COPD Flashcards
What is COPD?
respiratory disorder largely caused by smoking that is characterized by:
-progressive, partially reversible airway obstruction
-lung hyperinflation
-systemic manifestations
-increasing frequency and severity of exacerbations
What is emphysema?
abnormal enlargement of the airspace distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis
What is chronic bronchitis?
chronic cough for at least 3 months x 2 consecutive years
Provide a brief overview of the epidemiology of COPD.
772,200 (4%) Canadians >35yrs with COPD
cigaretter smoking is the principle underlying cause of COPD
-responsible for 80% of deaths
3rd leading cause of death worldwide
What are the non-host risk factors for COPD?
exposure to particles
-cigarette smoking/exposure to 2nd hand smoke
-occupational dusts, organic and inorganic
-outdoor air pollution
-indoor air pollution
infections
-frequent childhood respiratory problems/prior TB or HIV
socio-economic factors
What is the most significant risk factor for COPD
cigarette smoking/exposure to 2nd hand smoke
What are the host risk factors for COPD?
genetics: 1-antitrypsin deficiency
age (because of particle exposure?)
lung growth and development
airway hyper-responsiveness
-asthma=increased risk?
What is 1-antitrypsin?
serum protein produced by the liver and normally found in lungs
prevents neutrophil elastase from destroying lung tissue
What is the pathophysiology of COPD?
stimulus (smoking)–>inflammatory process–>narrowing of peripheral airways–> reduced FEV1
-oxidative stress may play an important role in amplifying the inflammatory process
-a protease-antiprotease imbalance is noted in the lungs of COPD patients (protease mediated destruction of elastin)
-increased CD8 and other inflammatory mediators induce structural changes
Describe expiratory flow limitation as part of the pathophysiology of COPD.
hallmark of COPD
due to increased resistance from mucosal inflammation, airway remodeling, fibrosis & secretions
Describe lung hyperinflation as part of the pathophysiology of COPD.
obstruction of the small airways results in air-trapping which causes lung hyperinflation
develops early in disease and causes exertional dyspnea
Describe gas exchange abnormalities as part of the pathophysiology of COPD.
results in hypoxemia & hypercapnia
gas transfer for O2 & CO2 worsens as disease progresses
Describe mucous hypersecretion as part of the pathophysiology of COPD.
results in chronic productive cough
not necessarily associated with airflow limitation
Describe exacerbations as part of the pathophysiology of COPD.
triggered by infection, environmental pollutants or unknown
during exacerbations there is increased hyperinflation and gas trapping with decreased expiratory flow
Describe significant comorbid illness as part of the pathophysiology of COPD.
pulmonary HTN may develop late in course of COPD due to hypoxic vasoconstriction of small pulmonary arteries
muscle wasting and cachexia, skeletal muscle dysfunction
osteoporosis, depression, anemia, metabolic syndrome, CV, lung disease
What are the three cardinal symptoms of COPD?
phlegm
chronic cough
shortness of breath
Aside from the cardinal symptoms, what are some other symptoms of COPD?
barrel-shaped chest
fatigue
frequent lung infections
unexplained weight loss
reduced ability for daily activities
What are the end-stage symptoms of COPD?
adopt positions that relieve dyspnea
use of accessory respiratory muscles
expiration through pursed lips
cyanosis
enlarged liver from right heart failure
How do patients initially present with COPD?
sedentary lifestyle and general fatigue
-avoiding exertional dyspnea
-shifted expectations and limited their activities
complains of dyspnea and chronic cough
-initially noted on exertion only
-progressively triggered by less exertion
-morning sputum production
episodes of cough, sputum, wheezing, fatigue, and dyspnea
-intervals between episodes shortens
Differentiate asthma and COPD using the following parameters:
-age on onset
-smoking history
-sputum production
-allergies
-clinical symptoms
-disease course
-importance of co-morbid illness
-spirometry
-airway inflammation
-response to ICS
-role of bronchodilators
-role of exercise training
-end of life discussions
age on onset
-COPD: usually >40 yrs
-asthma: usually <40 yrs
smoking history
-COPD: usually >10 pack-years
-asthma: not causal, but worsens control
sputum production
-COPD: often
-asthma: infrequent
allergies:
-COPD: infrequent
-asthma: often
clinical symptoms
-COPD: persistent and progressive
-asthma: intermittent and variable
disease course
-COPD: progressive worsening
-asthma: stable
importance of co-morbid illness
-COPD: often important
-asthma: often important
spirometry
-COPD: may improve but never normalizes
-asthma: often normalizes
airway inflammation
-COPD: neutrophilic
-asthma: eosinophilic
response to ICS
-COPD: helpful in mod-severe dx and freq AECOPD
-asthma: essential for optimal control
role of bronchodilators
-COPD: regular therapy usually necessary
-asthma: prn only
role of exercise training
-COPD: essential therapy
-asthma: rarely formally used
end of life discussions
-COPD: often essential
-asthma: rarely necessary
When should we consider a clinical diagnosis for a patient?
any patient who has:
-dyspnea
-chronic cough
-sputum production
-history of exposure to risk
What is required to make a diagnosis of COPD?
spirometry
spirometry post-bronchodilator FEV1/FVC ratio <0.7 confirms diagnosis
True or false: evidence supports population screening with spirometry for COPD
false
Which patients should be screened for COPD?
smokers/ex-smokers >40yrs who have:
-persistent cough or sputum production
-frequent respiratory tract infections
-progressive activity-related SOB
-evening wheeze
What are some good questions to ask when screening someone for COPD?
do you cough regularly
do you cough up phlegm regularly?
do even simple chores make you short of breath?
do you wheeze when you exert yourself or at night?
do you get frequent colds that persist longer than those of other people?
IF YES–>SPIROMETRY
What are the steps in the clinical evaluation of COPD?
- pulmonary function testing
-must determine degree of reversibility
-FEV1 <80% and FEV1/FVC ratio <0.7 - assessment of risk factors
-quantification of tobacco consumption
-record environmental exposures - assessment of severity of breathlessness using the MRC dyspnea scale or CAT test
- assessment of frequency and severity of exacerbations
- assessment of symptoms that could point to complications
- assessment of the symptoms that suggest comorbidities
- assessment of medications
Describe the mMRC dyspnea scale.
grade 0:
-breathless with strenuous exercise
grade 1: mild
-SOB when hurrying on level or walking uphill
stage 2: moderate
-walks slower than people of same age on level or stops for breath while walking at own pace on same level
stage 3: moderate
-stops for breath after walking 100m or after few mins on same level
stage 4: severe
-too breathless to leave house, or dressing
What is the CAT test?
validated, short and simple patient completed questionnaire
reliable measure of the impact of COPD on a patients health status
score ranging from 0-40:
-0-10=low impact
-10-20=medium impact
-21-30=high impact
->30=very high impact
What is the spirometry that can diagnose someone with COPD?
post bronchodilator FEV1 <80% predicted
FEV1/FVC ratio < 70%
What are the corresponding spirometry values for the stages of COPD?
mild:
-FEV1 >80% predicted
-FEV1/FVC ratio <0.7
moderate:
-FEV1 50-79% predicted
-FEV1/FVC ratio <0.7
severe:
-FEV1 30-49% predicted
-FEV1/FVC ratio <0.7
very severe:
-FEV1 <30% predicted
-FEV1/FVC <0.7
How is FEV1 used in assessing COPD?
used to stage/assess severity
What are the goals of treatment for COPD?
prevent disease progression
prevent and treat exacerbations
alleviate breathlessness and other respiratory symptoms
improve exercise tolerance and daily activity
prevent and treat complications of the disease
improve health status
reduce mortality
What are the 8 possible treatments of COPD?
smoking cessation
eliminate occupation/environmental exposures
comprehensive patient/family education
avoid sedatives/narcotics in severe disease
rehabilitation programs
vaccines
long-term oxygen therapy
pharmacologic therapy