COPD Flashcards
COPD definition
- common
- preventable
- treatable
- Small airway inflammation
- Airway fibrosis
- luminal plugs
- UP airway resistance
- Daily cough with sputum production >3 months, 2 years in a row
Chronic Bronchitis
- parenchyma/alveolar destruction
- Loss of alveolar attachments
- decrease of elastic recoil
Emphysema
COPD Phenotypes
- Emphysema
- Chronic Bronchitis
- ACOS - Asthma COPD Overlap Syndrome
- Emphysema Interstitial Fibrosis Syndrome
- Smoking-related Lung Disease (no obstruction)
All smoker’s get COPD?
NO
Only about 1/4
COPD Risk factors
- CIGS
- Occupational chems
- Environmental smoke
- indoor + outdoor pollution
+ GENOTYPE / INFECTIONS / SOCIO-ECONOMIC STATUS
_#__ leading cause of death
4th in world
3rd in US
Who has more COPD?
Men vs. Women
WOMEN
Once you show symptoms of COPD exacerbations…
The process takes off, no return
COPD associated conditions
- Fat-free mass = low BMI ~ higher mortality
- Impaired systemic muscle function
- Osteoporosis
- Anemia
- Depression
- Pulmonary Hypertension
- Cor pulmonale
COPD Assessment
- Risk factors
- Symptoms
- Spirometry = severity of airflow limitation
- Impact on patient’s health
- Risk of future exacerations
Best predictor of airflow obstruction
40-pack year smoking hx
*look for:
Hz of more than 55 pack years
wheezing
COPD s/s
- dyspnea
- chronic cough
- chronic sputum (whitish/gray)
PE
- Hyperinflation
- hyper-resonance
- DOWN breath sounds
- wheezing
- prolonged expiratory
- crackles on inspiration
Don’t give diuretic for PulmTN
Right-sided failure can’t pump low volume across Pulm HTN pressure, OK for left-sided failure
Tripod
Push abdominal contents up to curve diaphragm
Spirometry COPD
Before + after SABA
Post-bronchodilator FEV1/FVC (<0.7)
*compare to age related normal
FEV1 =
FVC =
FEV1 =4 L
FVC = 5 L
Allergists : 0.8
Pulmonologists: 0.7
GOLD 1:
Mild
FEV1 = 80%< predicted
Gold 2:
Moderate
FEV1: 50%-80%
Gold 3 :
Severe
FEV1: 30% - 50%
Gold 4
Very severe
FEV1: <30%
CXR
- Hyperinflation
- increased lucency
- increased retrosternal space
- UP AP diameter
- flattened diaphragm
COPD other investigations
- Oximetry/Arterial Blood gases
- Caucasian under 45 w/ COPD or FH? –>Alpha 1 anti-trypsin deficiency
- ventilation/perfusion scans NOT HELPFUL unless removing lung section
Mild exacerbation?
Change in bronchodilator dose/antibio use
Moderate exacerbation
Systemic corticosteroids
Severe exacerbation
Hospital Admit
High risk COPD (exacerbation)
Past year:
- 2+ mild/moderate exacerbations
- one+ severe exacerbations
FRC =
Resting state
COPD - exercise decreases inspiratory capacity (IC)
- Residual volume UP
- inspiratory capacity DOWN
- intra-thoracic pressure UP
- CO down
CAT test
Measure of symptoms + impact on health status
Modified medical research council questionnaire
Dyspnea measure
2= fall behind walking with friends
Goals of Tx
REDUCE S/S
*exercise tolerance, health status
REDUCE RISK
- prevent disease progression
- exacerbations
- mortality
COPD tx
- SMOKING CESSATION
- pharmacotherapy/nicotine replacements
- Physical activity
- no pollution
- Vaccination (flu, pneumococcal)
TX
Bronchodilators
- DOWN s/s
- NO CURE
- Beta ags + antichols + theophylline
Systemic steroids?
Only during exacerbation , should be off by 10 day after discharge
COPD A group
SAMA or SABA
Group B Tx
LABA or LAMA
Then
LAMA + LABA
Group C tx
LAMA
Then
LABA + LAMA /OR/ ICS+LABA(no)
Group D tx
LAMA + LABA
then
LAMA+LABA+ICS
If need add:
Roflumilast. /. Macrolide
Nebulizer = low inspiratory capacity
Unhelpful Tx
- alpha-1 antitrypsin (if no deficiency)
- Mucolytics
- antitussives (tesselon pearls) = Give codeine
- vasodilators
Other tx
O2 therapy = Chronic respiratory failure (min 15 hours per day)
Ventilatory support = w/ long term O2
(Good w/ daytime hypercapnea)
COPD surgery
- UPPER-LOBE PREDOMINANT EMPHYSEMA + LOW EXERCISE CAPACITY = lung volume reduction surgery (living area will expand)
- SEVERE COPD? Lung transplantation
New Rx to patient?
Get back in 4 weeks, demonstrate how to use meds
MDI
DPI
SMI
Metered dose inhaler
Dry powder inhaler
Slow mist inhaler
Specific Rx guided by
Patient’s insurance
Gold Category A
- Less symptoms = CAT <10
- Less Breathlessness = mMRC 0-1
- Low risk = 1 exacerbation /year not leading to hospital admit
Gold category B
- more symptoms = CAT >10
- Less Breathlessness = mMRC>2
- Low Risk= 1 exacerbation no hospital admit
Gold category C
VERY LITTLE HERE
- Less symptoms = CAT <10
- Less breathlessness mMRC = 0-1
- High risk = >2 exacerbations no admit OR >1 w/ admit
Gold Category D
*More symptoms : CAT>10
More breathlessness: mMRC>2
*Higher risk: >2 exacerbation no admit OR >1 exacerbation w/ admit
LABAs
Salmeterol
Formoterol
Indacaterol
Vilanterol
SAMA
Ipratropium
LAMAs
Tiotropium
Aclidinium
Umeclidinium
Glycopyrrolate
ICS
Fluticasone
Mometasone
Budesonide
PDE4 inhibitors
Roflumilast
