COPD Flashcards
45yo male with chronic productive cough over the past three months. Over the last 2 years this has been episodic. He has been worked up with other causes ruled out. What is his most likely diagnosis?
Chronic bronchitis
What is the definition of emphysema?
Abnormal and permanent enlargement of the air spaces distal to the terminal bronchioles that is accompanied by destruction of airspace walls.
What is the physiology of chronic obstructive pulmonary disease?
Lungs too big = difficult getting air out
Therefore: Wheeze
What is the most common cause of COPD?
Smoking
List THREE risk factors for COPD
- Smoking***
- Alpha-1 antitrypsin deficiency (1%)
- Environmental (air pollution, occupational exposure)
You suspect your patient has Chronic Obstructive Pulmonary Disease. What FIVE questions would you ask on history?
- Do you smoke? (Pack years)
- Any history of environmental exposure to air pollution or occupational chemicals?
- Severity of dyspnea?
- Chronic cough?
- Sputum production?
- Wheeze?
- History of exacerbations - Frequency ER visits and Hospitalizations (severity)
- Evidence of complications - Righ Heart Failure=pedal edema, progressive weight gain
- Current or previous treatments? Inhalers, oral corticosteroids and antibiotics
You suspect your patient has acute exacerbation of chronic obstructive pulmonary disease. List FIVE symptoms you would expect on history.
- Increased sputum production
- Dyspnea
- Wheeze
- Prolonged/Recurrent cough
- Decrease exercise tolerance
- Increase inhaler use
You suspect your patient to have chronic obstructive pulmonary disease. How would you confirm this diagnosis?
Pulmonary Function Test (spirometry):
FEV1/FVC < 0.7
FEV1 < 80% predicted
In your patient with COPD if you were to order lab work what would you order and why?
Hemaglobin - to rule out anemia or rule in COPD if polycythemia (hematocrit >56%)
alpha-1 antitrypsin if pt <45yo or strong FHx COPD
Your patient has COPD and presents with increased dyspnea. Why would you order plain flim chest radiography?
Rule out comorbidities - DDx:
Bronchietasis, Cancer, Tubercolosis, Pneumonia, Pneumothorax, Congestive Heart Failure
What are some indications for pulse oximetry and arterial blood gases?
Acute Exacerbation of COPD
O2 Sat 92%
FEV1 <50% predicted
You have just diagnosed your patient with COPD, list FIVE non-medical treatment options
- Smoking cessation = prevent progression & increase survival
- Encourage healthy diet
- Recommend updated vaccinations - annual influenza and pneumoccocal
- Recommend regular exercise
- Referral to respiratory technician OR Pulmonary Rehabillitation Personel
List FOUR classes of medical treatment for COPD
- Short-acting ß2-Agonists - salbutamol
- Short-acting anticholinergics - ipratropium
- Long-acting ß2-Agonists - salmeterol/formeterol
- Long-acting anticholinergics - tiotropium
How would you treat a patient with stable mild COPD?
Short-acting bronchiodilators:
- Anticholinergics - ipratropium prn
- ß2-Agonists - salbutamol prn or terbutaline prn
You start your patient on an anticholinergic inhaler, discuss potential side effects.
Dry mouth
Dilated pupils=mydriasis
Urinary retention
Glaucoma if in eye
You have started your patient on a salbutamol inhaler as needed, what are some side effects you need to discuss?
Tremors
Nervousness
Tachycardia
Palpitations
Your patient’s spirometry results show FEV1 = 60% predicted, what category of COPD is he in?
FEV1 50-80% predicted = Moderate-Severe
How would you treat patients in the moderate-severe COPD class?
- Stable Mod-Severe = long-acting bronchiodilator (tiotropium) + SABA prn
- Mod-Severe with < 1 AECOPD/yr = Tiotropium + LABA + SABA prn
- Mod-Severe with Hx AECOPD = Tiotropium + LABA-ICS + SABA prn
What is the spirometry criteria for severe COPD?
FEV1 < 30% predicted
What should you consider in management of severe COPD?
- Long acting theophylline - need to monitor blood levels for toxicity.
- Referral to pulmonology
*Pts should be on regular tiotropium and LABA-ICS
What are the indications for supplemental oxygen?
Stable COPD with hypoxemia:
- PaO2≤55mm Hg on ABG OR SaO2<88%
- PaO2 55-59mm Hg with bilateral ankle edema/cor pulmonale/polycythemia >56%
Under what conditions would oxygen supplementation not be indicated?
- Respiratory arrest
- Hemodynamic instability
- High risk aspiration
On physical examination what may be some signs of COPD?
- Hypoxia/cyanosis
- Hyperinflation: widened anteroposterior chest diameter, hyperresonance on percussion, and diminished breath sounds
- Cor pulmonale: accentuated second heart sound, peripheral edema, jugular venous distension, and hepatomegaly
- WOB: accessory respiratory muscles, paradoxical abdominal movement, increased expiratory time, and pursed lip breathing
- Wheeze
- Cachexia
Your patient presents with acute exacerbation of COPD, what are the likely causes?
Viral Upper Respiratory Tract Infection (50%)
Bacterial (50%) - Streptococcus pneumonia, Haemophilus influenza, Moraxella catarrhalis
Severe = Klebsiella, Gram negatives e.g. Pseudomonas aeruginosa
List FIVE instances where you would admit a patient with acute exacerbation of COPD
- Increasing intensity of symptoms or new physical signs
- Severe COPD with failure of AECOPD response to Tx
- Severe comorbidities
- Frequent AECOPD
- Older age with insufficient home support
You have a patient with dyspnea, worsened sputum production and cough. How would you treat the patient?
- Dyspnea = SABA and anticholinergics
- oral corticosteroids (Prednisone 25-50mg po daily x 7-14d)
- Antibiotics b/c has 2/3:
i) increase dyspnea/cough*
ii) increase sputum*
iii) sputum purulence
You decide your patient with AECOPD is low risk and want to start antibiotics, which do you choose?
Low risk = ø O2, ø severe comorbidities (CHF/CAD), infrequent AECOPD (<3/yr):
- Doxycycline 100mg po daily x 7d
- Clarithromycin 1g po daily x 7d
- Amoxil
- Septra
Your patient with AECOPD is high risk, and you would like to start antibiotics, what could you use?
High risk = severe comorbidities (CHF/CAD), >3 AECOPD/yr:
Amoxicillin-Clavulin 875mg po bid x 7d
Macrolide (Azithromycin/Clarithromycin)
Quinolone (Moxifloxacin 400mg po daily x 5d)
You suspect your patient to have AECOPD, what investigations would you order and why?
- Pulmonary function tests (spirometry) if no previous spirometry
- Arterial Blood gas if SpO2 low
- White Blood Cell count = ?infection
- Blood culture = ?infection
- Hemaglobin = ?hemolysis 2° infection
- Chest X-ray = ?CHF/Pneumonia/Pneumothorax
- Sputum gram stain + culture if purulent with ABx in last 3months, poor lung function, frequent exacerbations
Mr. Snook a 65yo male patient in your practice presents for refill of his medications, he has end-stage chronic obstructive pulmonary disease, but is stable. You should not forget to discuss ONE issue during this visit, what is it?
Re-evaluate and document is code status.
***You should periodically discuss and document his code status***
