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Nayla Foundations Exam 3 > COPD > Flashcards

COPD Flashcards

1
Q

What does GOLD stand for

A

Global initiative for chronic Obstructive Lung Disease

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2
Q

COPD is the

A

4th leading cause of death in the world, and projected to be the 3rd by 2020 (d/t continued exposure to RF and aging of population)

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3
Q

What are the treatment objectives

A
  1. relieve and reduce impact of symptoms

2. reduce risk of adverse health events that can affect pt later

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4
Q

What are the GOLD levels of evidence

A

A: RCT, high quality evidence w/o significant limitation or bias
B: RCT with important limitations, limited body of evidence
C: non-random trials, observational studies
D: panel consensus judgement

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5
Q

What is COPD (definition)

A

common, preventable and treatable disease with PERSISTENT RESP SX and AIRFLOW LIMITATION due to airway or ALVEOLAR ABN, caused by SIGNIFICANT exposure to noxious particles/gas

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6
Q

What are the most common respiratory symptoms

A

Dyspnea (popcorn!)
Cough (first to shoe)
Sputum production
(these are underreported by patients)

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7
Q

What are the RF for COPD

A 
#1- Tobacco Smoking! 
also, biomass fuel exposure (stoves w/o chimney), fuel exposure, and air pollution
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8
Q

Patients with COPD due to fuel exposure have less __

A

Emphysema

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9
Q

What host factors predispose a pt to COPD

A

genetic abnormalities (asthma as kid, low birth weight)
abnormal lund development
accelerated aging

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10
Q

What happens during the course of COPD

A

exacerbations- acute worsening respiratory Sx needing additional therapy

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11
Q

COPD is associated with __ in most patients

A

significant concomitant chronic diseases- this increases M&M

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12
Q

COPD is more prevalent in what people

A

Those 40+ y/o, compared to those less than 40
M>W
Smokers>non-smokers

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13
Q

COPD exacerbations are responsible for the

A

greatest proportion of total COPD financial burden

Direct costs in U.S. are 32 billion $

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14
Q

What is “Disability adjusted life year” (DALY)

A

sum of years lost d/t premature mortality/years of live lived with disability, adjusted for severity of disability

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15
Q

What factors affect disease progression

A 
genetics, age, gender
lung growth/development
particle exposure
socioeconomic status
asthma
chronic bronchitis
infections
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16
Q

What is the pathology of COPD

A

chronic inflammation and structural changes

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17
Q

What is the pathophysiology of COPD

A

airflow limitation and gas trapping
gas exchange abnormalities
mucus/pulmonary HYPERsecretion

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18
Q

What processes allow COPD to have such detrimental effects

A

Oxidative stress
Protease inhibitors
inflammatory cells/mediators
peribronchiolar and interstitial fibrosis

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19
Q

When should COPD be considered

A

if the patient has dyspnea, cough, or sputum production (top 3 Sx), and/or Hx of exposure to RF

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20
Q

What test is required to make diagnosis

A

Spirometry! (shows SEVERITY of limitation and helps you make therapeutic decisions)
FEV1:FVC <70 confirms airflow limitation

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21
Q

What are the goals of COPD assessment

A

determine level of airflow limitation
impact of disease of pt health
risk for future events

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22
Q

What are concomitant diseases often present with COPD

A 
CVD
skeletal muscle dysfunction
metabolic syndrome 
osteoporosis
depression/anxiety
lung cancer
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23
Q

More detail on the top 3 COPD symptoms

A

Dyspnea: progressive, worse with exercise
Cough: intermittent, can be dry, recurring wheeze
Sputum: any pattern

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24
Q

What are OTHER symptoms of COPD

A

wheezing, chest tightness, fatigue, weight loss, syncope, rib fx, ankle swelling
depression/anxiety

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25
Q

What medical history indicates COPD

A

Fix (esp. mom)
comorbidities (cardiac, asthma, fibrosis)
smoking, occupation, environment RF exposure

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26
Q

Are physical exams diagnostic

A

Not usually- but they help r/o other DDx

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27
Q

When should you NOT use spirometry

A

for screening an asymptomatic patient

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28
Q

What are obstructive spirometry results

A

FEV1: reduced
FVC: normal
FEV1:FVC: reduced

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29
Q

What are the GOLD classifications of severity of airflow limitation

A

1: Mild, FEV1 >80%
2: Moderate, FEV1 50%-80%
3: Severe, FEV1 30%-50%
4: Very severe, FEV1 <30%

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30
Q

How do you truly diagnose COPD

A

Symptoms + RF + Spirometry

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31
Q

What are the tests used to assess COPD

A

*COPD assessment tool (CAT)
*Modifiec Medical Research Council questionnaire (mMRC)
(SGRQ too complex for in office)

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32
Q

What is the biggest RF for a future exacerbation

A

History of an exacerbation

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33
Q

How do you treat the classes of COPD

A

Mild: SABD
Moderate: SABD + abx/bronchodilators
Severe: hospitalizations

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34
Q

What lab study can help predict exacerbations

A

Blood eosinophils (if treated with LABA and w/o ICS)

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35
Q

What is the ABCD assessment

A

A: mMRC 0-1/CAT <10– 0-1 Exacerbations, no hospital
B: mMRC 2+/CAT 10+– 0-1 Exacerbations, no hospital
C: mMRC 0-1/CAT <10– 2+ exacerbations/1 hospital
D: mMRC 2+/CAT 10+– 2+ exacerbations/1 hospital

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36
Q

What does the new system (Grade 1-4 + ABCD) allow

A

PCP to better classify patients and understand when to increase or decrease meds

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37
Q

Who should be screened for AATD (alpha-1 antitrypsin deficiency)

A

all patients with COPD Dx (at least once)

<45 y/o with pan lobular basal emphysema

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38
Q

What are AATD levels

A

low concentration (<20% of norm) highly suggestive of homozygous deficiency

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39
Q

Some Ddx include

A 
Asthma
CHF
Bronchiectasis
TB
diffuse panbronchiolitis
obliterative bronchiolitis
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40
Q

hat is the KEY to maintenance therapy (greatest capacity to influence natural history of COPD)

A

Smoking cessation- esp. with pharm and nicotine replacement

But, efficiency of e-cigarettes is uncertain

41
Q

How can pharm therapy help

A

it can reduce COPD Sx, frequency and severity of exacerbations, and improve health status

42
Q

What management technique needs to be assessed regularly

A

inhaler technique!

43
Q

What vaccine helps decrease incidence of lower respiratory tract infections

A

Influenza

pneumococcal (PCV 13, and PPSV 23 for all 65+)

44
Q

What helps improve survival of patients with severe resting chronic hypoxemia

A

long term oxygen therapy

45
Q

When should Oxygen NOT be routinely prescribed

A

If patient has stable COPD
If patient has resting or exercise induced moderate desaturation
(BUT, consider individual patient factors)

46
Q

What patients benefit from long term ventilation (decrease mortality and prevent re-hospitalization)

A

Patients with severe chronic hypercapnia

47
Q

What treatments are beneficial for advanced emphysema patients

A

Surgical or bronchoscope interventional treatments

48
Q

What are brief strategies to help a patient willing to quit

A 
Ask (EVERY patient EVERY time)
Advise (urge them to quit)
Assess (if willing)
Assist (aid in quitting)
Arrange (schedule follow up)
49
Q

What meds are central to symptom management in COPD

A

Inhaled bronchodilators- commonly on a regular basis to prevent or reduce symptoms

50
Q

What med helps improve FEV1 and symptoms

A

regular and as-needed use of SABA and SAMA- combo is superior to individual

51
Q

What do LABA and LAMA do in COPD

A

improve lung function, dyspnea, and reduce exacerbation

52
Q

What are mortality rates following hospitalization

A

23-80%, but they are declining

53
Q

What meds can be used for palliative care

A

opiates, neuromuscular electrical stimulation, oxygen, and blowing a fan in their face helps with breathlessness
nutrition supplement improves respiratory muscle strength in malnourished
pull. rehab, nutrition support, and mind body interventions can help fatigue

54
Q

What is the standard of care for decreasing M&M in patients hospitalized with exacerbations

A

Non-invasive ventilation as Non-invasive Positive Pressure Ventilation

55
Q

What is lung volume reduction surgery (LVRS)

A

parts of lung are resected to reduce hyperinflation, which improves mechanical efficacy of respiratory muscles - esp in Emphysema patients

56
Q

What is a downside to LVRS

A

increased M&M- so instead, some opt to do a less invasive bronchoscope approach to lung reduction

57
Q

What should management strategies be

A

pharmacologic Tx complemented with non-pharmacologic Tx

58
Q

What should effective management be based on once COPD has been diagnosed

A

individual assessment to reduce current symptoms and future risk of exacerbation

59
Q

What are ways to reduce RF exposure

A

Smoking cessation
Efficient ventilation
Clinicians advise pt to avoid continues exposure/irritants

60
Q

What three types of counseling were found effective in treating tobacco dependence

A

Practical, social support of family and friends, social support outside of Tx

61
Q

What facilitates smoking cessation

A

First line pharm (varenicline, bupropion, nicotine gum/inhaler/nasal spray/patch)
Financial incentive programs

62
Q

How do Pharm Tx help treat stable COPD

A

reduce symptoms, risk and severity of exacerbations, and improve health status and exercise tolerance- but they are inhaled, to PROPER TECHNIQUE

63
Q

When are LABA and LAMA preferred over short acting

A

patients with only occasional dyspnea

Inhaled>oral

64
Q

When is Theophylline recommended

A

when other long term treatment bronchodilators are unavailable/unaffordable

65
Q

Long term ICS is NOT recommended as

A

long-term monotherapy- must add LABA with it!

66
Q

When can you consider adding a PDE4 inhibitor

A

If patient is not responding to LABA+ICS+LAMA and has very severe airflow obstruction

67
Q

What meds are not recommended when managing COPD

A

Anti-tussive
Statins
Methylxanthines

68
Q

What dosing therapy is recommended for managing COPD

A

initiation and subsequent escalation and deescalation pharm management
BUT, not for groups C and D

69
Q

What med can be added to a group D patient that is a former smoker and still having exacerbations

A

Macrolide (Azithromycin!)

70
Q

What is “self management”

A

a major component of chronic care model that’s aim is to motivate, engage and coach patients to positively adapt their behaviors and develop skills to better manage their disease

71
Q

What are essential, recommended, and local dependent NON-pharm guidelines

A

Essential: smoking cessation
Recommended: physical activity
Dependent: flu/pneumo vaccine

72
Q

When is long term oxygen therapy recommended

A

PaO2 <7.3 or SaO2 <88%- twice in three weeks

PaO2 7.3-8 or SaO2 <88% if evidence of P-HTN or peripheral edema (CHF), or polycythemia (H >55%)

73
Q

When should surgical or bronchoscope modes of lung volume reduction be considered

A

In patients with emphysema and hyperinflation refractory to optimized medical care

74
Q

What is recommended for patients with a large bulla

A

Bullectomy

75
Q

When should a lung transplant be considered

A

Very severe COPD if w/o contraindications

76
Q

What should “end of like care” conversations involve

A

discussion with patient and family about their views on resuscitation, advanced directives, and place of death preference

77
Q

Is patient education important

A

Yes- but when used alone, no evidence that it will change patient behavior

78
Q

When is rehab indicated

A

in all patients with relevant symptoms/at high risk for exacerbation

79
Q

How should you monitor disease progression in your patient

A

Measurements: FEV1 decrease
Symptoms: ask about cough, sputum, dyspnea, fatigue, activity limit, sleep disturbance
Exacerbations: frequency, severity, type, and cause
Imaging: indicated if clear or worsening symptoms
Smoking status: ask at each visit

80
Q

What should patient monitoring focus on

A 
Dose of Rx meds
adherence to regimen
inhaler technique
current regimen effectiveness
side effects
81
Q

What usually precedes an exacerbation

A

respiratory tract infection

82
Q

What initial bronchodilators are recommended to treat an acute exacerbation

A

SABA (inhaled) +/- short acting anticholinergic

83
Q

What chronic med should be started before leaving the hospital

A

long acting bronchodilators

84
Q

How long and why use systemic corticosteroids

A

5-7 days

to improve FEV1, oxygenation, and shorten recovery time

85
Q

Can antibiotics be used?

A

Sometimes, for 5-7 days

to reduce risk of early relapse, shorten recovery time and hospitalization duration

86
Q

What should be the first mode of ventilation used in COPD with acute respiratory failure

A

Non-invasive mechanical ventilation

87
Q

How are exacerbations classified

A

Mild (use SABD)
Moderate (SABD + Abx +/- oral corticosteroids)
Severe (hospitalization), can appear with acute respiratory failure

88
Q

This is NOT respiratory failure

A

RR: 20-30 w/o accessory muscles
No change in mental status
Hypoxemia improved with O2 mask (28-35%)
No PaCO2 increase

89
Q

This is Acute Respiratory Failure, non-life threatening

A

RR >30 with accessory muscles
No change in mental status
Hypoxemia improved with O2 mask (25-30%)
PaCO2 elevated 50-60 mmHg (hypercarbia)

90
Q

This is Life threatening Acute Respiratory Failure

A

RR >30 with cessory muscles
Acute change in mental status
Hypoxemia not improved w/ O2 mask (or needs >40%)
PaCO2 elevated >60 mmHg (hypercarbia)

91
Q

What are potential indications for hospitalization

A

Severe Sx (worse dyspnea, high RR, low O2 sat, confusion, drowsy)
Acute respiratory failure
New onset cyanosis, peripheral edema, etc.
Exacerbation fails to respond to initial medical management
Presence of serious comorbidities (HF)
Insufficient home support

92
Q

How do you manage a NON life threatening exacerbation

A 
ass severity, blood gases, chest imaging
Give O2 therapy
Bronchodilators 
\+/- corticosteroid, abx, NIV 
*Monitor fluid balance, consider heparin, treat associated conditions
93
Q

What are indications for ICU admission

A 
Severe dyspnea not relieved with therapy 
changes in mental status
persistent or worsening hypoxemia 
need INVASIVE mechanical ventilation 
hemodynamic instability
94
Q

What are indications for NIV

A

Respiratory acidosis (PaCO2 >6)
Severe dyspnea w/ signs of respiratory muscle fatigue
Persistent hypoxemia despite O2 therapy

95
Q

What meds reduce frequency of exacerbations

A 
Bronchodilators (LABA/LAMA)
Corticosteroid regimen (LABA+ICS)
NSAID (Roflumilast) 
Anti-infective (vaccine, long term macrolide) 
Mucoregulators
96
Q

What is a main cause of death in COPD patients

A

lung cancer

97
Q

What comorbidity is associated with increased risk of exacerbations

A

GERD

98
Q

What other comorbidities are frequent

A

Cardiovascular (CVD, HF, IHD, PVD, HTN, arrhythmia)
Osteoporosis, depression/anxiety
Bronchiectasis, obstructive sleep apnea

99
Q

If a patient has COPD with a bunch of comorbidities, what should your attention be on

A

Ensuring simplicity of treatment to minimize polypharmacy

Nayla Foundations Exam 3 (5 decks)

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