COPD Flashcards
what is the definition of COPD ?
respiratory symptoms due to persistent airway obstruction due to inflammation of the small airways and parenchymal destruction
COPD was formerly subdivided into what ?
Chronic bronchitis: productive cough (cough with expectoration) for at least 3 months each year for 2 consecutive years
Emphysema: permanent dilatation of pulmonary air spaces distal to the terminal bronchioles, caused by the destruction of the alveolar walls and the pulmonary capillaries required for gas exchange
what is the aetiology of COPD?
smoking
Exposure to air pollution or fine dusts
Nonorganic dust: industrial bronchitis in coal miners
Organic dust: ↑ incidence of COPD in areas where biomass fuel (e.g., wood, animal dung) is regularly burned indoors
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Endogenous factors
- Lung growth and development abnormalities
- Recurrent pulmonary infections and tuberculosis
- Premature birth
- α1-Antitrypsin deficiency!!!
what is the classification of COPD ?
GOLD classification
classifies COPD according to the severity of airflow limitation (GOLD 1–4) and the ABCD assessment tool
Classification based on airflow limitation in patients with FEV1/FVC < 70%
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Gold 1
symptoms :mild
FEV1 % predicted : ≥ 80%
Gold 2
moderate
50% ≤ FEV1 < 80%
Gold 3
Severe
30% ≤ FEV1 < 50%
Gold 4
< 30%
what is the classification of COPD with combined assessment tools?
Group A
- degree of severity : GOLD 1/2
- exacerbation per year : 1 or less with no hospital admission
- symptoms : mild
- mMRC dyspnea a scale : <2 or equal
- CAT score : <10
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Group B
- degree of severity : GOLD 1/2
- exacerbation per year : 1 or less with no hospital admission
- symptoms : severe
- mMRC dyspnea a scale : >2 or equal
- CAT score : 10 or more
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Group C
- degree of severity : GOLD 3/4
- exacerbation per year : 2 or more
or 1 or more hospital admission - symptoms : mild
- mMRC dyspnea a scale : <2
- CAT score : <10
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Group D
- degree of severity : GOLD 3/4
- exacerbation per year : 2 or more
or 1 or more hospital admission - symptoms : severe
- mMRC dyspnea a scale : 2 or more
- CAT score : 10 or more
what is the CAT score
mMRC dyspnea scale
CAT score
assessment tool to quantify impact of copd on patient’s functional status. Patients rate symptoms including cough, phlegm, chest tightness, breathlessness, activity limitation, confidence to carry out activity, sleep, and energy levels.
mMRC
assessment tool - evaluate extent of patient’s functional disability caused by dyspnea
0 - dyspnea only with strenuous exercise
4 - too dyspneic to leave the house or breathless when dressing
Classification based on underlying morphological changes?
CENTRILOBULAR EMPHYSEMA (CENTRIACINAR EMPHYSEMA)
common type of emphysema
Classically seen in smokers
destruction of the respiratory bronchiole (central portion of the acinus); spares distal alveoli
Usually affects the upper lobes
=========== PANLOBULAR EMPHYSEMA (PANACINAR EMPHYSEMA)
Rare type of emphysema
Associated with α1-antitrypsin deficiency
Characterized by destruction of the entire acinus (respiratory bronchiole and alveoli)
Usually affects the lower lobes
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CICATRICIAL EMPHYSEMA
caused by exposure to quartz dust
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GIANT BULLOUS EMPHYSEMA
Characterized by large bullae (congenital or acquired) that extrude into the surrounding tissue
Bullae may rupture, leading to pneumothorax.
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SENILE EMPHYSEMA
Loss of pulmonary elasticity with age may lead to an emphysematous lung.
clinical features of COPD ?
Chronic cough with expectoration
Dyspnea and tachypnea
Pursed lip breathing
The patient breathes in through the nose and breathes out slowly through pursed lips.
Prolonged expiratory phase
end-expiratory wheezing
crackles,
muffled breath sounds
coarse rhonchi on auscultation
Cyanosis due to hypoxemia
Tachycardia
clinical features of advanced COPD?
jugular vein distention
Barrel chest: most commonly seen in individuals with emphysema.
Asynchronous movement of the chest and abdomen during respiration
Use of accessory respiratory muscles due to diaphragmatic dysfunction
Hyperresonant lungs,
Decreased breath sounds on auscultation: “silent lung”
Peripheral edema (most often ankle edema)
Right ventricular hypertrophy with signs of right heart failure and cor pulmonale
Hepatomegaly
Often weight loss and cachexia
Secondary polycythemia
Confusion: due to hypoxemia and hypercapnia
Nail clubbing in the case of certain comorbidities (e.g., bronchiectasis, pulmonary fibrosis, lung cancer)
according to their appearance COPD is classified into ?
pink puffer
emphysema
CF : non cyanotic cachexia pursed lip breathing mild cough
PaO2 - slightly reduced
PaCO2 -normal
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blue bloater
chronic bronchitis
CF:
productive cough
overweight
peripheral edema
Pao2 - markedly reduced
PaC02 = increased, early hypercapnia
what is the diagnosis of COPD ?
Spirometry
FEV1 decreases more than FVC, causing the ratio to decrease as well
FEV1/FVC < 70%
Decreased FEV1
Increased FRC and RV
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TLC
Chronic bronchitis: normal
Emphysema: increased
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Postbronchodilator test
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Blood gas analysis and pulse oximetry
ABG: only indicated when O2 is < 92%
Decreased pO2: partial respiratory failure
Decreased pO2 and increased pCO2: global respiratory failure
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Imaging
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other tests
Testing for AATD: recommended for all patients with COPD regardless of age or ethnicity !!!
Gram stain and sputum culture: in the case of suspected pulmonary bacterial infection (e.g., fever, productive cough, new infiltrate on chest x-ray)
how to perform and what is the objective of the bronchodilator test ?
Objective: assesses reversibility of bronchoconstriction
Procedure
Spirometry to establish a baseline
Inhalation (e.g., salbutamol)
Perform spirometry again after ∼10–15 min.
Results: FEV1/FVC < 0.7 is diagnostic of COPD (in patients with typical clinical features and exposure to noxious stimuli).
irreversible bronchoconstriction: COPD is more likely than asthma.
reversible bronchoconstriction Asthma is more likely than COPD.
what is the general treatment of COPD ?
Cessation of tobacco use: single most effective step to slow the decline in lung function
Pneumococcal vaccination: reduces the incidence of community-acquired pneumonia and invasive pneumococcal diseases
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Influenza vaccination (annual): reduces the incidence of lower respiratory tract infections and death in COPD patients
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Pulmonary rehabilitation
Indicated in patients with GOLD B, C, and D
Includes physiotherapy with breathing exercises
Physical activity helps maintain endurance and alleviate dyspnea.
Supportive treatment (e.g., postural drainage)
Vitamin D3 and calcium in cases of deficienc
Vitamin D3 also reduces the risk of acute exacerbations.
what is the therapy of copd according to combined assessment tool?
A
Any bronchodilator (SABA or LABA)
exacerbation :
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B
Any long-acting bronchodilator (LABA or LAMA)
exacerbation : LABA AND LAMA
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C
LAMA
exacerbation : LAMA and LABA (preferred)
LABA and ICS
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D
LAMA
If highly symptomatic (CAT > 20):
LAMA AND LABA (preferred)
Consider LABA and ICS in patients with high eosinophil count
exacerbation :Triple therapy with LAMA, LABA, and ICS
Consider adding roflumilast if FEV1 < 50% predicted and chronic bronchitis
Consider adding macrolide (e.g., azithromycin) in former smoker
other treatment options for COPD?
Long-term oxygen therapy (LTOT) indicated in the case of:
PaO2 ≤ 55 mm Hg or
SaO2 ≤ 88% at rest
Mucolytics (e.g., N-acetylcysteine) liquefy mucus by reducing the disulfide bonds of mucoproteins
Ventilatory support: CPAP is useful in patients with COPD and obstructive sleep apnea.
