COPD - Aoki Flashcards
Obstructive lung disease - what is happening
air trapping
work of breathing is increased and you will likely end up trapping air because not all of it will come out
Airway diseases
Upper airways Asthma COPD Chronic Bronchitis Broneictasis
Obstructive lung disease - categorized in what two ways
Reversible
Irreversible
Asthma is rev or irrev
rev
COPD is rev or irrev
irrev
Problem with airway - clinical presentation
cough - prod or non
Dyspnea
Dec ex capacity
How do we evaluate flow
Spirometry
Gold standard for obstruction
Capture volume being exhaled
PFT = what
pulmonary function test
What does PFT tell you
Spirometry
Then lung volumes - the size - changes in pressure
Then diffusing capacity - how good gas exchange is
FEV1 means
amount of air that comes out in the first second of forced expiration
FVC means
total amount of air your patient exhales
Forced vital capacity
What will a patient with obstruction show on the PFT lab report
the amount that comes out in first second is less than total exhaled
FEV1:FVC ratio is decreased!
PEF means
peak expiratory flow
when doing forced expiration what is the highest peak - often used for asthma management
If obstruction what happens to volume-time curve
It takes them longer to exhale
Normally we should finish exhalation in how many seconds
6
How do you determine if there is obstruction to air flow - what is the ratio
Yes obstruction if ratio is less than 5th percentile (less than 70%)
No if greater than 5th percentile
How do you know how severe the obstruction is
Look at FEV1 - magic number is 50%
If below 50% you are saying that there is severe obstruction
If they have an abnormal FEV1/FVC ratio - what is the next step
Want to determine if it is reversible or not
Try Inhaled Bronchodilator - and see if there is a response
Flow - volume loop looks like what in a normal/healthy person
upside down ice cream cone!
Should be smooth!
Flow - volume curve - what is the top? and the bottom?
Top = exhalation Bottom = inhalation
Flow - volume curve - what is typical of someone with obstruction
Concave exhalation - sometimes they may not even reach 0 line
Asthma and COPD - the concave is common
Upper airway obstruction - what do you see on flow - volume loop
Flattening of inspiratory portion - someone ate the ice cream!
How is upper airway obstruction tx - what is happening
speech therapy
when they take breath in, they have vocal cord dysfunction - closing on inspiration
Intrathoracic airway - asthma - define
Inflammatory disease of the airways with episodic and reversible airflow obstruction
Asthma - characterized by whay
increased airway reactivity to various stimuli
Epidemiology with asthma
present at different ages - including late adulthood!
Prevalence of asthma
5-7% of total population
Clinical presentation of asthma
Wheezing (narrowing)
Cough - prod or non (defensive mechanism)
Dyspnea
Precipitating factors - asthma
allergens viral infection occupational exposure dust, fumes tobacco exercise gastro reflux post nasal drip medications that induce BC
Pathophysiology - asthma
- inflammatory process
1 airway hyperactivity with bronchospasm - BC
2 inflammation of bronchial mucosal
3 increased mucous production - secretions
Treatment medication - asthma
Bronchodilators - beta agonists (albuterol)
Antiinflammatories
- Steroids
Antileukotriens
What receptor on airway smooth muscle
beta 2
What if symptoms persist with asthma
add an inhaled steroid!
what is the gold standard in patients with persistent asthma
inhaled steroid
What might suffice in those with intermittent asthma
beta agonist BD
Idea of spacer on inhaler
allows for space between mouth so this allows for better delivery - less turbulence this way so that don’t lose medication
Inhaler vs. Nebulizer
More just about technique - the effectiveness is the same for both
Asthma exacerbation - define
Acute or subacute episodes of progressively worsening SOB, coughing, wheezing, and chest tightness or any combination thereof
What to do with asthma exacerbation
use steroids
Status Asthmaticus - define
Acute severe asthma attack that does not respond to usual use of inhaled BDs
Status Asthmaticus - associated with what
sx of potential respiratory failure
Life threatening and require immediate medical attention
COPD - what percent of US population
6.3%
RISK FACTOR - SMOKING
Pop with higher COPD prevalence
65-74 yrs Non hispanic whites Women Low income Current or former smoker
Risk factors COPD
Smoke Occupational dust, chemicals Environmental smoke Air pollution Genes Infections SES Aging
Mechanism of COPD - impacts what
Small airway AND parenchymal destruction
COPD - small airway disease - what is happening
airway inflammation
airway fibrosis, luminal plugs
Inc airway resistance
COPD - parenchymal destruction - what is happening
loss of alveolar attachments
dec of elastic recoil
Chronic bronchitis - define
Cough that occurs every day with sputum production that lasts at least 3 months - two yrs in a row! Plus SOB
Chronic bronchitis - rev or irrev
irrev - remodeling is irreversible
Emphysema -
parenchymal destruction
abnormal and permanent enlargement of airspaces
End up trapping air
Clinical presentation - emphysema?
avg onset over 60
productive cough
dyspnea
Clinical presentation - emphysema - later in the disease
Use of accessory mm to breath
Inc AP diameter
R heart failure may develop
Weight loss
Why have hard time breathing in supine with resp. disease
Depend largely on diaphragm and normally intraabdominal pressure is higher than intrathoracic but when in supine intraabdominal pressure pushes diaphragm so we are stretching it - so it is not in the optimal place to be contracted
Clincial presentation chronic bronchitis
Chronic cough with sputum
Cyanosis
Polycythemia - inc hgb content
COPD is a spectrum of disease T or F
TRUE
COPD includes what
chronic bronchitis and emphysema
COPD - how will your pt present clinically
Accessory mm to breathe Inc AP diameter Pursed lip breathing Prolonged exp phase Tripod position Distant breath sounds
COPD - comorbidities
cardiovascular disease osteoporosis resp infection anx and dep diabetes lung cancer bronchiectasis
Stable COPD - goals of therapy
Reduce symptoms
Reduce risk
Stable COPD - goals of therapy - how do we reduce symptoms
Relieve symptoms
Improve ex tolerance
Improve health status
Stable COPD - goals of therapy - how do we reduce risk
prevent disease progression
prevent and treat exacerbations
reduce mortality
Single most important intervention to prevent disease and slow progression of disease
Tobacco smoking cessation Counseling Nicotine replacement therapy Bupropion Varenicline
Lung function, aging, and smoking graph
With smoking - your lung function goes downhill earlier and faster than the rest of your body
With cessation - will slow down the decline! no matter when you quit it will slow down
Pharmacotherapy in COPD
Not to treat but moreso used to dec symptoms and complications and improve functional status
Long acting BDs usually last how long
12-24 hrs
Inhaled corticosteroid use for COPD
only in advanced, extreme cases
Stage 3 or 4 with significant sx or recurrent exacerbations
Which stage of COPD are we adding therapy in
Stage 2 (moderate)
Systemic steroids for COPD
Only for exacerbations - NOT using it daily
Oxygen therapy - COPD
Use of ox therapy intermittent - no impact on mortality
Continuous - does have impact
Vaccines imporant for COPD
Infleunza
Pneumococcal
Pulm Rehab - COPD - when indicated
Indicated in COPD pts with dyspnea on exertion GOLD for stage 2-4
Pulm rehab - COPD - what does it do
improves exercise capacity dec dyspnea improve QOL dec health care utilization benefits last up to 18 months
COPD acute exacerbation - define
an acute worsening of the patients respiratory symptoms that is beyond normal day-to-day variations and leads to a change in medication
Consequences of COPD exacerbations
neg impact on QOL impacts sx and lung function accelerates lung function decline inc mortality inc costs
COPD exacerbation - assessment - what do you need to determine first
baseline level of respiratory functioning
COPD exacerbation - assessment - what are the signs of a severe exacerbation
mental status changes speaks only with single words silent chest hemodynamic instability labored breathing
What do you wnat to evaluate for - COPD exacerbation - assessment -
possible concurrent conditions like pneumonia, pleural effusion, pneumothorax, CHF
Use of non-invasive ventilation - COPD
Improves resp acidosis
Dec RR, dyspnea
Dec need for intubation
Restrictive pathologies involve what
the layers around the lungs - onion
Limits amount of air you can contain - reflected on total lung capacity
First layer around lungs
visceral pleura
parietal pleura
in between the two you have pleural space
Diaphragmatic dx can present like
restrictive dysfunction
When would you not want to request lung function or spirometry
when patient is acutely ill
Restrictive process - can be due to
NM - myesthenia, GB, SBI Skeletal - kyphosis, scoliosis Diaphragm paralysis Pleural disease - effusion, pneumothorax Parenchymal disease - atelectasis, post surgical, interstitial lung disease, pulm edema
Restrictive can be in the __- or ___
Pulmonary (in the lungs) or in the layers (extrapulmonary)
Restrictive - Total lung capacity - what is standard
if you are 80-100% of your reference, you are good
Restriction less than 80%
Restrictive - how to decide if in the lungs or the layers
look at gas exchange
If normal - think layers
If abnormal - think lungs
Circulation - just pulmonary vasculature - can they be normal on physical exam with sounds
YES - you might hear nothing but they are short of breath and turning blue
Most common cause for pulmonar circulation issue
Pulmonary vascular diseases - DVT!
Imaging for PE
CT!
Is ambulation contraindication with DVT
no
Pulm hypertension can result from
clots
Groups for pulm htn
1 pulmonary arterial hptn
2 LEFT HEART DISEASE
3 chronic hypoxemia
4 thromboembolic
tx for pulm hptn
treat the underlying cause
Can people with COPD and/or restrictive dsyfunction develop pulm hptn
yes
who qualifies for VDs with pulm htpn
only group 1
pulmonary arterial hptn
Resp failure - define
inability of the respiratory system to meet the metabolic demands of the body
Resp failure can be ___ or ___
acute or chronic
Early rehab is critical
Types of resp. failure
1 oxigenatory
2 ventilatory
Resp failure - oxigenatory
gas exchange is impaired
acute vs. chronic - based on oxygen saturation
Resp failure - ventilatory
you are not moving air - acute vs. chronic based on ABG and blood bicarbonate level
Resp failure - what do you want to look at
ABG
Clinical presentation - acute resp failure
progressive dyspnea use of accessory mm paradoxical breathing tachypnea, tachycardia, nasal flaring Cyanosis agitation/lethargic
normalization of blood gas in someone who is in acute respiratory failure is
BAD sign
