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Respiratory 3 > COPD and its medical management > Flashcards

COPD and its medical management Flashcards

1
Q

Definition of COPD?

A

“A preventable and treatable disease state characterized by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and is associated with an abnormal inflammatory response in the lungs to noxious particles or gases, primarily caused by cigarette smoking. Although COPD affects the lungs, it also produces significant systemic consequences”

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2
Q

Components of COPD?

A
  • Preventable and treatable chronic lung disease
  • Heterogeneous group of small airway diseases
  • Airflow limitation is not fully reversible
  • Abnormal inflammatory response to noxious particles of gases
  • Usually progressive
  • A complex systemic disease syndrome
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3
Q

COPD subtypes?

A

A group of diseases characterized by airflow limitation
• Chronic bronchitis

  • Emphysema
  • Bronchiolitis or small airway disease
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4
Q

Chronic bronchitis is?

A

The production of sputum on most days for at least three months in at least two consecutive years when a patient with another cause of chronic cough has been excluded.

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5
Q

What is emphysema?

A

A pathologic diagnosis: abnormal, permanent enlargement of the distal air spaces, distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis.

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6
Q

Three lung diseases not considered to be COPD?

A

• Asthma • Bronchiectasis • Cystic Fibrosis

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7
Q

compare and contrast asthma and COPD?

A
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8
Q

Explain the multi componentness of COPD?

A
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9
Q

What are some risk factors for COPD?

A
  • Smoking – Number one risk factor - single most important • Cigarette >> pipe and cigars • Passive/second hand smoke • Only minority of smokers develop COPD
  • Non-Smoking – • Occupational exposures • Genetic susceptibility • Air pollution  Outdoors  Indoor/biomass • Asthma/hyper responsive airways
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10
Q

Impact of smoking on COPD?

A
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11
Q

Epidimiology of COPD?

A
  • WHO estimates 210 million patients worldwide.
  • NHANES III 23.6 million U.S. Adults
  • 4 th leading cause of death world wide
  • 3 rd leading cause of death in the US
  • 75% or more of patients with COPD remain undiagnosed

US COPD Mortality Rates Have Increased by 163%

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12
Q

COPD and lung cancer risk in men and women?

A
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13
Q

COPD burden?

A
  • Prevalence of COPD among women significantly higher than among men.
  • Since 2000 more women than men have died from COPD
  • Increased risk of women developing lung cancer as compared to men as FEV1 declines.
  • Prevalence of COPD higher in older age groups
  • Economics – Direct cost estimate 29.5 million largely related to acute exacerbation COPD. – Indirect cost estimate 20.4 billion due to lost earning for patient and caregiver.
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14
Q

Pathology of COPD?

A

 Chronic inflammation  Structural changes

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15
Q

Pathogenesis of COPD?

A

 Oxidative stress

 Protease-antiproteaseimbalance

 Inflammatory cells

 Inflammatory mediators

 Peribronchiolar and interstitial fibrosis

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16
Q

Pathophysiology of COPD?

A

 Airflow limitation and gas trapping

 Gas exchange abnormalities

 Mucus hypersecretion

 Pulmonary hypertension

  • Increased airway inflammatory response
  • Protease – anti-protease imbalance
  • Oxidant/antioxidant imbalance and oxidative stress
  • Alveolar loss through apoptosis and Vascular Endothelial Growth Factor (VEGF) decrease
  • Genetic factors
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17
Q

What does Flow equal in the airways?

A

Flow=pressure/resistance

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18
Q

Summarize the pathophysiology of COPD?

A
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19
Q

what is Alpha 1 antitrypsin? how is it released?

A
  • A glycoprotein – The major inhibitor of serum proteases, including neutrophil elastase
  • Degradation of interstitial elastin fibers by elastase is central in the development of emphysema
  • The threshold point for increased risk of emphysema is an Alpha1-Antitrypsin level of about 80 mg/dL which is about 30% of normal
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20
Q

Phenotypes of Alpha1 antitrypsin and the risk of emphysema?

A
21
Q

panlobular versus centrilobular image with emphysema?

A
22
Q

Current COPD disease definitions?

A
  • Chronic Bronchitis –Chronic productive cough for 3 months in each of 2 successive years when other causes of chronic cough have been excluded
  • Emphysema –Abnormal permanent enlargement of airspaces distal to the terminal bronchioles
23
Q

Chest X-rays of a Patient with Advanced Emphysema?

A
24
Q

Chronic bronchitis?

A

Presence of chronic productive cough for 3 months in each of 2 successive years in a patient in whom other causes of chronic cough have been excluded

25
Q

Diagnosis of COPD?

A

The diagnosis of COPD should be considered in any patient who has the following symptoms; cough, sputum production, dyspnea, or a history of exposure to risk factors for the disease.

26
Q

Chest exam with COPD?

A
  • Increased AP Diameter
  • Decreased intensity of breaths and/or heart sounds
  • Wheezing and prolonged expiratory time
  • Pursed-lip breather and use of accessory respiratory muscles
  • Hoover’s sign – inward movement of the rib cage during inspiration

Note: Digital clubbing is not typical in COPD. Consider other diseases process CF, lung cancer.

27
Q

Other clinical findings with COPD?

A
  • Fatigue
  • Depression/Anxiety
  • Weight loss/Muscle wasting
  • Anorexia
  • Osteoporosis vertebral collapse rib fracture from coughing
  • Ankle swelling
28
Q

Pulmonary function tests for COPD?

A

Spirometry pre and post bronchodilatory:

  • Post-bronchodilator FEV1/FVC < 0.70 establishes the presence of persistent airflow obstruction
  • Degree of post-bronchodilator response by FEV1 is not required for the diagnosis of COPD
  • Up to 2/3 of COPD patients can have a significant bronchodilator response despite not having a diagnosis of COPD

Lung Volumes assess for:

  • Hyperinflation TLC> 120% predicted or FRC >120%
  • Air trapping RV > 120%and/or RV/TLC ratio increased
  • Inspiratory capacity to TLC ratio ≤ 25% independent predictor of mortality in COPD

DLCO to assess degree of diffusion impairment

29
Q

COPD diagnostics?

A
  • Radiographic – Chest x-ray – not useful in diagnosing COPD but, helps rule out other diseases – Typical COPD findings: increased airspace, increased radiolucency, flat diaphragm
  • CT – Not recommended for routine diagnostic purposes – Low dose CT – screening for lung cancer (based on age and cigarette smoking history) – In evaluation for lung volume reduction surgery
  • Lab – Alpha 1 Antitrypsin level (by ATS/ERS in all patients diagnosed with COPD) – Arterial blood gases (helpful to have a baseline)
30
Q

Co-morbidities of COPD?

A
  • Weight loss with decreased fat-free mass
  • Muscle wasting and weakness
  • Other systemic effects: –osteoporosis –anemia –depression
31
Q

Goals of COPD management?

A
  • Assess and Monitor Disease – History, physical exam, PFT, labs, chest imaging
  • Identity and Reduce Risk Factors – Improve quality of life – Goal to prevent progression of disease – Avoidance of acute insults – Smoking cessation and air pollutant reduction – Reduce occupational and environmental exposure – Vaccination: flu and pneumococcal – Assess osteoporosis risk
  • Management of Stable Disease – Bronchodilators, steroids, PDE 4 inhibitors – Supplemental O2 as indicated – Improve exercise tolerance/pulmonary rehab – Nutritional evaluation and support to maintain IBW – Psychological support – Palliative care and hospice
  • Manage acute exacerbation
32
Q

Key points of COPD management?

A

► COPD should be considered in any patient who has dyspnea, chronic cough or sputum production, and/or a history of exposure to risk factors for the disease.
► Spirometry is required to make the diagnosis; the presence of a post-bronchodilator FEV1/FVC < 0.70 confirms the presence of persistent airflow limitation.
► The goals of COPD assessment are to determine the level of airflow limitation, the impact of disease on the patient’s health status, and the risk of future events (such as exacerbations, hospital admissions, or death), in order to guide therapy.

► Concomitant chronic diseases occur frequently in COPD patients, including cardiovascular disease, skeletal muscle dysfunction, metabolic syndrome, osteoporosis, depression, anxiety, and lung cancer. These comorbidities should be actively sought and treated appropriately when present as they can influence mortality and hospitalizations independently.

33
Q

Oxygen use in COPD?

A
  • The only therapy that has ever been shown to prolong life in patients with COPD
  • It should be used in all patients with hypoxemia after their condition becomes stable with maximum conventional therapy
34
Q

Long term O2 administration?

A
  • NOTT – Nocturnal Oxygen Therapy Trial Group, U.S. Study – 12 hr O2/d – 2 year survival 59% – 18 hr O2/d – 2 year survival 78%
  • Medical Research Council, British Study – After 5 years no supplemental O2 – 33% survival in control group – After 5 years O2 15 hr/d – 55% survival
35
Q

Oxygen therapy in COPD benefits?

A
  • Relieves hypoxia
  • Proposed additional beneficial affects – Lowers TNF Alpha
  • ? Less wasting – Reduces sympathetic activity – Less skeletal muscle dysfunction – Lowers pulmonary vascular resistance
36
Q

Candidates for home O2?

A
  • Resting PaO2 < 55 mmHg
  • With exercise O2 saturation < 88%
  • Resting PaO2 < 59 and one or more of the following conditions are present: –Peripheral edema/cor pulmonale –HCT > 55% –EKG evidence of P. pulmonale
37
Q

What is required to diagnose COPD?

A

Spirometry

38
Q

Explain the GOLD criteria for COPD severity?

A
39
Q

How do we assess COPD?

A

Assess symptoms:

  • COPD Assessment Test (CAT)
  • Clinical COPD Questionnaire (CCQ)
  • St. George’s Respiratory Questionnaire (SGRQ)
  • Chronic Respiratory Questionnaire (CRQ)
  • mMRC Breathlessness Scale
40
Q

How do we Assess the exacerbation risk?

A

► COPD exacerbations are defined as an acute worsening of respiratory symptoms that result in additional therapy.

► Classified as:  Mild (treated with SABDs only)  Moderate (treated with SABDs plus antibiotics and/or oral corticosteroids) or  Severe (patient requires hospitalization or visits the emergency room). Severe exacerbations may also be associated with acute respiratory failure.

► Blood eosinophil count may also predict exacerbation rates (in patients treated with LABA without ICS).

Exacerbation History • Low risk: 0-1 exacerbation not leading to hospital admission • High risk: ≥ 2 exacerbations, or >1 leading to hospital admission

41
Q

Explain the ABCD model with GOLD?

A

► Consider two patients:  Both patients with FEV1 < 30% of predicted  Both with CAT scores of 18  But, one with 0 exacerbations in the past year and the other with 3 exacerbations in the past year.
► Both would have been labelled GOLD D in the prior classification scheme. ► With the new proposed scheme, the subject with 3 exacerbations in the past year would be labelled GOLD grade 4, group D. ► The other patient, who has had no exacerbations, would be classified as GOLD grade 4, group B.

42
Q

What are the goals of pharmacologic therapy in stable COPD?

A
  • Reduce symptoms
  • Reduce the frequency and severity of exacerbations
  • Improve exercise tolerance and health status
43
Q

What are the drugs we give for stable COPD?

A
  • Beta 2-agonist
  • Anticholinergics
  • Methylxanthines – problematic
  • Inhaled corticosteroids (ICS)
  • Oral glucosteroids
  • Phosphodiesterase-4/(PDE4) inhibitors
  • Antibiotics-macrolides
  • Mucolytic and antioxidant agents (NAC) limited role
44
Q

Explain medical treatment based off of grouping of COPD?

A
45
Q

Summarize the medical management of COPD?

A
  • The goals of management of COPD focus on controlling symptoms, improving quality of life, preventing exacerbations, and slowing the progression of the disease
  • Instituting smoking cessation should be the initial management strategy for COPD.
  • Pharmacologic intervention
  • Non-pharmacologic interventions: pulmonary rehabilitation, optimizing nutrition and vaccination
  • When assessing response to therapy for COPD, several outcome measures in addition to lung function should be taken into consideration.
46
Q

Explain the COPD outcome measure, the BODE index?

A
  • B: body mass index
  • O: Degree of airflow obstruction
  • D: dyspnea
  • E: exercise capacity
47
Q

COPD management flow chart?

A
48
Q

Surgical management of COPD?

A
  • Lung volume reduction:
  • Surgery (LVRS)
  • Bullectomy
  • Endobronchial placement of • valves • Coils, via bronchoscope

or Lung transplant

Respiratory 3 (10 decks)

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