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Clin Med II- Exam 2 > COPD > Flashcards

COPD Flashcards

1
Q

highest COPD prevalence

A

65-74 YO

morbidity greater in males

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2
Q

Pathphys behind COPD

A

inflammation –> small airway disease (inflammation/remodeling) & parenchymal destruction (loss of alveolar attachments/decrease in elastic recoil) –> airflow limitation

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3
Q

chronic bronchitis

A

mucous blocks airways;

inflammation and swelling further narrows airway

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4
Q

Emphysema

A

damage to alveoli prevent air exchange;

air becomes trapped

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5
Q

Blue bloater

A

Chronic bronchitis

cyanosis and overweight
hypoxemia and respiratory acidosis more common; cor pulmonale from pulm HTN (trouble getting air in AND out)

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6
Q

Pink puffer

A

emphysema

pursed-lip breathing
skin color and thin body
accessory mm. use (makes them thin)

gets air in but can’t get it out

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7
Q

COPD subtypes

A

chronic bronchitis
emphysema
chronic obstructive asthma

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8
Q

What is considered chronic bronchitis?

A

chronic PRODUCTIVE cough for 3+ months during 2 consecutive yrs w/ no other cause

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9
Q

Structural change for chronic bronchitis

A

mucous gland enlargement –> hyper secretion
bronchial squamous metaplasia
loss of ciliary transport

inflammation of bronchial wall and infiltration of sub-mucosal layer by NEUTROPHILS

obstruction is INSPIRATORY and EXPIRATORY

hypoxemia & hypercapnia

less parenchymal damage than emphysema

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10
Q

Emphysema changes

A

entrapment of air in spaces distal to terminal bronchioles due to destruction of alveolar walls
decreased elastic recoil
loss of alveolar supporting structure = airway narrowing

not clearly understood:

  • may be too much elastase
  • may be too little antitrypsin activity

obstruction is EXPIRATORY
not associated w/ significant hypoexmia until later in disease (destruction of capilarry bed, resulting in reduced DLCO)

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11
Q

neutrophil elastase

A

protease enzyme secreted by . neutrophils and macrophages during inflammations; destroys bacteria and host tissue

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12
Q

alpha-1 antitrypsin

A

inhibitor of neutrophil elastase; deficiency leads to breakdown of lung structure by elastase

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13
Q

Asthma

A

chronic inflammatory disorder of airways - EOSINOPHIL MEDIATED

airway hyper-reactivity –> increased secretions, mucosal edema, constriction of bronchial smooth mm. –> airway obstruction

REVERSIBLE

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14
Q

Risk factors for COPD

A 
SMOKING!
enviornmental/occupation
second hand smoke
hyper-responsiveness (asthma)
genetic RF: alpha-1-antitrypsin deficiency (premature emphysema)
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15
Q

Cig smoking

A

stimulates elastase

causes cytotoxic oxygen radicals from WBC’s in lung tissue

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16
Q

How to dx alpha-1-antitrypsin deficiency

A

emphysema <45 YO

process accelerated in smokers w/ AAT deficiency

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17
Q

Clinical presentation of COPD

A

dyspnea (DOE earliest sx), chronic cough, sputum production

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18
Q

PE findings for COPD

A 
tripod positioning
cyanosis
tobacco staining of fingers
JVD, use of accessory mm.
pursed lip breathing
Lung: barrel chest, prolonged expiration, increased resonance on percussion, decreased breath sounds, wheezing, crackles at bases
Heart: S3 gallop, RV lift
ABD: hepatomegaly
Ext: muscle wasting, peripheral edema
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19
Q

pursed lip breathing

A

ordinary breathing allows early bronchial collapse on exhalation; pursed lip breathing achieves resistance to outflow, raising intrabronchial pressure, keep bronchi open; thus more air can be expelled

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20
Q

Heart in COPD

A

S3, RV lift

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21
Q

Cor pulmonale

A

altered strucutre (hypertrophy or dilation) and/or imparied funciton of RV that results from pulmonary HTN associated w/ COPD

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22
Q

Labs/dx for COPD

A 
spirometry
CBC, BNP, cardiac enzymes, metabolic panel, AAT
pulse ox
ABG
EKG
Sputum exam
CXR/HRCT
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23
Q

FVC (forced vital capacity)

A

amt of air forcefully exhaled during max forced expiration (N: 80-120%)

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24
Q

FEV1 (forced expiratory volume in 1 sec)

A

normal: 80-120%

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25
Q

FEV1/FVC ratio

A

% of FVC expired in 1 sec (N: 70-80%; or greater that LLN 5th percentile)

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26
Q

Dx of COPD

A
  1. pre and post bronchodilator (FEV1/FVC <0.7 is obstructive pattern)
  2. review post-bronchodilator FEV1% predicted - determine GOLD grade
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27
Q

PFT in COPD

A

FEV1/FVC < 0.7
decreased FEV1
increased TLC (vital capacity + RV)
Decreased DLCO (if severe emphysema)

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28
Q

CBC in COPD

A

usually normal - r/o anemia
chronic bronchitis - polycythemia due to chronic hypoxia
leukocytosis may be present during acute exacerbations of COPD

29
Q

Pulse Ox

A

if <92%,, assess further w/ ABG

30
Q

ABG

A

usually mild-mod hypoxemia w/o hypercapnia

as disease progresses hypoxemia worsens and CO2 increases (respiratory acidosis)

31
Q

When to obtain sputum culture

A

in-patient and unresponsive to initial abx tx

32
Q

EKG findings in COPD

A

tachy
R atrial enlargement
R axis deviation and/or RVH

33
Q

CXR findings

A

exclude other ddx
signs of air trapping (increased AP diameter, hyperinflaation, hyperlucency, flat diaphragms)
blebs or bullae (pathognomonic for emphysema)
perivascular or peribronchial markings in chronic bronchitis

34
Q

Pathognomonic for emphysema

A

blebs or bullae

35
Q

CXR findings for emphysema

A

hyperinflation (possibly w/ bullae)
flattening of diaphragms
enlargement of retrosternal air space

36
Q

CXR findings suggestive of chronic bronchitis

A

cardiac enlargement
pulm. congestion
increased lung markings

37
Q

chest CT

A

helpful, but not needed for dx
obtain if sxs suggest complication of COPD (pneumonia, pneumothorax, large bullae), alt. dx (PE) or if considering lung volume reduction surgery (HRCT)

38
Q

Tx for group A

A
  1. SABA ORRRR

2. SABA + SAMA combo used PRN

39
Q

Tx for group B

A

long-acting bronchodilator (LABA or LAMA)

40
Q

Tx for group C

A

LAMA

41
Q

Tx for group D

A

LABA + LAMA, or consider ICS + LABA

42
Q

Effects of bronchodilators

A

bronchodilation
improved mucociliary clearance
diaphragmatic action
cardiact contractility

43
Q

SABA drugs

A

albuterol - 2 puffs q 4-6 hrs

44
Q

LABA drugs

A

salmeterol, formoterol

q12 h dosing

45
Q

B2 agonists

A

bronchilation; no effect on sputum/secretions

46
Q

SE of B2 agonists

A

palpitations, tachy, insomnia, tremors

47
Q

SAMA drugs

A 
ipratropium bromide (atrovent)
Ipratropium plus albuterol (combivent)

2 puffs BID-QID

48
Q

LAMA drugs

A 
tiotripium bromide (spiriva) - q daily
Umeclidinium (incruse ellipta) - q daily
49
Q

anticholinergics

A

good bronchodilation;
reduces air trapping in lungs
less cardiac stim. effect

50
Q

SE of anticholinergics

A

dry mouth, metallic taste, HA, cough

51
Q

Combo meds for COPD

A

LAMA + LABA

bevespi aerosphere (BID)
utibron neohaler (BID)
Stiolto respimat (QD)
Anoro Ellipta (QD)
52
Q

Theophylline (methylxanthine)

A

used for refractory cases

toxicity is common
tachy, arrhythmias, seizures, HA, nasea
drug-drug interxns

53
Q

Corticosteroids

A

alone or in combo w/ LABA

Advair, dulera, symbicort, breo ellipta

54
Q

what do ICS do

A

reduce mucosal edema/inflammation by inhibiting prostaglandins –> dec secretions

increase responsiveness to beta-adrenergics

55
Q

SE of ICS

A

oral candidiasis, bruising

56
Q

Tx for AAT

A

Antiprotease (weekly-monthly injections)

costly and controversial

57
Q

Lab values for AAT

A

<11 uM

58
Q

Adjunct therapy for COPD

A

pulm. rehab (Stages B-D)
Oxygen (goal >90%)
lung volume reduction surgery?

59
Q

Supplemental oxygen

A

prolongs survival

min. 12 hrs/day

60
Q

indication for supplemental oxygen

A

chronic dyspnea at rest

PaO2 <55 or SaO2 <88%

61
Q

Caution for supplemental O2

A

may reduce drive to breath and cause resp acidosis (maintain O2 sat 90-92%

62
Q

Minimizing complications

A

flu vaccine
pneumo vaccine (PPV13, PCV23)
exercise
early recognition of infection

63
Q

Acute exacerbation

A

increased dyspnea
increase in cough frequency/severity
sputum increases or becomes purulent

  • contribute to high mortality
64
Q

Trigger of acute exacerbations

A 
respiratory illness (70%)
pollution

viral most common: may lead to secondary bacterial pneumo (H. influenzae, S. pneumo M. catarrhalis, mycoplasma pneumo, pseudomonas)

65
Q

outpatient management of acute exacerbation

A

increase dose of shortacting bronchodilator; add ipratropium if not taking it

oral steroids: 40mg/day x 5 days (reduces recovery time and hospital time)

abx (mod-severe)

hospitilization if severe

66
Q

Abx for uncomplicated COPD acute exacerbation

A

Macrolide***

or cephalosporin, doxy, bactrim

67
Q

Abx for complicated COPD acute exacerbation

A

fluoroquinolone (moxifloxacin, gemifloxacin, levofloxacin) ***

(or augmentin)

68
Q

Indications for hospitilizations

A 
severe s/sx
severe COPD (FEV1<50)
comorbidities
new signs (cyanosis, edema, new arrhythmia)
failure to respond to meds
older
insufficient home support

Clin Med II- Exam 2 (7 decks)

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