copd Flashcards

1
Q

COPD definition

A

Presence of airflow obstruction due to chronic bronchitis or emphysema
- Obstruction is generally progressive -> PREVENTABLE AND TREATABLE DS
-+/- airway hyper-reactivity
-+/- PARTIALLY reversible
-Most patients with COPD have features of both emphysema and chronic bronchitis

Cause of COPD:
-significant exposure to noxious particles or gases

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2
Q

COPD sx and risk factors

A

Symptoms:
- MC: Dyspnea, cough, +/- sputum

Risk factors:
- TOBACCO Smoking**
- Occupation Dusts
- Air pollution
- Hereditary factors (deficiency of α1-antiprotease = emphysema)

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3
Q

chronic bronchitis vs emphysema dx

A

Chronic bronchitis:
-Clinical diagnosis*
-Daily* productive cough for 3 months or more for at least 2 consecutive years*

Emphysema:
-Pathologic diagnosis*
-Abnormal permanent enlargement of air spaces distal to the terminal bronchiole, with destruction of their walls and without obvious fibrosis

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4
Q

emphysema pathogenesis

A

-excessive LYSIS OF ELASTIN (structural proteins) by elastase from lung neutrophils, macrophages, and mononuclear cells

Outcome:
- permanent enlargement of airway spaces
- Destruction of alveoli
- destruction of connective tissue and pulmonary capillaries
-Airways floppy (increased compliance)
-Air flow obstruction

It can progress to….
-V/Q Mismatch
-Cor pulmonale: END STAGE COPD

Excessive elastase activity: Conditions like cigarette smoking, air pollution, and certain infections can activate neutrophils, macrophages, and mononuclear cells in the lungs to release higher amounts of elastase enzymes.

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5
Q

-V/Q Mismatch emphysema vs bronchitis

A

Emphysema: PERFUSION ISSUE (PE)
- Dead space ventilation
- ventilating areas not perfused due to destruction of capillaries
- ventilated well but not perfused

Chronic bronchitis: VENTILLATION ISSUE (CV)
- Capillaries intact, but not ventilated due to mucus plugs blocking air
- perfused well but not ventilated

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6
Q

Types of emphysema

A

Centrilobular-MC**

Panlobular- a1 antitrypsan deficency

Paraseptal

Irregular

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7
Q

air trapping in COPD (mostly emphysema)

A

COPD:
-loss of alveolar attachments and thickened inflammated airway
-loss of elasticity (emphysema)

outcome:
-airway collapses on expiration -> AIR TRAPPING bc inefficient breathing
-a lot of air trapping = SOB

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8
Q

DLCO pattern emphysema vs chronic bronchitis

A

Emphysema:
-alveoli are being destroyed, though they are increasing in size, the surface area ↓↓↓ = ↓ DLCO

Chronic bronchitis:
- NORMAL
- main problem is mucus and inflammation/narrowing of airway -> alveoli are functional

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9
Q

chronic bronchitis

A

-Hypertrophy bronchial mucous glands (plugging)
-Goblet cells increase in number
-Damaged cilia
-Bronchial mucosa inflammation
-Bronchial smooth muscle hyper-reactivity -> Bronchospasm
-Increase in MUCOUS production:


-Air flow obstruction
-V/Q mismatch
-Cor Pulmonale

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10
Q

presentation/symptoms of COPD 3 typical presenations

A

1: Few complaints, but extremely sedentary lifestyle
2: Chronic respiratory symptoms:
-Dyspnea on exertion, cough

3: Acute exacerbation
- Wheezing, PURULENT cough, dyspnea

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11
Q

physical exam: early and mod-severe ds

A

Early disease:
-Nl or prolonged expiration
-Wheezes

Moderate-severe:
Hyperinflation & air trapping
Decreased breath sounds: Wheezes, rhonchi, crackles
Increased AP diameter

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12
Q

end stage COPD

A

Significant trouble with expiration = need to reposition to exhale
- May be hypoxic = cyanotic
- May have light HF or HTN

Hoover’s Sign: Paradoxical retraction of lower interspaces during inspiration - sign of hyperinflation (emphysema)

Cor Pulmonale: Enlarged, tender liver +/- neck vein distention

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13
Q

type A pink puffer - emphysema sx

A

-Often presenting after age 50

Sx:
-DYSPNEA often severe*
-Cough = rare scant clear, mucoid sputum
-Present as thin (wt loss)
- Using accessory muscles for inspiration
-Chest is QUIET -> no congestion in lungs
-NO peripheral edema

  • mostly normal labs because of compensatory mechanism -> pursed lips
    Pink = “normal skin color”
    Puffer = “pursed lips”
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14
Q

Chest xray pink puffer

A

-Hyperinflation, FLAT diaphragms
-Vascular markings DECREASE
-Parenchymal BULLAE*

Sx:
-DYSPNEA severe
- Using accessory muscles for inspiration
-Chest is QUIET -> no congestion in lungs
-NO peripheral edema

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15
Q

Chest xray blue bloater

A

INCREASED interstitial markings *

sx:
- Chest is noisy with rhonchi, wheezes

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16
Q

Labs - pink puffer + blue bloater

A

Emphysema:
≅ Hb | ≅/↓ PaO2 | ≅/↓ PaCO2
- mostly NORMAL labs because of compensatory mechanism -> pursed lips

Blue bloater:
↑ Hb | ↓ PaO2 | ↑ PaCO2

17
Q

Pulmonary function tests: pink puffer vs blue bloater

A

pink puffer:
- Obstructive Pattern
- ↑ TLC: increased compliance
- ↓ DLCO

blue bloater:
-Obstructive pattern
- ≅/↑ TLC
- ≅ DLCO

18
Q

type B: blue bloater description + sx

A

Definition: Daily productive cough x3 months for at least 2 consecutive years
–Often presents in late 30s and 40s

sx:
-Mucopurulent chronic cough with frequent exacerbations due to infections
-Dyspnea mild
-Pt presents as overweight and cyanotic but seem comfortable at rest
-Peripheral edema common
-Chest is noisy with rhonchi, wheezes
———–

Blue = cyanosis because they are hypoxemia; hypercapnia (high CO2)
Bloater = fluid retention due to pHTN + overweight

19
Q

labs, imaging, PFTs: blue bloater

A

Labs:
↑ Hb | ↓ PaO2 | ↑ PaCO2

Chest radiograph:
-Increased interstitial markings (“dirty lungs”)
-Diaphragms not flattened

PFTs:
-Airflow obstruction
-Total lung capacity generally normal but may be slightly increased
-DLCO NORMAL
-Static lung compliance NORMAL

20
Q

classification of severity of COPD

A

GOLD 1 (Mild): FEV1 ≥ 80% predicted.
GOLD 2 (Moderate): 50% ≤ FEV1 < 80% predicted.
GOLD 3 (Severe): 30% ≤ FEV1 < 50% predicted.
GOLD 4 (Very Severe): FEV1 < 30% predicted.

21
Q

bronchodilators

A

Goal: Improve symptoms, exercise intolerance, and overall health status

Anticholinergics:
- Ipratropium Bromide
- Tiotropium bromide**
- First-Line Therapy
SABA
- Albuterol
- Metaproterenol

LABA
- Formoterol
- Salmeterol

22
Q

treatment based on group A, B, E

A

Group A- CAT<10, mMRC 0-1
- bronchodilator
Group B- more symptomatic but still no exacerbations
- LABA or LAMA
Group E- LABA+LAMA (has has exacerbations + hospital visit) -> consider LABA + LAMA + ICS -> prof is hesitant to give steroid ever

23
Q

steroids (inhaled)

A

-Improves quality of life
-Decreases severity and # of exacerbations in pts with moderate to severe copd
-topical agent -> need to reach target tissue
-Delivery system/Inhaler Choice and inhaler technique are very important
-It is very important to demonstrate the inhaler technique and assess patient’s ability to use it properly

-2020 GOLD Guidelines recommend reassessing inhaler technique and inhaler choice on every visit

24
Q

antibiotics

A

Commonly prescribed to outpatients with COPD for the following indications:
-Treat an acute exacerbation/infection
-NOT for prophylaxis

Drugs:
- Augmentin
-bactrim
-doxy

25
Q

pulmonary rehab

A

Goal: Improve exercise capacity & Decrease hospitalizations
- Goal is to be able to do more physical activity for the limited lung function that they have
- Graded aerobic physical exercise program

Graded aerobic physical exercise programs
- ex: walking 20 minutes three times weekly or bicycling
-Prevents deterioration of physical condition
-Improves ability to carry out daily activities
-Training of inspiratory muscles
-Decrease hospitalizations
-Improve Quality of lif

26
Q

O2 therapy

A

Indication: resting hypoxemia (<88%)

Benefits:
-Include longer survival
-Reduced hospitalization needs
-Better quality of life

Hypoxemic patients who are likely to benefit are:
-Pulmonary hypertension
-Chronic cor pulmonale
-Eythrocytosis
-Impaired cognitive function
-Exercise intolerance
-Nocturnal restlessness
-Morning headache

27
Q

other treatments for COPD?

A

-Human alpha 1 antitrypsin for deficient patients
-Opioids = controversial
-Lung transplantation- Substantial improvements in pulmonary function and exercise performance have been noted after

Lung volume reduction surgery:
-Bilateral resection of 20–30% of lung volume
- Goal: Providing adequate space for the normal lung to function

Endobronchial Valve placement can achieve the same goal without surgery

Bullectomy: indicated when large bullae occupies 30–50% of the hemithorax

28
Q

Acute Exacerbation of COPD- what tests should you do and what treatment?

A

1: CXR: R/O things that can cause exacerbation -> CHF, pneumonia, pneumothorax
- ABG useful; spirometry - not useful

Tx:
- Oxygen
- Bronchodilators
- Oral Steroids: Prednisone 40mg then taper
- Antibiotics: tx infection
- Non-invasive PPV: Decreases need for mechanical ventilation

Spirometry: NOT useful in acute setting

29
Q

prevention of COPD

A

STOP SMOKING!!!
-Slows the decline in FEV1

Get the Flu and pneumovax (pneumococcal) shot!!

30
Q

summary

A

-Obstructive airways disease largely due to SMOKING
-Not completely reversible like asthma
-Emphysema-Lung destruction and hyperinflation
-Chronic Bronchitis-Airway inflammation and mucous production
-GOLD Guidelines-Degree of obstruction plus exacerbations and symptoms
-Frequently reassess inhaler choice and pt’s ability to properly use the device
-SMOKING CESSATION