COPD Flashcards
What are the inclusion and exclusion criteria for lung volume reduction therapy?
Inclusion: (9 criterias)
1) emphysema type
2) FEV1 20-45%
3) RV >175%
4) RV/TLC >58%
5) Optimal med therapy
6) Nonsmoking
7) Post-rehab
8) Symptomatic MMRC >1
9) 6MWT 100-500m
Exclusion: (8 criterias)
1) significant bronchiectasis
2) previous lung surgery
3) pCO2 >60, +/- pO2 <45 RA
4) DLCO <20%
5) Pulm HTN
6) EF <40%
7) Comorbid that affect function & survival
8) Maintenance anticoag/ antiplt
Mx of COPD (General)
Mx of severe exac of COPD but not life-threatening
Indications for ICU in COPD exac
Indications for NIV in COPD exac
Indications for IMV in COPD exac
D/c criteria and f/up recommendations
Interventions that reduce COPD exac
Risk factors for lung cancer development in COPD pts
Causes of COPD
1) Tobacco smoke – inc marijuana
2) Air pollution – biomass fule for cooking/ heating
3) Occupational – organic/ non-organic dusts, chemical agents, pesticides
4) Genetic- alpha-1 antitrypsin
5) Age & sex – aging & female increase risk
6) Lung growth & development – low birth weight
7) Poverty
8) Asthma & hypersensitive airway
9) Chronic bronchitis
10) Infection
DDx of COPD
1) Asthma
2) Alpha-1 antitrypsin deficiency antibody – WHO suggested screening once in high prevalence countries.
<20% normal is homozygous
3) CCF
4) Bronchiectasis
5) TB
6) Obliterative bronchiolitis (usu young, non-smoker, RA, lung or bone marrow tplnt
7) Diffuse panbronchiolitis – usu Asian, non-smoker, males, with sinusitis
Etiotypes of COPD
Ix for COPD
1) Spiro
2) CXR
Features:
i) Hyperinflation – flat diaphragm & increased lung volume
ii) Hyperlucent lungs
iii) Rapid tapering of vasc markings
3) CT thorax
- TRO bronchiectasis & lung Ca
4) DLCO:
- Low DLCO (<60% predicted) – independent risk factor for death, reduced ET, worse Sx & health status
- DLCO <80% - marker of emphysema –> risk of developing COPD
5) ABG
– do if SpO2 <92%
6) Exercise testing
– 6MWT or paced shuttle walk test
7) Composite score – BODE (BMI, Obstruction, Dyspnoea & Exercise) method –> predicts survival
GOLD grades and severity
MMRC dyspnoea scale
0: SOB on exertion only
1: SOC on hurrying
2: walk slower than same age/ have to stop to catch a breath when walking at own pace
3: stop at 100m for breath
4: too breathless to leave house/ dress and undressing
CAT assessment
GOLD ABE classification
Treatment of COPD - non-pharmacological
1) Smoking cessation
2) Vaccination
a) Covid-19 vax
b) Influenza vax yearly
c) Pneumococcal:
One dose of PCV20 or
PCV15 followed by PPSV23
- Tdap (tetanus, diphtheria and pertussis) vax:
protect against pertussis in COPD who did not had it during adolescent
d) Zoster vax – for COPD ≥50y
3) Pulmonary rehab
= comprehensive, pt-tailored intervention that included exercise, behavioural change self Mx, to improve physical & psychological condition of ppl with chronic resp disease & to promote adherence to health-enhancing behaviors.
- For group B & E
4) Oxygen therapy
5) Interventional/ surgical:
a) Lung volume reduction surgery (LVRS),
b) bullectomy &
c) transplantation
6) Nutrition
7) Yearly spiro, check adherence & technique.
8) Action plan
9) Comorbidities: cardiac, GORD, OP, depression/anxiety
10) Palliative care
When to prescribe O2 to COPD pts
Surgical and interventional therapies in advanced emphysema
Lung transplantation:
- very severe COPD
- BODE 7-10
- not a candidate for LVRS
- with ≥1 of these:
a) admission with T2RF pCO2 >50
b) pulm HTN/ cor pulmonale
c) FEV1<20% and DLCO <20% or homogenous distribution of emphysema
Bronchoscopic intervention:
endobronchial valve (evidence A), lung coils and vapour ablation (evidence B)
- improves exertice tol, QoL & lung function at 6-12m
Confounders for COPD exac
Severity of COPD exac
Treatment of COPD - pharmacological
1) Beta2-agonists – SABA & LABA
2) Antimuscarinic drugs – SAMA & LAMA
e.g. ipratropium (SAMA),
LAMA: tiotropium (improves exercise performance), aclidium, glycopyrronium, umeclidium
3) Methylxanthines – theophylline SR 250mg BD
- Has moderate bronchodilator effect compared to placebo
- Combined with salmeterol –> improv FEV1 & SOB
- Metabolised by P450 –> clearance reduced with age & toxicity is dose related
Not recommended unless other bronchodilators unavailable
4) Roflumilast (a PDE4 inhibitor)
- dose: 500mcg/d
- use in:
i) severe airflow limitation (FEV1 <50%)
ii) chronic bronchitis
iii) recurrent exacerbations
5) Azithromycin
- use in:
i) esp ex-smokers
ii) recurrent exacerbations
Factors to be considered for ICS use in COPD
COPD definition
Chronic Obstructive Pulmonary Disease (COPD) is a
- heterogeneous lung condition
- characterized by
- chronic respiratory symptoms (dyspnea, cough, sputum production and/or exacerbations)
- due to
- abnormalities of the airways (bronchitis, bronchiolitis)
- and/or alveoli (emphysema)
- that cause
- persistent, often progressive, airflow obstruction.
Dx of COPD
FEV1/FVC <0.7 post bronchodilator on spiro
Other terms used:
1) Pre-COPD
= pts with respi Sx without airflow obstruction (FEV1/FVC>0.7%), with
a) structural lung lesion (e.g. emphysema)
b) physiological abnormalities (low-normal FEV1, gas trapping, hyperinflation, reduced DLCO, rapid FEV1 decline)
2) Preserved ratio impaired spirometry (PRISm)
= preserved ratio (FEV1/FVC ≥ 0.7 after bronchodilation) but impaired spirometry (FEV1 < 80% of reference, after bronchodilator)
- high prevalence among current or former smokers
- higher all-cause mortality risk
Both Pre-COPD and PRISm are at risk of developing COPD
6MWT & shuttle walk test
- method
- advantages & disadvantages
- contraindications
