COPD Flashcards
What is pink puffer ?
Emphysema
What is blue bloater?
Chronic Bronchitis
What are the differential diagnoses of hemoptisis and the most common?
- Bleeding disorder
- mitral Stenosis
- Heart failure
- Bronchitis (MC)
- Bronchiactesis
- Pneumonia
- Pulmonary TB
Compare acute and chronic bronchitis
Cough: dry then productive vs productive
Duration: less than 3w vs at least 3w for consecutive years
Etiology: viral vs smoking
Patient: less than 5 vs male adult
What are the stages of bronchitis?
-chronic simple bronchitis: hypertrophy of mucus glands leading to white mucoid discharge
- Chronic mucopurulent bronchitis: 2ndry bacterial infection (strept pn or H influenza) leading to yellow sputum
- Chronic obstructive bronchitis: mucus plugs and fibrosis leading to blue bloater
What is emphysema?
Abnormal permanent dilation of spaces distal to terminal bronchioles leading to loss of elastic recoil
What is the inheritance of alpha 1 antitrypsin deficiency
AR
What are the types of emphysema ?
True: congenital (alpha 1) or acquired (smoking)
False: senility and compensatory
Compare alpha 1 antitrypsin def and smoking on their effect on the lung
Alpha 1: pan acinar lower
Smoking: centri acinar upper
Compare pink puffer and chronic bronchitis (without examination)
Age: 50s vs 40s
Symptom: more severe Dyspnea than cough more severe cough than dyspnea
Complication:
• pneumothorax or Bullae
• exaccerbations/ 2ndry polycythemia/ corpulmonale
Prognosis good vs bas
Compare between pink puffer and blue bloater regarding examination:
General examination:
•Flushed and working accessory muscles
• weight loss
• tripod position
• pursed lip breathing
• central cyanosis
• weight gain
• peripheral edema
• pulmonary htn
Local examination:
Inspection: increased AP normal AP
Percussion: hyperresosanance vs normal
Ausculation: decreased sound vs harsh vesicular
No Ronchi vs ronchi
Compare pink puffer and blue bloater regarding investigations:
CXR: • decreased bronchivascular marking, jet black lungs, ribbon shaped heart, low flat diaphragm and horizontal ribs
• increased bronchovacular marking, normal sized lungs with or without right ventricular hypertrophy
ABG:
Hypoxia and normocapnia/hypocapnia
Hypoxia and hypercapnia
Compare pink puffer and blue bloater regarding investigations:
CXR: • decreased bronchivascular marking, jet black lungs, ribbon shaped heart, low flat diaphragm and horizontal ribs
• increased bronchovacular marking, normal sized lungs with or without right ventricular hypertrophy
What is COPD and its RF?
Chronic Obstructive Lung disease
1- Def: Umbrella term used to describe diseases that are cc by chronic progressive partially reversible
airway obstruction
2- R.F.: Smoking (Pack year 20 or more)
Give 3 examples of COPD
Refractory asthma
Emphysema
Chronic bronchitis
Describe the Clinical picture of a COPD patient
a- TOP: Old Heavy smoker
b- Symp.: Blue bloater or Pink puffer
Dyspnea
c- Signs:
1- G
a- Pulse = Pulsus Paradoxus or Arrhythmias
b- Head & Neck
1- Congested pulsating neck veins with Kussmaul’s sign
2- Tachypnea + Working accessory ms
- LL edema
2- L
I: Symmetrical, equal movement & increased A-P diameter, Hyper-inflation
P: Trachea (Centralized), TVF (Equal)
P: Bilateral hyper-resonance + Encroaching on heart & liver
A:
a- Breath S.: Type: Harsh vesicular (Prolonged expiration) + decreased Air entry Bilaterally
b- Additional S: Coarse crepitations + Rhonchi
What are the differential diagnosis of dyspnea?
- Anaphylaxis
- Cardiac Tamponade
- Mycardial Infarction
- Foreign body Inhalation
- Bronchial Asthma
- AECOPD
- Pneumothorax
8.Pulmonary embolism
What are the investigations of COPD?
4- Invest.:
A- LAB.:
1- Sputum culture (Exacerbation)/ dec AT, 2ry Polycythemia
2- ABG = dec POz ‡ inc PCOz (Blue bloater) or Normal PCO2 (Pink puffer)
3- DLco = Impaired (Pink puffer)
B- RAD.: Blue bloater + Pink puffer
C- INST.: Spirometry
Obstructive Hypoventilation pattern inc TLC, dec FVC, dec FEV1
Post Broncho-dilator Ratio of FEVI/FVC < 0.7
What are the complications of COPD?
Complications
1- Acute exacerbation (airway inflammation)
2- Lung
(Pnthx, Bronchiectasis, Pneumonia, Cancer & Resp. F )
3- Heart failure
COPD types
Type A emphysema
Type B Chronic bronchitis
What is the hallmark picture of COPD?
Dyspnea
What are the arrhythmias of COPD and the most common ones ?
Multiracial Atrial Tachycardia (mc)
Atrial fibrillation
What feature is not a feature of COPD and what does its presence indicate?
Clubbing
Bronchiactesis or Cancer
Explain the etiology of LL edema in COPD
Corpulmonale
Decrease in cop
Increase in Raas
Decrease O2 so increase in permeability
Increased CO2 leading to acidosis and increase in NaHCO3 reabsorption
How are acute exacerbations classified in COPD ?
Based on the presence of cardinal features
Increased Dyspnea
Increased sputum
Increased purulence
Mild
Moderate
Severe
What type of RF does a COPD patient experience
State it’s ABG
Type 2
O2 below 60
CO2 above 50
What does GOLD stand for (w menha t3rf its use)
Global Initiative for Lung Disease
What are the 3 corner stones of GOLD
Risk of Annual Exacerbations
Dyspnea Grades
Spirometry grades
Post bronchodilator test in COPD
Fev1/fvc is
Less than 0.7
List Gold levels
Gold 1 at least 80
Gold 2 80-50
Gold 3 50-30
Gold 4 less than 30
Dyspnea severity is measured by
Mmrc scale
COPD A Grade ttt and Diagnosis
- 0 or 1 Dyspnea severity
AND - no or 1 without hospitalization
SABA as needed
What is the most common cause of AECOPD ? And percentage and etiology stating the Mac
Infection 75%
Rhinovirus Mc
Strept pneumoniae
H influenza
COPD grade B diagnosis and ttt
- 2,3 or 4Dyspnea severity
AND - no or 1 without hospitalization
LABA AND LAMA ON REGULAR BASIS
C + D =
E
What is C grade diagnosis?
- 0 or 1 Dyspnea severity
AND - 2 or more and must require hospitalization
What is D grade diagnosis?
- 2,3 or 4 Dyspnea severity
AND - 2 or more and must require hospitalization
What is grade E ttt?
If esinophils are at least 300 cell per microliter add ICS on regular basis
What are the vaccinations that COPD patients can benefit from ?
Pcv 13
Influenza
When should pulmonary rehabilitation start?
Grade B
What is the advantage of Venturi mask ?
Improves quality of life
When to start Venturi mask ?
PO2 55 or less
Or
PO2 less than 60 with PTH
What is Venturi mask ?
Long term low flow oxygen therapy
What are the lines of TTT of COPD?
Community
1. Patient education (smoking cessation, respiratory muscle exercise and vaccination)
Pulomonolgy
2. Pulmonary rehabilitation
- Venturi mask
Internist
4. Symptomatic treatment of cough
- Group ttt as needed
Surgical
6. Surgical intervention
All grades of COPD require dual therapy of bronchodilators except
A
What surgical interventions can COPD benefit from ?
Bullectomy
Lung volume reduction
Transplantation
Describe how to treat a cough.
Dry: Codiene 10ml max 4 times a day
Productive:
Productive
Mucolytic (N acetyl cysteine) 200mg max 3 times a day
Expectorant (Guaifenesin) 200mg max 12 times a day
In COPD which route is it choice ?
Inhalation
Most important factor to stop progression of COPD
Smoking cessation
List bronchodilators you could use
B2 agonist
M3 antagonists
Methylxanthines (as theophylines pde 3 and 4 inhibitors)
Which type of bronchodilators are used for maintenance and control ?
Long acting bronchodilators
Long acting anti M3 or Long acting b2 agonists
Which are superior to which in exacerbations?
LAMA
Which are more superior in controlling Dyspnea ?
B2 agonist
ICS
M3 antagonist
B2 agonist
ICS
Which are more superior in controlling clinical picture ?
B2 agonist
ICS
M3 antagonist
B2 agonists
ICS
What musnt be used for long term COPD treatment (we can use them fel exacerbation 3ady) and why
ICS and steroids
Percipitate pneumonia
What should only be used in case there are no long acting bronchodilators (considered the last resort)?
Theophyline
What should only be used in case there are no long acting bronchodilators (considered the last resort)?
Theophyline
What is better to start with
And except in
Long acting inhalers
mild occasional dyspnea
In AECOPD
What should we use IV or oral
Both are of the same efficacy
Only use iv if patient is unable to swallow
Explain the etiology AECOPD
a- Etio.:
1- Infections
2- Exposure to pollution, Allergens, Chemicals & Cold weather
3- Pt. non-compliance
4- Heart failure, P. Embolism, Arrhythmias
Explain C/P of AECOPD
b- C/P:
Cardinal Features (inc Dyspnea, inc Sputum Amount, inc Sputum Purulence)
Other Features
(Fever, Upper Resp. Tract infection, inc
HR, R.R., Wheezes, Cough)
(Cyanosis & LL edema)
Explain TTT of AECOPD
c- TT:
1- Mild (inc Dose of TTT)
2- Moderate (Add Oral Steroids ‡ ABs)
3- Severe (Needs Hospitalization up to CU)
What is the most common infection in AECOPD?
Street pneumoniae