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COPD Flashcards

1
Q

What do epithelial cells produce to create small airway fibrosis

A

TGF-B

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2
Q

What do macrophages produce to increase inflammation

A

LTB4 and IL-8 (neutrophil and T-cell chemottractant)

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3
Q

Primary lymphocytes involved in pathogenesis of COPD

A

CD8+ cytotoxic T cells

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4
Q

Male and female death in copd, who is more effected

A

female > male

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4
Q

Worse prognostic gene in AAT

A

ZZ worst
Then SZ
then MZ, then SS and MM with highest AAT serum level

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4
Q

emphysema in non-smoking person aged <45yo

A

AAT deficiency

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5
Q

Imaging associated with AAT

A

bullous disease at lung bases, panacinar

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6
Q

When is IV a1-antitrypsin therapy indicated and effect

A
  1. high-risk homogenous phenotype patient (ZZ)
  2. FEV1 35-65% (GOLD); ATS recs <80%
  3. plasma AAT level <11 or 57 mg/dL; other therapy optimized
  • Modest effect in slowing lung function decline but NO effect in preventing exacerbations
  • Not recommended for other emphysema
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7
Q

Is digital clubbing not typical in COPD?

A

no

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8
Q

Rate of FEV1 decline each year in non-smokers vs smokers

A

30 ml/year vs. 60 ml/year

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9
Q

Inspiratory capacity of ___ is an independent predictor of mortality in COPD

A

<25%

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10
Q

Bronchial thermoplasty indication and contraindications in asthma

A

<18
Steroids 2 in the past year

Contraindicaions
FEV1 <60
More than 3 exacerbations

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11
Q

CAT score components and cut offs

A

Cough
Phlegm
Chest tightness
Breathlessness
Activities
Confidence
Sleep
Energy
Max 40, min 0
Cut off of 10 = quality of life impact
Minimal important difference is 2

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12
Q

COPD GOLD score number cut offs

A

> 80
50
30

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13
Q

Predictor of survival in COPD

A

BODE
BMI (lower BMI is a poor prognostic marker)
Obstruction (FEV1% predicted) >65 = 0 (then 50, 36)
Dyspnea (mMRC) (same numebers as mmRC)
Exercise (6MWT) >350m = 0 (then 250, 150 cut offs)

Each component is 3 (except BMI (<21 = 1, >21 = 0) Refer for LT if BODE = 7-10 (80% mortality at 52 mo)

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14
Q

56F with COPD describes dyspnea when hurrying on level ground, post bronch FEV1 is 45% predicted, no h/o exacerbations w/in the past year. GOLD combined assessment?

A

GOLD Stage 3A; mMRC 1

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15
Q

TORCH trial findings

A
  • Salmeterol reduced exacerbations
  • Salmeterol-fluticasone combination reduced exacerbations
  • Pneumonia more likely in patients taking fluticasone
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16
Q

UPLIFT trial revealed that tiotropium was associated with the following outcomes:

A
  • Reduction in exacerbations
  • Reduction in hospitalizations related to exacerbations
  • Improved quality of life
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17
Q

Things that reduce COPD exacerbations

A

LABA, LAMA and LABA/ICS

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18
Q

Which therapy has been shown to slow the rate of FEV1 decline in COPD

A

smoking cessation
(not inhalers)

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19
Q

Pulm rehab improves:

A

Dyspnea
quality of life
6MWD

Not FEV1

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20
Q

Benefit of pulmonary rehabilitation BREATH(e) EASY

A

Breathless reduction
Recovery after exacerbation
Exercise capacity (6MW shuttle walk)
Anxiety and depression reduction
Training of respiratory muscles
Hospitalization frequency and days in hospital decreased
Enhanced efficacy
Arm function improvement and endurance training of upper limbs
Survival
Your quality of life improvement

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21
Q

LVRS Benefits (3)

A

survival
Exercise
QOL

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22
Q

LVRS patient selection for greatest mortality benefit

A
  1. Upper lobe-predominant emphysema, poor exercise capacity <40W in men, <25W in women after pulm rehab
  2. Upper lobe-predominant emphysema and high exercise capacity has no survival benefit BUT improves QOL and exercise capacity

NETT trial 2003

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23
Q

LVRS physiological benefit (3)

A
  1. improves elastic recoil
  2. expiratory airflow
  3. mechanical function of diaphragm
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24
Q

LVRS Contraindications (5)

A
  1. FEV1 <20
  2. DLCO <20
  3. diffuse/homogenous emphysema on CT
  4. Combination of diffuse emphysema and high exercise capacity (increased mortality)
  5. prior mediasternotomy
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25
Q

Oxygen benefits and how many hours it’s needed

A

> 15 hours/day

  1. survival
  2. exercise tolerance

Only in NOTT trial (avg 18h/d), not validated in LOTT trial - no survival or QOL benefit

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26
Q

Who benefits from O2 therapy

A

PaO2 <55mmHg or SaO2 <88%

PaO2 56-59 mmHg or Sao2 <89% AND
- EKG Evidence of cor pulmonale
- Hematocrit >55
- RHF/pulmonary HTN

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27
Q

Why is using FEV1/FVC <0.7 a better tool for COPD than using LLN

A

helps discriminate COPD-related hospitalization and mortality vs. LLN

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28
Q

GETomics

A

Gene, environment interaction over the lifetime

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29
Q

Prevalence men to female in COPD, which is more

A

female

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30
Q

COPD risk in smokers (percentages per pack)

A

15-20% of 1 ppd smokers and 25% of 2 ppd smokers will develop COPD

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31
Q

Cadmium fume exposure is associated with

A

COPD

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32
Q

pesticide exposure, organic and inorganic dust is associated with ___

A

COPD

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33
Q

50% of COPD deaths in developing countries are from

A

biomass smoke, 75% are women

34
Q

Cells found in airways in non-smoker COPD

A

eosinophils

35
Q

Definition of chronic bronchitis

A

chronic cough and sputum for 3mo/year for 2 consecutive years

36
Q

Mucin in chronic bronchitis that cause more exacerbations

A

MUC5AC
MUC5AB cause more exacerbations

37
Q

Lung function peaks at what age ____

A

20-25 yo
50% of COPD could be due to people never achieving peak FEV1

38
Q

Dysanapsis

A

mismatch of airway tree caliber to lung size in early life

39
Q

SABA and SAMA benefit (separately) (2)

A

FEV1
Symptoms

40
Q

LABA and LAMA benefit (separately) (4)

A

lung function
dyspnea
health status
exacerbations

41
Q

LAMA benefit (3)

A

exacerbation
hospitalizations
effectiveness of pulmonary rehab

42
Q

Combination LAMA+LABA benefit (3)

A

improves FEV1
Symptoms
Exacerbations
MORE than monotherapy

43
Q

ICS+LABA combination

A

more effective than single therapy
FEV1
Health status
exacerbations

44
Q

Triple therapy benefits over dual therapy (4)

A

better than dual therapy in 4 components
1. REDUCES MORTALITY in symptomatic COPD with h/o frequent exacerbations
2. lung function
3. QOL
4. Exacerbations

45
Q

Regular treatment with ICS in COPD increases ___

A

risk of pneumonia
in those with severe disease

46
Q

Who might benefit from ICS in COPD

A
  • frequent exacerbations 1-2 or more
  • AEC 300
  • concomitant asthma
47
Q

Who may not benefit from ICS in COPD

A

blood eos <2% or <100
Repeated pneumonia events
History of NTM/MTB

Independent of ICS, blood eos <2% associated with increased risk of pneumonia

48
Q

FLAME Study compacompared LABA/LAMA vs ICS/LABA and found ____

A

Study population: FEV1 25-60% + mMRC 2+ and at least 1 exacerbation in the past 1 year
(high dose salmeterol-fluticasone)

  • longer time to first exacerbation in LABA/LAMA group
  • Higher incidence of pneumonia in ICS group
49
Q

IMPACT and ETHOS trials showed: ___

A

ETHOS: Triple therapy vs ICS/LABA or LABA/LAMA
- 2 doses of steroids vs ICS/LABA and LAMA/LABA
- rate of mod-severe exacerbation was lowest in triple therapy
- in patients with mod-severe COPD, 2+ exacerbation, FEV1 <50% pred
- Eos did not modify effect
- Decreased mortality shown in higher dose of ICS

IMPACT: Triple therapy vs LAMA/LABA and ICS/LABA
- decreased all cause mortality compared to LABA/LAMA but NOT to ICS/LABA

50
Q

Macrolide benefit in COPD

A

erythromycin and azithromycin prolongs time to first exacerbation, decreases exacerbation

51
Q

What population does macrolides not work as well in (for those with COPD)

A

current smokers

52
Q

Indications for Roflumilast and what is the trial

A

REACT 2015
- 13% reduction in exacerbations

Indications:
- FEV1 <50% & chronic bronchitis
- use of steroids +2x, 1 hospitalization

53
Q

MOA of Roflumilast

A

PDE4 inhibitor

54
Q

Prevalence of A1AT deficiency in COPD

55
Q

Benefit of Dupilumab in COPD

A

AEC >300: 30% reduction in exacerbations when added to triple inhaled therapy

AND in smokers

56
Q

COPD treatment based on groups

A

A: a LAMA (one bronchodilator)
B: LABA+LAMA
E: LABA+LAMA consider ICS in eos >300

57
Q

Mode of inheritance A1AT

A

autosomal co-dominant pattern - SERPINA1 gene chromosome 14

58
Q

Normal and abnormal allele in A1AT

A

M is normal
S or Z is associated with deficiency

59
Q

A1AT is associated with (3)

A
  1. liver disease/ cirrhosis
  2. Necrotizing panniculitis
  3. c-ANCA positive vasculitis
61
Q

Major Contraindication to AAT augment therapy

A

IgA deficiency –> anaphylaxis (pooled human AAT)
- plasma serum lvl >11 micromol/L or 57 mg/dL

62
Q

Lung Health Study smoking cessation study shows ___

A
  1. Slower FEV1 decline
  2. Mortality benefit in sustained quitters
    some in intermittent quitters
63
Q

Vaccinations needed for COPD

A
  1. Influenza
  2. RSV
  3. COVID
  4. TdaP
  5. PCV20
64
Q

Benefits of pulmonary rehab (4)

A
  1. Improvement in dyspnea, exercise capacity, QOL/anxiety/depression
  2. Reduces frequency of exacerbations
  3. Reduces the number of readmissions in the YEAR following initiation
  4. Initiation within 90d of discharge = reduction in all-cause mortality at 1 year
65
Q

Optimum duration of pulm rehab

66
Q

When is O2 therapy indicated during exercise

A

Desaturation or PaO2 <55 during exercise only

67
Q

Indication for NIV in COPD

A

pCO2 >52 and pH >7.35

68
Q

Target of NIV in COPD

A

decrease paCO2 by 20% from baseline
OR
<48 mmHg

69
Q

NIV in COPD benefit

A

mortality at 1 year
(high PIP of 25 PEEP 5 in this study)

Kohnlein, Lancet 2014

70
Q

BLVR indication/patient selection (4)

A
  1. hyperinflation due to severe emphysema (ok if it is homogenous)
  2. nonsmoking >4 mo
  3. BMI <35
  4. Has been stable on <20 mg prednisone
71
Q

BLVR risk

A

PTX 20-30% (most in the first 3 days)

71
Q

BLVR benefit (5)

A

improved FEV1
Dyspnea
6MWD
QOL
RV

NOT mortality

72
Q

COPD is related to (7 comorbidities)

A
  1. HF (20-70%)
  2. CAD and MI 30 days after AECOPD
  3. Osteoporosis (emphysema and severity of airflow F>M, low BMI)
  4. GERD
  5. Metabolic syndrome >30%
  6. OSA overlap –> WORSE prognosis
  7. PVD
73
Q

Factors associated with increased risk of exacerbation

A
  1. SINGLE BEST PREDICTOR regardless of severity: prior exacerbations
  2. Blood AEC >300

Others: advanced age, PH, cobormid conditions, h/o antibiotic use, severity of airflow limitation

74
Q

Most common cause of COPD exacerbation

A

infections

viral = longer recovery

75
Q

What increases mortality in COPD

A
  1. frequent exacerbations (1y after hospitalization, 28% mortality)
  2. PaCO2 >50 mmHg (33% mortality in 6 mo, 43% mortality at 1 year)
76
Q

Benefit of antibiotics in AECOPD

A
  1. shorten recovery time
  2. reduce risk of treatment failure
  3. reduce hosp duration
77
Q

Contraindication to BLVR (12)

A

Noncomplete fissure (collateral ventilation) (CT Chest and AI) >95% completion is good –> then use another method to check this by obstructing airflow (CV-, flow should cease after a while)

DLCO <20
FEV < 15 or >45%
RV/TLC >150-175%
TLC >100
RVSP >45
LVEF <45
Hypoxemia paO2 <44 mHg
Hypercapnia >60
Large bullae >30% occupation
Nodule that is high risk to be malignant
Smoking

LIBERATE trial

78
Q

Evaluation of when to give O2 in high altitude/flight in COPD

A

COPD with resting SpO2 <92% or <95% and dyspnea, do a 6MWT

COPD with SpO2 <84% with 6MWT, HAST is advised

If >84% while walking 6MWT, no in-flight O2 is advised

79
Q

Benefit in NIV with high-intensity vent during sleep and what type of vent

A

mortality benefit
decreased rehospitalization

ASV

80
Q

Definition of bronchopulmonary dysplasia

A

need for O2 at least for 28 days after birth

81
Q

How long do you have to do pulm rehab to see the evidence-based benefits, and what are the benefits

A

24 mo

Prolongs walking distance and COPD assessment scores (BODE)

82
Q

Criteria for List for lung transplant in COPD

A

One or more of the following:

BODE 7-10
FEV <20%
Mod-severe PH
History of severe exacerbations
Chronic hypercapnea

Has to be age <70 and BMI 16-35

PULMONARY BOARDS (9 decks)

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