COPD Flashcards
COPD is defined as a respiratory disorder largely caused by:
smoking, progressive, par’ally reversible airway obstruc’on, lung hyperinfla’on, increasing severity of exacerba’on
Prevalence
COPD affects > 200M people world wide • 65-100M of whom have moderate to severe COPD • COPD increases > 40 yrs. of age • > 700,000 Canadians • 3rd leading cause of death globally • Underdiagnosis and misdiagnosis of COPD common
What are the prime symptoms of COPD
Shortness of breath and exercise limita’on
Pathogenesis
Amplified inflammatory response in COPD pa’ents • Inflammatory cells • Release inflammatory mediators • Inflammatory mediators • Increased in COPD and amplify the inflammatory response • Differences exist in the inflammatory cells and mediators involved in asthma and COPD • COPD – neutrophilic • Asthma – eosinophilic
Pathophysiological changes in COPD lead to:
Airflow limita’on and gas trapping • Gas exchange abnormali’es • Mucus hypersecre’on • Pulmonary Hypertension • Exacerba’ons • Systemic features
Normal terminal bronchioles and alveoli ->
• Distended bronchioles communica’ng -> with each other • Destruc’on of bronchioles and capillary bed
Hyperinfla-on
Airway obstruc’on progressively traps air in the lungs during expira’on resul’ng in hyperinflation ___________________ Consequence of air trapping • The lungs become overinflated and cause pa’ents to breathe (uncomfortably) at much higher lung volumes.
elasticity decreases in the lung
exercise where : not exhaling all the way and trying to breath again
co2 build up
risk factors
environmental
Exposure to par’cles • Tobacco smoke • Occupa’onal exposures • Air pollu’on • Second hand smoke • Across lifespan (prenatal, childhood, adolescence)
host:
Genes (including alpha-1 an’trypsin deficiency) • Age and gender • Lung growth and development • Asthma/bronchial hyperreac’vity • Chronic bronchi’s • Childhood infec’ons • Physical inac’vity • Nutri’on
COPD Severity: Symptoms and Breathlessness Scale
grade from 0 to 4 (very severe)
Grade 1/
Shortness of breath (SOB) -strenuous exercise to I am too breathless to leave the house, or breathless when dressing or undressing; or presence of chronic respiratory failure/clinical signs of right heart failure
Metabolic Phenotypes of COPD
Emphysema • Cachexia, loss of skeletal muscle mass and fat mass • Anxious facial expression • Accessory muscle use • Indrawing (substernal, subclavicular, intercostal) • Paradoxical movement of the lower ribcage (due to limited movement of the diaphragm) • Use of pursed lip breathing • A “tripod” posture – a posi’on in siqng leaning forward with hands supported on the knees.
Chronic Bronchitis:
Cough with sputum • Central cyanosis • Obesityà Increased subcutaneous and visceral adipose ’ssue • Increased CV risk
Why Skeletal Muscle Dysfunc-on in COPD
Related to COPD Skeletal muscles -reduced strength/ endurance; fa’gue/weakness Ie: malnutrition inflammation hypoxia- low blood oxygen hypercapnia- high co2 levels in blood
Related to co/multi morbidies:
Condi’ons/diseases that can result in muscle dysfunc’on Ie: Deconditoning (not exercising so getting out of shape) Cardiovascular dysfunction (not pumping blood well enough Age-related changes (comorbidities) Electrolyte imbalance Steroid induced myopathy
Consequence of body deple-on
• Respiratory muscle impairment àIncreased lung infec’ons and subsequent respiratory failure • Skeletal and diaphragm muscle weakness àDecreased exercise capacity • Decreased quality-of-life • Weight loss, low body weight àrisk for poor survival
Common co/mul–morbidi-es in COPD
Cardiovascular disease (CVD) - more pressure on the right ventricule• Heart failure • Ischaemic heart disease (IHD) • Arrhythmias • Peripheral vascular disease • Hypertension • Osteoporosis • Anxiety and depression • COPD and lung cancer • Metabolic syndrome and diabetes • Gastroesophageal reflux (GERD) • Bronchiectasis • Obstruc’ve sleep apnea
Hypoxemia
•
Low oxygen levels in the blood • Signs: cyanosis, clubbing, polycythemia • Oxygen > 15 hours/day in chronic hypoxemia improves survival • If not treated: pressure in blood vessels increaseà pulmonary artery hypertension à right sided heart failure
Does COPD affect a person’s nutri-on status? How?
Observa’onal studies have shown that people with COPD do experience issues that impact dietary intake and nutri’on status: Nutri’on issues: fatigue, medication, meal size, severity of COPD, dry mouth, dysphagia, poor apetite • Malnutri’on in 30-60% of inpa’ents and 10-45% of outpa’ents (BMI <20 or <90% IBW)
• Bo\om Line: Small, frequent meals and supplements to limit and avoid early sa’ety, dyspnea; improves compliance to dietary rec. -
Interven-on: COPD Pa-en
issues: inadequate food intake,
reason:
Poor food choices, Appetite is reduced
strategie:
Selecting foods which are higher in calories and protein Use Canada’s Food Guide to plan Adding protein Adding a supplement Adequate milk products
issue: dyspnea/fatigue
reason:
Tired, lack of energy. Early satiety related to hyperinflation of the lungs, causing flattening of the diaphragm and pressure on the abdominal cavity during eating
stratefies:
encourage patient to rest before meals Easy to prepare food suggestions, 6 smaller meals Use bronchodilator and secretion clearance techniques before meals
early satiety: reason
strategie
Drinking too many fluids before or with meals
Smaller meals, more frequently throughout the day, limiting fluids with meals,
social isolation
Difficult to be motivated to shop or prepare meals
Use simple recipes, prepare ahead of time (freeze portions); invite someone else to help cook
Lack of financial resources
May prevent adequate food purchases and limit choices
Budget ideas, shop for foods in season, (ie vegetables/fruits)
What about GERD?
Grade of Evidence C: • GI reflux involved in pathogenesis of acute exacerba’on of COPD. Combina’on of coughing, microaspira’on of gastric contents/bronchospasm, increased intrabdominal pressure may play a role • Observa’onal studies indicate that gastroesophageal reflux disease (GERD) is common in people with COPD and can increase risk of acute exacerba’ons of COPD
Bo\om Line: Lack of dietary interven’on studies for COPD and GERD. Prudent to follow current recommenda’ons for managing symptoms
What about supplements?
Grade of Evidence: C
Systema.c Review: • Nutri’on supplements taken during pulmonary exercise rehabilita’on programs have been shown to result in improved energy intake and weight gain. • No benefit of nutri’on supplements on nutri’on status and exercise capacity with COPD • Long term use of steroids and effect on bone
Bo\om Line: People with COPD should consume adequate Calcium and vitamin D according to DRI Frequent doses of oral nutri’on supplements (125 mls, 3x/day) than larger volumes help to avoid gastric sa’ety and dyspnea complica’ons and improve compliance
Will omega-3 fa]y acids, magnesium supplements help my breathing?
Grade of Evidence: D
• Observa’onal studies data inconsistent regarding the protec’ve effect of omega – 3’s or fish intake • Lack of interven’on studies; inconsistent protec’ve effect à no current recommenda’on for addi’onal omega 3’s or magnesium for preven’ng or trea’ng COPD
Bo\om line: Assess current intake to meet adult rec.
An-oxidant supplementa-on for COPD?
Grade of Evidence: B, C, D • Observa’onal studies and clinical trials: receiving high an’oxidant intake of food or supplements (vitamin C, vitamin E, beta-carotene, zinc)à no beneficial effect or significant improvement in lung func’on.
Bo\om Line: Prudent to recommend indiv. consume a diet that meets the DRI’s
Nutri-on - COPD
Nutri’onal needs omen recognized late in disease • The > severity of airflow obstruc’on/limita’on and hypoxemia; > nutri’onal needs and weight loss • Malnutri’on associated with COPD can lead to a reduc’on in muscle mass, changes in propor’on and size of muscle fibres and muscle dysfunc’on.
• Early Interven.on – Op.mize Nutri.o
COPD and Underweight
Grade of Evidence: C • Observa’onal studies: stable COPD, BMI <20, low FFM are independently associated with increased disease severity and poor prognosis Ie: Malnourished: ______ Malnutri’on evaluated by: ______ • Low FFM: - posi’vely correlated with airway obstruc’on, lung hyperinfla’on and inspiratory load. - shown to be an independent predictor of long term survival in pts. requiring long term supplemental O2
Bo\om Line: Importance of early nutri’on interven’on
Overweight and COPD
Challenging as pa’ents have difficulty in preparing, and selec’ng healthy food choices and incorpora’ng exercise when they are experiencing symptoms ie: Fa’gue, SOB
• Recommenda’ons: weigh mangment counselling
individual group sessions
