COPD Flashcards
conditions that make it hard to exhale all of the air in the lungs
Obstructive lung disease
how many people does COPD affect in the US?
32 million
what # cause of death in the US?
4th
triad of COPD
chronic bronchitis
emphysema
asthma
chronic bronchitis definition
chronic inflammation and thickening of the walls of the bronchial tubes with excess mucus
emphysema definition
abnormal, permanent enlargement of air spaces distal to terminal bronchioles accompanied by destruction of their walls and without obvious fibrosis
when does COPD start?
later in adulthood (40s), worsens with age
when does asthma start?
childhood, does not worsen with age
what triggers COPD
smoking inhaled fumes pollution dusts chemicals
what triggers asthma
allergens
weather
heredity
symptom pattern of asthma
symptom-free between attacks
symptom pattern of COPD
chronic, occurring all of the time
airflow restoration in asthma
can be treated and quickly restored
airflow restoration in COPD
some airflow can be restored by quitting smoking and taking prescribed meds
three main issues of COPD
airway inflammation
mucociliary dysfunction
airway structural changes
biggest culprit of COPD
smoking
other causes of COPD
environmental factors airway hyerresponsiveness alpha1-antitrypsin deficiency IVDA HIV GERD
environmental factors contributing to COPD
air pollution
chemical fumes
dust
second hand smoke
airway hyperresponsiveness is characterized by
easily triggered bronchospasm
how do we assess airway hyperresponsiveness
bronchial challenge test with methacholine or histamine
how does the bronchial challenge test work?
blow an irritant at the pt and see their response to it before treating them
when do we use a bronchial challenge test?
when spirometry test is not conclusive
what pathologies do we see airway hyperresponsiveness in?
asthma
COPD
what is the genetic predisposition to COPD
alpha1-antitrypsin deficiency (AAT)
how is AAT inherited
autosomal co-dominant
pathophys behind AAT deficiency
lack of protein released from liver that protects lung parenchyma from elastolytic breakdown
what other pathology do we see AAT issues with?
liver issues
what patient population do we see AAT in?
younger patients (around 26)
what should we do if we suspect AAT?
bloodwork!
how many IV drug users get emphysema?
2%
how does IVDU result in COPD?
pulmonary vascular damage due to insoluble fiber (such as talc, cornstarch, cotton fibers, and cellulose) in IV drugs
what HIV population is it common to see COPD in?
those with CD4 counts >500
how many HIV pts have COPD?
23%
what is the most common non-infectious pulmonary disease amongst HIV pts?
COPD
what GI pathology exacerbates COPD?
GERD
how many COPD patients have GERD?
28%
what is presence of COPD and GERD associated with?
increased risk of hospitalization
when does DOE occur in COPD?
in 6th decade
by the time FEV1 is less than 50% normal
most common variable to grade COPD severity
FEV1
what kind of cough do COPDers have?
productive cough
worse in AM
3 general symptoms of COPD
productive cough
acute chest illness
wheezing (especially with exertion)
best single predictor of an airflow obstruction?
history of >40 pack-years of smoking
PE findings for COPD
respiratory rate (increases with severity) increased JVP cyanosis accessory muscle use barrel chest decreased breath sounds distant heart sounds hyperresonance prolonged expiration coarse crackles on inspiration peripheral edema
term for accessory muscle use
hoover sign
why does a hoover sign occur?
flattened diaphragm
describe a “blue bloater
obese frequent cough/expectoration accessory muscle use coarse rhonchi wheezing right sided heart failure symtoms (edema, cyanosis)
how advanced are blue bloater’s COPD
end stage
describe a pink puffer
thin barrel chest little-no cough/expectoration pursed lips accessory muscle use tripod hyperresonant wheezing distant heart sounds
what is the FEV1/FVC level for COPD?
<70%
what determines how effectively gases are exchanged between the blood and airways in the lungs?
diffusion lung capacity with CO (DLCO)
how do they test DLCO?
put pt in a glass box and blow CO at them to assess diffusion
pt inhales CO, helium, and O2 and holds breath for 10 seconds
gas levels analyzed from exhaled breath
pCO2, pH, and HCT relative levels with COPD DLCO
increased CO2
decreased pH
increased HCT
why is HCT increased in COPD?
body’s response to not having enough oxygen
overcompensates by creating more RBC
Xray findings in COPD
low flattened diaphragm
hyperinflation
increased AP retrosternal airspace
narrow cardiac silhouette
what happens in small airway disease in COPD?
airway inflammation and remodeling
what happens in parenchymal destruction in COPD?
loss of alveolar attachments
decrease of elastic recoil
what causes small airway disease and parenchymal destruction?
inflammation
what does small airway disease and parenchymal destruction cause?
airflow limitation
what does the GOLD criteria stand for?
global initiative for chronic obstructive lung disease
who contributes to the GOLD criteria?
NIH and WHO
3 criteria areas for GOLD
symptoms (based on modifed medical research council (mMRC) or COPD assessment test (CAT)
airflow obstruction (FEV1)
exacerbation hx
relative difficulty and scale for mMRC questionaire?
easy (1 question)
grade 0-4
COPD assessment test format
rate a few questions 0-5
how do we ultimately want to classify COPD patients based on their severity?
category A-D
MOA of SABA
beta2 agonist
relaxes bronchial smooth muscle
inhibits release of immediate hypersensitivity mediators from mast cells
indications for SABAs
adults and kinds
COPD
Acute asthma exacerbations
exercise-induced asthma prophylaxis
drug interactions of SABAs
beta blockers
adverse effects of SABAs
tachycardia URI Nausea Pharyngitis **a-fib **hypokalemia
generic for SABA
albuterol
brand names for SABA
ventolin, proventil
pregnancy category of SABAs
C
clinical teaching of SABA
warn of side effects proper inhalation rinse wash mouthpiece if used > 2x/week consider controller therapy
SAMA MOA
anti-cholinergic effects
suppresses tightening of bronchial smooth muscle
anti-secretory properties
indications of SAMAs
adults and kids
COPD
asthma exacerbation
allergic rhinitis
adverse effects of SAMAs
headache URI bronchitis xerostomia dry nasal mucosa **bronchospasm **anaphylaxis **glaucoma
what med is often mixed with albuterol (to make duoneb)
SAMAs
generic SAMA
ipratropium
brand SAMA
atrovent HFA (MDI)
pregnancy category of SAMA
B
clinical teaching for SAMAs
avoid activities requireing mental alertness or coordination –> dizziness
improvements from nasal spray may be delayed
proper inhalation technique
SABA + SAMA MOA
beta2 agonist and anti-cholinergic effects
suppresses tightening of bronchial smooth muscle
anti-secretory properties
indications for SABA+SAMA
adults and kids
COPD
asthma exacerbation
adverse effects of SABAs+SAMAs
headache URI **bronchospasm **anaphylaxis **hypokalemia
generic of SABA + SAMA
albuterol/ipratroprium
brands of SABA+SAMA
combivent (MDI)
DuoNeb (neb)
pregnancy category of SABA+SAMA
B
clinical teaching for SABA+SAMA
avoid activities requiring mental alertness/coordination
improvments from nasal spray possibly delayed
proper inhalation technique
LABA MOA
beta2 agonist
relaxes bronchial smooth muscle and inhibits release of immediate hypersitivity mediators from mast cells
indications for LABAs
COPD
asthma
exercise-induced asthma prophylaxis
what class drug reduces need for rescue medications by 21%
LABAs
what class drug has the black box warning of increased risk for asthma related death, intubation, or hospitalization in ages 4-11 but not when combnined with an inhaled steroid
LABA
adverse effects of LABAs
HA musculoskeletal pain **death **prolonged QT **asthma exacerbations
generics of LABAs
salmeterol
formoterol
salmeterol brand
serevent (LABA)
formoterol brand
foradil (LABA)
pregnancy category of LABA
C
clinical teaching of LABAs
not for acute exacerbation
adverse effects
inhalation technique
LAMA MOA
anti-cholinergic effects
suppresses tightening of bronchial smooth muscle
anti-secretory properties
indications of LAMAs
COPD
adverse effects of LAMAs
URI xerostomia bronchitis constibation **bowel obstruction **bronchospasm **glaucoma
generic of LAMA
tiotropium
brand of tiotropium
Spiriva (LAMA)
pregnancy category of LAMAs
C
clinical teaching of LAMAs
avoid activities requiring mental alertness or coordination
improvements may be delayed
proper inhalation technique
LAMA + LABA MOA
anti-cholinergic and LABA
indications of LAMA+LABA
COPD
adverse effects of LAMA+LABA
pharyngitis diarrhea extremity pain **asthma related death **anaphylaxis **HTN **hypokalemia **prolonged QT
generic of LAMA + LABA
umeclidium/vilanterol
umeclidium/vilanterol brand
anoro ellipta
pregnancy category of LAMA+LABA
C
clinical teaching of LAMA+LABA
if using other inhalers, use at least another minute before using another
ICS+LABA MOA
beta2 agonist relaxes bronchial smooth muscle and inhibits release of immediate hypersensitivity mediatorys from mast cells
mimics cortisol with salt-retaining properties
indications for ICS+LABA
adults and kids
COPD
asthma
adverse effects of ICS+LABA
oral candidiasis GI upset HA nasopharyngitis URI **hypokalemia **glaucoma **cataracts **asthma related death
generic of ICS + LABA
formoterol/budesonide
salmeterol/fluticasone
formoterol/mometasone
brand of formoterol/budesonide
symbicort (ICS+LABA)
`brand of salmeterol/fluticasone
advair (ICS+LABA)
brand of formoterol/mometasone
dulera (ICS+LABA)
pregnancy category of ICS+LABA
C
clinical teaching of ICS+LABA
not indicated for acute reduced growth rate in kids adrenal supression rinse mouth oral infections
MOA of PED4i
reduces neutrophil and eosinophil counds in lungs
PDE4i stands for
phosphodiesterase-4 inhibitor
indications for PDE4i
COPD (chronic, exacerbation, prophylaxis)
adverse effects of PDE4i
weight loss GI upset influenza back ache dizziness HA insomnia **suicidal thoughts
generic of PED4 i
roflumilast
roflumilast brand
daliresp (PDE4i)
pregnancy category of PDE4i
C
clincial teaching for PDE4i
not for acute bronchospasm
warn SE
report weight loss
report depression, anxiety, suicidal ideation, unusual changes in behavior
theophylline MOA
bronchodilation through smooth muscle relaxation
suppression of airway stimuli
class of theophylline
methylxanthene
indications of theophylline
COPD
asthma exacerbation
asthma
newborn apnea
adverse effects of theophylline
nausea vomiting HA insomnia restlessness irritability **a-fib **stevens-johnson **seizures
brand of theophylline
theo-dur
pregnancy category of theophylline
C
clinical teaching of theophylline
not for acute exacerbations
theophylline toxicity
symptoms of theophylline toxicity
vomitting
arrhythmia
seizures
COPD complications
respiratory infections pulmonary HTN increased risk of heart disease GERD lung CA depression
what happens to FEV1 with smoking cessation
rate of decline is slowed
what reduces the frequency of the common cold which triggers COPD exacerbations?
PPIs
when do we give O2 therapy to COPDers?
when chonically hypoxic
resting O2 <90%
which vaccination should all COPD pts have?
influenza
which vaccination should COPDers >65 have?
pneumococcal
how good is AAT treatment?
questional benefit
what can reduce dyspnea in selected pts?
bullectomy
what surgeries can be done for COPD?
lung volume reduction surgery
lung transplant
is surgery common for COPD?
no
chronic infections in COPD
S. pneumonia
M. catarrhalis
H. influenza
severe infections in COPD
p. aeruginosa
what should we consider with COPD pts and infections?
have a low threshold for treating them because they are more prone
what does airtrapping look like on CXR
hyperlucency (black)
reliever meds for COPD
SABAs
controller meds for COPD
LABAs
preventer meds for COPD
inhaled corticosteroids
definition of bronchiectasis
abnormal, permanent dilation/destruction of bronchi walls where mucous pools
who is bronchiectasis more common in?
slender white women >60
what is lady windermere’s syndrome?
bronchiectasis
what infection did lady windermere die from?
M. avium (MAC)
what is an important cause of lung disease in developing countries?
bronchiectasis
what deficiency is common in bronchiectasis
vitamin D
what is vitamin D deficiency a marker of
disease severity
what are vitamin D deficient bronchiectasis patients more commonly colonized with?
pseudomonas aeruginosa
what bronchi are most affected by bronchiectasis
proximal and medium sized
is dilation of the bronchi focal or diffuse in bronchiectasis
either
how does one get bronchiectasis?
acquired (more common)
congenital
causes of bronchiectasis
congenital infection airway obstruction impaired drainage toxic gas exposure CF
what do affected bronchi show in bronchiectasis?
transmural inflammation
mucosal edema
craters
ulcers
causes of infection in bronchiectasis
S. pneumonia (most common) S. aureus H. influenza M. tuberculosis P. aeruginosa M. avium M.catarrhalis RSV
what causes airway obstruction in bronchiectasis?
foreign body aspiration due to altered mental status or GERD
stroke patients because they cannot protect their airway
impaired drainage with bronchiectasis caused by
CF
primary ciliary dyskinesia
allergic bronchopulmonary aspergillosis (ABPA)-fungal infection
toxic gas exposure in bronchiectasis caused by
chlorine (water disinfectant)
ammonia (used in fertilizer, refrigerants, cleaning solutions)
what caused 1/3 of bronchiectasis
CF
clinical manifestations of bronchiectasis
cough mucopurulent sputum production lasts months-years blood-streaked sputum or hemoptysis little or no sputum can be a sequela of TB
what is bronchiectasis hard to differentiate from?
COPD
non-specific bronchiectasis symptoms
dyspnea
pleuritic chest pain
wheezing
fever
specific symptoms to bronchiectasis
weakness
weight loss
non specific physican exam findings for bronchiectasis
crackles rhonchi wheezing inspiratory squeaks cyanosis
specific bronchiectasis physical exam findings
digital clubbing
wasting
weight loss
what do you make the bronchiectasis diagnosis based off of
clinical presentation
sputum analysis
high-resolution CT (confirmatory)
how do we often control infections in bronchiectasis
fluoroquinolones
how do we reduce inflammation in bronchiectasis
beta agonists
anti-cholinergics
ICS
how do we improve bronchial hygiene
airway mucous clearance-
chest percussion and postural drainage
CF definition
disease of exocrine gland causing production of abnormally thick mucus, leading to blockage of bronchi, pancreatic ducts, and intestines
how is CF inherited
autosomal recessive
chromosome 7
what is the most common lethal hereditary disease in the white population
CF
median age of CF dx
6-8 months
median survival age for CF
41
how many live births are affected with CF
1/3000
what is the genetic defect of CF
defect in CF gene (protein transmembrane conductance regulator (CFTR)
how many mutations are possible in CF
> 1500
what is missing in CF
missing the gene so it doesn’t move the chloride ions out and mucous becomes sticky
what ions are increased/decreased in CF
decreased secretion of chloride
increased reasborption of sodium and water
what other secretions are affected in CF
respiratory tract
pancreas
GI tract
sweat glands have increased viscosity
clinical manifestations of CF
severe lung disease pancreatic insufficiency nasal polyposis sinus disease meconium ileus rectal prolapse chronic diarrhea pancreatitis cholelithiasis cirrhosis
CF PE findings
rhinitis nasal polyps cough tachypnea respiratory distress with retractions wheezes, crackles increased AP chest diameter clubbing cyanosis hyperresonace
what kind of cough to CF pts have?
worse at night and upon awakening
viscous, purulent, green sputum
GI PE findings for CF
abd distention hepatosplenomegaly (portal HTN) rectal prolapse dry skin (vit A deficiency) cheilosis (vit B deficiency) swelling of submandibular or parotid gland aquagenic wrinkling of palms
male urogenital PE for CF
undescended testicles
hydrocele
absence of vas deferens
what percent of CF men are sterile
> 95%
female urogenital PE findings for CF
severe nutritional deficiency –> amenorrhea
what percent of CF female are sterile?
20%
what too abnormalities does vitamin D deficiency cause in CF?
scoliosis and kyphosis
how does CF affect the nose?
sinusitis due to obstruction of sinus ostia
what occurs from inflammation of pulmonary vessels in CF
hemoptysis
what occurs from rutpured alveoli in CF
pneumothorax
what effects does CF have on the GI tract?
pancreatic insufficiency
diabetes (decreased flow from pancreatic duct)
cholithiasis (decreased bile flow = sludge)
other effects on the body from CF
weak muscles due to malabsorption
stress incontinence due to decreased strength of pelvic floor muscles)
diagnosis of CF
postive sweat chloride test or positive genetic test AND one of the following COPD documented pancreatic insufficiency positive family history
what imaging should we do for CF
initially CXR then consider CT
primary goals of treatment for CF
maintain lung function
administer nutritional therapy to maintain adequate growth
manage complications with supplements and vaccines
how do we clear the airways of mucus for CF patients?
bronchodilator before chest physiotherapy
mucolytic- dornase alpha (pulmozyme) + hypertonic saline solution aerosols
what vitamins/ supplements do CF patients need?
vitamins (ADEK)-fat soluble
pancreatic enzymes
high energy, high fat diet
how may we manage diabetes CF complications?
insulin
how may we manage pneumothorax CF complications?
chest tube
will CF patients get nasal polys?
yes –> polypectomy
what GI complications may we have to treat for CF?
ileus
prolapse
gastrotomy tube for supplemental feeding
other treatment for CF
CFTR potentiators
MOA of CFTR potentiators
target defective CFTR protein
indication for CFTR potentiators
patients with IG551D mutation
generic of CFTR potentiator
ivacaftor
brand for ivacaftor
Kalydeco (CFTR potentiator)
