COPD and Bronchiectasis Flashcards
preventable and treatable disease, is characterized by persistent respiratory symptoms and airflow limittaion that is due to airway and/or alveolar abnormalities caused by significant exposure to noxiuos particles or gases
COPD
Most common respiratory symptoms of COPD
Dyspnea
cough
sputum production
Most important risk factor in COPD
Cigarette smoke
key cell playes in COPD
Neutrophils, macrophages and CD8
Pathogenesis of COPD
Plasma leakage, sensory nerve impairment, smooth muscle constriction
____is already present in the early stages of COPD
Inflammation
Gold stage 0
asymptomatic but smoking individual
Airway inflammation is characterized by
Increased numbers of neutrophils, macrophages and CD8 lymphocytes
Effect of COPD in bronchus
Wall thickening and inflmmation -> mucus gland hypertrophy -> increased secretions -> phlegm
Effect of COPD in bronchiole
Wall thickening->inflam_>repair->remodeling->loss of alveolar attachment
Effect of COPD in alveoli
Wall thinning ->inflammation ->elastolysis coalescence ->decreased elasticity
In asthma the basement membrane
Thicken because smooth muscles are hyper reacting
Mediators in asthma
IL-4 IL5
LTD4, histamine, ROS
Mediators in COPD
IL-8 and TNF alpha
LTB4, ROS
Effects in asthma are in the___
All airways
Effects in COPD are in the _____
Peripheral airways
Mechanisms underlying airflow imitation in COPD
Small airway disease
PArenchymal destruction
Cause of airflow limitation
Irreversible, Fibrosis and narrowing of airways
Loss of elastic recoil due to alveolar destruction
Primary site of airflow limitation:
Peripheral airways (bronchi and nronchioles <2mm)
PFT results in COPD
FRC increases
RV increases to detriment of inspiratory capacity decreases
TLC and TV stays the same
Pathophysiological Changes in COPD
Mucus hypersecretion Ciliary dysfunction Airflow limitation Pulmonary hyperinflation Gas exchange abnormalities Pulmonary hypertension cor pulmonale - leads to death
total volume of air expired after a full inspiration
Fore vital capcity
volume of air expired in the first second during maximal respiratory effort
FEV1
Goal of COPD Assessment
To determine level of airflow limitation, its impact to patient’s health status and the risk of future events to eventually guide therapy
Classification of severity of airflow limitation in COPD:
GOLD 1: mild FEV1/FV <0.70
GOLD 2: Moderate; 50%
Tools for assessment in COPD
mMRC breathlessness scale
COPD assessment Test (CAT)
Clinical COPD questionnaire
Modified MRC Questionnaire
Assesses patient’s level of breathlessness or dyspnea at various activities
COPD Assessment Test
8 item questionnaire
Scoring system : 0 to 40
If score is at least 10-more = symptomatic
Assess Risk of exacerbation
Ask history:
> 2 in the past year
FEV1 postBD <50% predicted
1 hospitalization for COPD in the past year
Performed when COPD develops in patient of caucasian descent >45 years or with a strong family history COPD
Alpha-1 Antitrypsin Deficient Screening
Characterized by persistent airflow limitation with several features usually associated with asthma and COPD
Asthma-COPD Overlap syndrome
How to manage ACOS
treat asthma first, then COPD
Goals of therapy in COPD
Reduce symptoms
Reduce risk
Avoidance of risk factors through:
Greatest capacity to influence the natural history of COPD
Smoking cessation
Brief strategies to help the patient willing to quit smoking
ASK ADVICE ASSESS ASSIST ARRANGE
Stimulate beta-2 receptors, thus relax airway smooth muscle
Beta-2 agonist
Block the effect if Ach on M3 receptors and relax smooth muscle
Anti-cholinergics
Exact MOA controversial; Antagonize bronchoconstriction through PDE4 inhibition in smooth muscle;
Methylxanthines
Eacerbations are reduced by ______in patients with severe and very severe COPD (GOLD 3 and 4) and a history of exacerbations
ROFLUMILAST (PDE4) inhibitors
Management of Group A
Give bronchodilator->Evaluate effect _> change if ineffective
management of group B
Mandatory put in LAMA or LABA depending on patient and behavior on side effect
management of Group C
LAMA, if with exacerbations, shift to LAMA +LABA
Alternatively LAMA +ICS
management of Groupd D
Dual therapy (LAMA+LABA)
If with exacerbations, sequentially add:
ICS, PDE4, Macrolide, Descalation of symptoms
Pneumococcal polysaccharide vaccine is recommended for those who are
65 years old and older
Younger than 65 with FEV1 <40% predicted
Removal of hyperinflated section
Lung volume Reduction Surgery
an acute event characterized by worsening of the patient’s respiratory symptoms that is beyond normal day to day variation and leads to a change in medication
Exacerbations
Most common cause of COPD exacerbation
Viral infection
Antonisen Criteria
At least two of the following cardinal symptoms:
Shortness of breath
Sputum purulence
Increase sputum volume
or any one of the above plus URTI Wheeze Cough Increased PR/RR
Mild Exacerbations
Requiring more reliever medication
Moderate Exacerbations
Systained worsening symptoms (2-3 days)
Need for antibiotic and or systemic CS
Unscheduled hospital visits
Severe Exacerbations
Require hospitallization
Oxygen saturation
88-92%
Antibiotics should be given to patients with
Increased dyspnea, sputum volume, and sputum purulence
Abnormal and permanent dilatation of the medium-sized bronchi , destruction of elastic and muscular components of their walls, primarily mediated by neutrophils
Bronchiectasis
Primary criteria for bronchiectasis
Impairment of mucociliary drainage in one or both of the lungs.
- Acute or chronic infection
- Anatomic airway obstruction
- Congenital disease that predisposes to chronic infection
enzyme deficiency that produce non-functional cilia
Alpha-1 anti trypsin deficiency
SIte of pathology in bronchiectasis
Medium sized bronchi
- replaced by fibrous tissue
Causes of bronchiectasis
Post infective Mechanical obstruction Deficient immune response Inflammatory pneumonitis Congenital Excessive immune response Abnormal mucus clearance Fibrosis
reed classification
Radiologic classification
Reed classification (Radiologic)
Cylindrical Bronchiectasis -Sections of bronchi are consistently widened
Varicose Bronhiectasis - There are local constrictions and there is an irregular pattern that closely mimics that of the varicose veins
Saccular (Cystic) Bronchiectais - dilation increases towards the peripheral areas of the lung; honeycombing
Predominant organism in sputum of bronhiectasis patient
gram negative
Cystic fibrosis
Mucoviscoidosis
AR disorder
CFTR protein
Cystic fibrosis Diagnosis
Gibson-Cooke Sweat Test
-Gold standard
-Forearm sweat stimulated with pilocarpine
(+) >60mml/L Cl
Clinical features of Cystic fibrosis
Coughing, dyspnea, and expiration of foul, voluminous secretions especially prevalent in the morning
Signet ring sign on Chest CT
bronchiectasis
Only curative treatment of bronhiectasis
Surgical Treatment
