis (typically lips or nails)
Rarely nail clubbing¹
What do you typically see on fingers with smoking history?
Signs of heavy smoking
Yellowing of fingers / nails
How long do you need cough for chronic bronchitis?
Productive cough >3 months for 2 consecutive years
Why do you see pneumothorax from emphysema?
Alveoli ruptures
What test do you do for COPD?
PFTs
Spirometry
What do you do to screen COPD?
Capture screening
Only screen adults who present with at least 1 of the 3 cardinal symptoms OR if they have a gradual decline in activity with risk factors for COPD
Consider CAPTURE Questionnaire
What labs do you order for COPD?
Labs - CBC, BMP, TSH (decreased respiratory drive), BNP/NT-proBNP (excess fluid), serum alpha-1 antitrypsin (if family history), CMP possibly, because the antitrypsin may be low
CXR
polycythemia
Is COPD reversible with an inhaler?
No, because there is dmg to the alveoli that cannot be fixed merely with a bronchodilator like albuterol
What is the FVC and FEV1/FVC of COPD?
FVC > 80% with FEV₁/FVC < 0.7
When might you concern Dlco in COPD?
In presence of moderate / severe airflow limitations (FEV₁ ≤50% predicted)
Resting O2 ≤92%
Exertional hypoxemia (<90%)
Severe dyspnea (mMRC ≥2)
When would you order an aterial blood gas (ABG)?
Low FEV₁ (< 40% predicted)
Low O₂ saturation on pulse ox (< 92%)
Depressed LOC
Assessment of hypercapnia in “CO₂ retainers” who are given supplemental oxygen (risk of hypercapnic respiratory failure)
Signs of right heart failure
done inpatient
What do you see in mild vs moderate/severe COPD in ABG?
Mild COPD: low pO₂ and normal pCO₂
Moderate to severe COPD: worsening pO₂ and elevated pCO₂
What is base excess if it’s negative?
More negative it is an acidosis
More positive it is an alkalosis
When do you order a CXR for COPD?
Imaging is not needed for making the diagnosis of COPD
Consider CXR and CT chest (w/o contrast)
CT has greater sensitivity to detecting disease than CXR
Indications
Dyspnea/cough etiology is unclear
Rule out complicating process during acute exacerbations
Pneumonia, pneumothorax, heart failure
Evaluate for comorbidities
Lung CA, bronchiectasis, pleural disease, ILD, heart failure
What do you typically see in CXR of emphysema
Restrosternal air space
Long narrow heart shadow
What do you use to stage COPD? And what three things is this based on?
Global Initiative for COPD GOLD
Airflow limitation
symptom severity
exacerbation
After gold category is determined, what is assessed?
severity of symptoms, based on mMRC and CAT test
What does mMRC assess?
severity of breathlessness
What does the CAT assess?
multitude of symptoms present
For staging, what do we base the category off of?
The higher number of mMRC or CAT
What is therapy management for COPD based on?
The patient! Even if the algorithm says something else.
What non-pharm is good for COPD?
Smoking cessation
gradually increase exercise
behavioral counseling
bupropion
What vaccines should COPD patients have up to date?
Influenza
COVID-19
PCV-20 OR PCV-13 followed by PCV-23
Tdap
Zoster in patients >50
What is often seen in COPD patients?
Vitamin D, so you should supplement in that case
If a patient has a low O2 sat, what might you need?
O2, but this may get stuck and make it to where they cannot get rid of CO2
When is pulm rehab indicative
Referral
Indicated for class B and E
often do elliptical, counseling on smoking cessation, coping skills because it is a chronic disease process
If you use an inhaler, what should you do?
Wash out mouth, because steroids suppress the immune system
How often do you follow up COPD?
3-6 months if doing well
1-3 months if initation of therapy
yearly spirometry (need to order)
What are the risk factors of COPD exacerbation?
Advanced age
Chronic productive cough
Duration of COPD
History of prior antibiotic therapy
COPD-related hospitalization within past year
Comorbid conditions (CAD, CHF, DM)
Respiratory infections (trigger ~70% of exacerbations)
What is an acute COPD exacberation?
Same s/s, just worsens over hours-days
hemoptosis
respiratory complications
mental status change (likely acidotic)
Can ask for CAT score during this time
How often are acute COPD patients managed outpatient? When do you consider inpatient?
80%
When to consider inpatient management
Severe symptoms → sudden worsening of resting dyspnea, high respiratory rate, decreased O2 sat, confusion, drowsiness
Acute respiratory failure
Onset of new PE findings (cyanosis, peripheral edema)
Failure to respond to initial medical management
Presence of serious comorbidities (CHF, arrhythmias)
Insufficient home support*
Outpatient management of acute COPD exacerbation
Outpatient Management
Adjust bronchodilator therapy
Increase dose/frequency of SABA
Consider adding SAMA if not already utilized
Consider spacers / nebulizer therapy
Consider oral glucocorticoid therapy
Example: prednisone 40 mg/day x 5 days vs. prednisone 30 mg taper
Antibiotics for increased cough, sputum production, and purulence
Macrolide (azithromycin, clarithromycin)
2nd or 3rd gen cephalosporin (cefuroxime, cefdinir)
Amoxicillin-clavulanate (Augmentin)
Respiratory fluoroquinolone (levofloxacin, moxifloxacin)
How long can a patient be on a steroid?
No longer than 5 days, because there will be a risk of infection
What antibiotics are used for Acute COPD exacerbation?
Empiric and then culture for sensitivity to get a specific med
Why do you not want to have O2 supplement greater than 92% for COPD exacerbation?
Because you are worried about trapping too much O2 in the lungs
When do you follow up patients with acute exacerbation of COPD?
4 weeks and then 12-16 weeks
What genetic issue can cause COPD?
Alpha-1 Antitrypsin Deficiency
What does Alpha-1 Antitrypsin Deficiency lead to? What should you order?
Alpha-1 Antitrypsin (ATT) is an enzyme naturally produced by the liver and migrates to the lungs via the blood
ATT protects the lungs from neutrophil (elastase) damage
ATT deficiency occurs when there is a genetic defect of ATT preventing its release from the liver
Two pathophysiologic processes
ATT deficiency in the lungs leads to loss of elastin in the alveolar wall and early onset emphysema
An accumulation of ATT in the liver leads to destruction of hepatocytes and liver disease
Order LFTs or CMP
What is Alpha-1 Antitrypsin Deficiency symptoms?
Symptoms of chronic hepatitis, cirrhosis, or hepatocellular carcinoma
Symptoms of panniculitis → inflammation of subcutaneous tissue
Hot, painful, red nodules or plaques characteristically on the thigh or buttocks
How do you treat Alpha-1 Antitrypsin Deficiency symptoms?
Same as COPD
Difference between bronchiectasis and bronchitis?
An irreversible focal or diffuse dilation and destruction of the bronchial walls
Bronchietasis sputum
Copious, foul-smelling, thick, purulent sputum is characteristic
What do you see in CXR of Bronchietasis?
tram tracks
take CXR to r/o pneumonia
How do you diagnose Bronchietasis?
CT
shows bronchial wall thickening and dilated airways
Ballooned or “honeycomb” appearance
What is the treatment for Bronchietasis?
Non-pharmacologic management as in COPD
Empiric antibiotics for acute exacerbations
Amoxicillin, Amoxicillin-clavulanate, Doxycycline, TMP-SMX
Consider long-term antibiotics for pts with ≥ 3 exacerbations/year¹
Bronchial hygiene
Mucolytic therapy, bronchodilators, chest physiotherapy
Surgical resection → indicated in poorly controlled focal disease
Lung transplant → indicated when FEV₁ <30% predicted
OSA
dx w/ sleep studies
males, obese
OSA dx criteria
≥5 obstructive respiratory events (apneas, hypopneas, or respiratory-related arousals) per hour of sleep plus one or more of the following:
Sleepiness, non-restorative sleep, fatigue, insomnia
Waking with breath-holding, gasping, or choking
Habitual snoring or breathing interruptions
HTN, mood disorder, cognitive dysfunction, CAD, CVA
≥15 or more predominantly obstructive respiratory events per hour of sleep, regardless of associated symptoms or comorbidities
