COPD Flashcards
emphysema
air spaces are enlarges as a consequence of destruction of alveaolar septae
chronic bronchitis
dz w/ chronic cough that is productive of phlegm occuring on most days for 3 mnths of the year or for 2 + consectutive yers w. out a defined cuase
what are other causes of COPD?
environmental pollutants, recurrent URI, eosinophilia, bronchial hyperresponsivemenss, alpa 1 antitrypsin
PE of emphysematous COPD
dry cough and weight loss
PE of pt w/ advanced COPD
asthenia, dyspnea, pursed-lip breathing, grunting expirations
Chest exam
- barrel chest=increased AP diameter
- percussion yields increased resonance=caused by hyperinflaion and air trapping
what do you hear on auscultaion?
decreased breath sounds, early inspriatory crackles (cuased by airway inflammation and mucus oversecreation)
what about wheezing in COPD
may not be present at rest, but can be evoked w. forced expiration or exertion
-common finding in exacerbation “continuous musical lung”
what do you hear in pts w. chronic bronchitis?
rhonchi- reflect secretions in the airways, breathing is raspy and loud
Laboratory testss
CXR,, PFT, CBC Puls ox, ABG
CXR
+/- hyperinflation- not sensitive enough to serve as a diagnostice tool
emphysema pathognomic?
parenchymal bullae or subpleural blebs
chronic bronchitis pathogonomic?
nonspecific peribronchal and pervascular markings
PFTS
-The FEV1/FVC ratio is decreased (< 0.70 or less than the lower limit of normal
**must be incompletely reversible w. inhaled bronchodilator
what would a CBC show?
polycythemia from chronic hypoxia
-think impaired gas exchange in lung parenchyma-worsens w/ exercise
what are 3 signs of impending respiratory failure?
hypercapnea, hypoxia, and respiratory acidosis
where is theophylline metabolized?
the liver
Stage 1
mild.
FEV1/FVC < 70% and FEV1 ≥ 80%, with or without symptoms
o Often minimal SOB with or without cough and/or sputum. Usually goes unrecognized that lung function is abnormal
stage 2
moderate.
FEV1/FVC < 70% and FEV1 = 50-80% predicted value, with or without symptoms
o Often moderate or severe SOB on exertion, with or without cough, sputum or dyspnea. Often the first stage at which medical attention is sought due to chronic respiratory symptoms or an exacerbation
STage 3
severe. FEV1/FVC < 70% and FEV1 = 30-50% predicted value, with or without symptoms
o More severe SOB, with or without cough, sputum or dyspnea – often with repeated exacerbations which usually impact quality of life, reduced exercise capacity, fatigue
Stage 4
very severe. FEV1/FVC < 70%, FEV1 < 30% predicted value or FEV1 < 50% with chronic respiratory failure
o Appreciably impaired quality of life due to SOB – possible exacerbations which may even be life threatening at times
How is COPD defined by the GOLD?
a common preventable and treatable disease characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases
what is a COPD exacerbatopm?
an acute event characterized by a worsening of the pts respiratory sx that is beyond normal day to day variations and leads to a change in meds
what are clinical features of an exacerbation?
increase in baseline dyspnea, cough, and or sputum production
what are some non pulmonologic features or an COPD exacerbation?
mental status change, fever, maliase, fatiuge
what must you rule out in someone that presents with a COPD ex?
acute respiratory failure-would need PEEP or mechanical ventialtion
what would some present with that would need a mechanical ventilatro?
hypoxia, hypercaria, tachypnea, shallow pursed-lip breathing,
what are some common PE finding in stable pt in a COPD ex?
decreased breath sounds, wheezing, prolonged expiratory phase
what are some PE findings in more advanced COPD?
barrel-shaped chest, cyanosis, clubbing
what are causes of COPD exacerbations?
infections, exposure to pollutants, and medication nonadherence
what are the most common cause of COPD ex?
viral (1/3) and bacterial (1/2)
what is the most common viral cause
rhinovirus
influenza may be a RF for developing secondary bacterial PNA, MRSA!
common bacterial pathogens?
H. flu, Strep pna, moraxella catarrhalis,
what pt would be more likely to get Pseudomonas aeruginosa
state 3/4 COPD (FEV1 < 50% predicted value)
what are RF for Psuedomonas aurginosa
- low FEV
- chronic use of systemic corticosteroids
- abx use w/in the last 3 mnths
what are some DDX of COPD ex
PNA, heart failure, Pulmonary embolism, heart failure, Pneumothorax
what are factors assoicated with a positive predictablilty for a PE in pts with a COPD ex?
hx of venous throbmboembolism
underlying malignancy
decrease in PaCO2 of at least 5 mmgh
diagnostic evaluation of an COPD ex
- typically a clinical dx
- PE (pulse ox)
-ABG not routinely order, but may be useful for pts with acute or actue on chronic respiratory failure
( helps with basline)
- CXR
- CT of thorax if suspected PE
- CBC
- flu, MRSA swab
- spirometry is not recommended
when would yoou get a sputum culture for a COPD pt
in pts that don’t imporve w/abx (culture w/ sensitivities)
or
pts with comorbid conditions and requrie mechanical ventilation
what causative antigens may you find in the pts urine?
- S. Pneumonia
- Legionella pneumophila
indications for hospital admissions?
**in the future hospitalization may serve as a measure for risk stratification and prognostic indications
- severe signs/sx
- severe comorbidities
- inadequate home support
- older adults
ICU admission?
- noninvasive ventilation (bipap): avoid complications of intubation
- severity
-worsening hypoxemia, respirator acidosis, or failure of noninvasive ventaion
who needs intubations?
-worsening hypoxemia, respirator acidosis, or failure of noninvasive ventilation
what does roflumilast do?
maintenance tx to reduce exacerbations in pts with severe COPD and chronic bronchitis
MOA of roflumilast?
PDE-4 inhibition -increases intracellular adenosine monophosphate causing an overall reducton in inflammatory cells
what are some commonly used short-acting bronchodilators that are helpful with FEV1 improvemnt
SABA (Beta 2): albuterol and levalbuterol
SACA (anticholinergic): ipratropium
are long-acting bronchodilators recommended?
nope. no in COPD exacerbations (salmetrol)
what is the mainstay tx for COPD exacerbaion?
systemic corticosteroids
what is the GOLD recommended dosage?
prednisone 40 mg for 5 days
what are the clinical outcomes of systemic corticosteroid usage?
- imporved lung fxn
- decreased recovery time
- fewer tx failures
when is the use of abx recommended?
- dyspnea, excessive sputum, purulent sputum,
* all pts on mechanical ventalaion need an abx
what is the preferred abx tx?
aminopenicillin +/- clavulanic acid, macrolies, or tetracyclines (but consider local bacterial resistance)
what is the preferred route of abx?
oral, but IV can be used
what is the recommended duration of abx tx for COPD exacerbation?
5-10 days
when to know if pts is ready for discharge?
clinical stability- vital signs and ABG should be stable fo12 to 24 hours before discharge
SABA should not be used more than every 4 hours- and pts should be transition to LABA
what are some interventions that can be used to reduce the freqency of COPD exacerbations?
stope smoking
self-management eduction, pulmonary rehab
vaccine againse flue and PNA
what has been found to reliably slow progression of cOPD
stop smoking
what does pulmonary rehabe included?
nutrition advice, psychological counseling, eduction, exercise training
