COPD Flashcards
What diseases are included in COPD?
COPD encompasses several diffuse pulmonary diseases including chronic bronchitis, asthma, and emphysema
COPD description
Progressive development of irreversible airway obstruction which leads to limited airflow.
COPD vs. Asthma
COPD - irreversible
Asthma - reversible
COPD definition
- Chronic airflow limitation
- Airflow limitation not fully reversible with bronchodilators
- Minimal variability in day to day symptoms
- Slowly progressive and irreversible deterioration in lung function leading to progressively worsening symptoms
- Associated with systemic consequences
COPD Risk factors
- smoking (90%) typically >20 pack years
- cannabis use (1 joint is equivalent to 2.5-5 cigs)
- severe viral pneumonia early in life (leads to scarring of lungs)
- aging
- airway hyperactivity
- occupational exposure (dust/chemicals)
- pollution (outdoor and indoor)
Which obstructive lung diseases act on bronchus?
- Chronic bronchitis
- Bronchiectasis
- Asthma
Which obstructive lung disease acts on the bronchioles?
Bronchiolitis (small airway disease)
Which obstructive lung disease acts on the alveoli?
Emphysema
Chronic bronchitis major pathology
- Mucus gland hyperplasia
- Excess mucus
- Inflammation
Bronchiectasis major pathology
Airway dilation & scarring
Asthma major pathology
- Smooth muscle hyperplasia
- Excess mucus
- Inflammation (eosinophils)
Bronchiolitis major pathology
Inflammatory scarring & obliteration
Emphysema major pathology
- Airspace enlargement
- Wall destruction
- No fibrosis
COPD is characterized by…
varying degrees of chronic inflammation of the small airways and destruction of alveolar walls
COPD pathology
- Mucous Gland Hyperplasia- more so in larger airways, mucous hypersecretion leading to a chronic productive cough
- Squamous Metaplasia- replacement of normal ciliated columnar epithelium by squamous epithelium
- Loss of ciliary function-leads to impairment of the normal functioning of mucociliary escalator
COPD chronic inflammation and fibrosis pathology
- occurs in small airways, characterized by CD8 lymphocyte, macrophage, and neutrophil infiltration, with release of pro-inflammatory cytokines
- recurrent infections may perpetuate airway inflammation
How does COPD cause emphysema?
due to alveolar wall destruction causing irreversible enlargement of airspaces distal to the terminal bronchiole (acinus) with subsequent loss of elastic recoil and hyperinflated lungs
Locations of emphysema
- Panlobular- occur with dilated aispaces evenly distributed
- Centrilobular or proximal- occur with dilated airspaces found in association with the respiratory bronchioles
- Paraseptal- occur with dilated airspaces at the edge of terminal bronchial unit and abutting a fixed structure, such as the pleural or a vessel
COPD pathology continued…
- Thickened pulmonary arteriolar wall and remodeling-occur with chronic hypoxia (leads to increase in vascular resistance, and pulmonary hypertension in some COPD patients)
- Increase in airflow resistance- multifactorial. Small airway inflammation reduces the airway lumen. Secretions may be present in the airways.
How does emphysema affect small airways?
Emphysema destroys the radial attachments to the small airways, which normally holds airways open and resist dynamic compression
COPD Symptoms
- Increased sputum production
- More purulent sputum
- Progressive dyspnea, decreased exercise tolerance (“I can’t do what I used to.”)
- Wheezing
- Chest tightness
- Non specific symptoms- malaise, sleepiness, depression
Symptoms depending on severity
- Increased respiratory rate
- Hyperexpanded or barrel chest
- Prolonged expiratory time >5 seconds
- Pursed lip breathing
- Use of accessory mm of respiration
- Diminished breath sounds
- Possible crackles/rales
What are the signs of cor pulmonale?
ankle edema, raised jugular venous pressure, warm peripheries, bounding pulse
COPD Stage 1: Mild
- Spirometry shows mild airflow limitation (FEV1 > 80% predicted; FEV1/FVC < 0.70)
- Primary symptoms are chronic cough and sputum production
COPD Stage 2: Moderate
- Spirometry shows a worsening airflow limitation (FEV1 > 50% and < 80% predicted; FEV1/FVC < 0.70)
- Patients often experience dyspnea, which may interfere with their daily activities
COPD Stage 3: Severe
- Spirometry shows severe airflow limitation (FEV1 > 30% and < 50% predicted; FEV1/FVC < 0.70)
- Symptoms of cough and sputum production typically continue, dyspnea worsens, and repeated exacerbations occur.
COPD Stage 4: Very Severe
- Spirometry shows very severe airflow limitation (FEV1 < 30% or < 50% predicted; FEV1/FVC < 0.70 plus chronic respiratory failure)
- Complications such as a respiratory failure or heart failure may develop
Chronic Bronchitis definition
- Increased mucus production and recurrent cough present on most days for at least 3 months (out of 12 months) during at least 2 consecutive years
- Increased sputum production is the result of mucus hypersecretion
- Enlargement of seromucus glands in the tracheobronchial tree, along with an increase in the density of glands
Chronic Bronchitis Clinical Presentation
Patient will c/o: productive cough, SHOB with or without wheezing, cough up blood, morning headache (hypercapnia) and frequent infections (lung), weight gain
Chronic Bronchitis Physical Exam
- cyanosis (hypoxemia)
- wheeze may or may not be heard on auscultation
- course breath sounds/rhonchi (mucus in airways)
- diminished breath sounds (secondary to barrel chest/hyperinflation and air trapping)
- distant heart sounds
- pedal edema
- tachycardia
- fatigue
*blue bloaters
Emphysema Definition
The destruction of interalveolar septa, occurs in the distal or terminal airways and involves both airways and lung parenchyma
*Most severe form of COPD
Emphysema Clinical Presentation
Patient will c/o: minimal cough, little to no sputum, SEVERE SHOB, weight loss
Emphysema Physical Exam
- thin (cant eat because working so hard to breath/using so much energy to breath)
- barrel chest
- minimal wheezing
- accessory muscle use (elbows on thighs)
- pursed lip breathing
- pink in color
- breath sounds diminished
- tachycardia
*pink puffers
Emphysema Auscultation, Palpation, Percussion
- Auscultation: decreased breath sounds (decreased airflow, prolonged expiratory time, decreased vocal resonance, dry basilar rales
- Palpation: decreased tactile fremitus
- Percussion: hyperresonance with, decreased excursion of diaphragm
Emphysema work-up
Labs: ABG and CBC
Tests: PFT, ECG, CXR, CT scan, pulse ox, nocturnal oximetry/sleep study, sputum culture, exercise test – walk them to see how low their pulse ox drops.
What will CXR show for emphysema?
small heart, hyperinflated lungs, flat diaphragms and possible bullous changes
When should you do ABG on Emphysema patient?
if the patient is always hypoxic or if there’s a risk of CO2 increase.
What are GOLD guidelines for COPD?
GOLD guidelines use a combined COPD assessment approach to group pts according to symptoms and risk for exacerbations.
General treatment of COPD exacerbations
Nebulizer + steroids +/- antibiotics
Mild COPD
- Symptoms: Dyspnea, cough, change in sputum color/thickness
- Signs: Wheeze, +/-fever, DOE, chest tightness
- No need for ABG
- Treatment @ home
- Quick relief meds: increase dose and/or frequency of albuterol and ipratropium
- Corticosteroids: Consider if inadequate response to initial BD treatment or FEV1< 50% pred.
- Antibiotics if fever present, color of phlegm
Moderate COPD
- Symptoms: New or more intensity of sx; failure to respond to tx
- Signs: accessory MM use, cyanosis, hypoxia
- ABG: If O2 sat <90% on RA
- Treatment in hospital
- Quick relief meds: Albuterol Q 1 hour
- Corticosteroids: IV steroids
Severe COPD
- Symptoms: severe sx not responding to initial tx, confusion, lethargy
- Signs: Hemodynamic instability
- ABG: PaO2 <50, PaCO2 >70, pH <7.30
- Treatment in ICU
- Quick relief meds: high dose albuterol + ipratropium
- Corticosteroids: IV steroids
COPD Treatment
- Vaccinations: Pneumonia + Influenza
- Home oxygen is the ONLY drug therapy that is documented to improve the natural history of COPD
Home oxygen for COPD
- Helps to prevent cor pulmonale
- Decreases mortality if used >15 hours/day
- Start as soon as they meet requirements
- Indications: PaO2<55, SaO2<89 consistently
COPD Complications
- Pulmonary HTN due to reactive vasoconstriction secondary to hypoxemia
- Cor Pulmonale refers to the altered structure (hypertophy or dilatation) and/or impaired function of the RV that results from chronic pulmonary hypertension that is associated with diseases of the lung (COPD)
- Pneumothorax due to formation of bulla in emphysema
What questions should you ask COPD patients?
- Have your ever been prescribed oxygen? If so, where is it?
- How often have you been using inhaler or nebulizer?
- Do you even have a nebulizer?
- How often do you usually take these?
- Have you taken steroids before? If so, what has worked in the past? MDP vs high dose prednisone x amount of days or taper?
- Do you have a pulmonary physician?
