copd Flashcards
COPD definition
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
COPD sx and risk factors
Symptoms:
- MC: Dyspnea, cough, +/- sputum
Risk factors:
- TOBACCO Smoking**
- Occupation Dusts
- Air pollution
- Hereditary factors (deficiency of α1-antiprotease = emphysema)
chronic bronchitis vs emphysema dx
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
emphysema pathogenesis
-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.
-V/Q Mismatch emphysema vs bronchitis
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
Types of emphysema
Centrilobular-MC**
Panlobular- a1 antitrypsan deficency
Paraseptal
Irregular
air trapping in COPD (mostly emphysema)
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
–
DLCO pattern emphysema vs chronic bronchitis
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
chronic bronchitis
-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
presentation/symptoms of COPD 3 typical presenations
1: Few complaints, but extremely sedentary lifestyle
2: Chronic respiratory symptoms:
-Dyspnea on exertion, cough
3: Acute exacerbation
- Wheezing, PURULENT cough, dyspnea
physical exam: early and mod-severe ds
Early disease:
-Nl or prolonged expiration
-Wheezes
Moderate-severe:
Hyperinflation & air trapping
Decreased breath sounds: Wheezes, rhonchi, crackles
Increased AP diameter
end stage COPD
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
type A pink puffer - emphysema sx
-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”
–
Chest xray pink puffer
-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
Chest xray blue bloater
INCREASED interstitial markings *
sx:
- Chest is noisy with rhonchi, wheezes
Labs - pink puffer + blue bloater
Emphysema:
≅ Hb | ≅/↓ PaO2 | ≅/↓ PaCO2
- mostly NORMAL labs because of compensatory mechanism -> pursed lips
Blue bloater:
↑ Hb | ↓ PaO2 | ↑ PaCO2
Pulmonary function tests: pink puffer vs blue bloater
pink puffer:
- Obstructive Pattern
- ↑ TLC: increased compliance
- ↓ DLCO
blue bloater:
-Obstructive pattern
- ≅/↑ TLC
- ≅ DLCO
type B: blue bloater description + sx
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
–
labs, imaging, PFTs: blue bloater
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
–
classification of severity of COPD
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.
bronchodilators
Goal: Improve symptoms, exercise intolerance, and overall health status
Anticholinergics:
- Ipratropium Bromide
- Tiotropium bromide**
- First-Line Therapy
SABA
- Albuterol
- Metaproterenol
LABA
- Formoterol
- Salmeterol
treatment based on group A, B, E
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
–
steroids (inhaled)
-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
antibiotics
Commonly prescribed to outpatients with COPD for the following indications:
-Treat an acute exacerbation/infection
-NOT for prophylaxis
Drugs:
- Augmentin
-bactrim
-doxy
pulmonary rehab
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
O2 therapy
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
other treatments for COPD?
-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
Acute Exacerbation of COPD- what tests should you do and what treatment?
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
prevention of COPD
STOP SMOKING!!!
-Slows the decline in FEV1
Get the Flu and pneumovax (pneumococcal) shot!!
summary
-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
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