COPD - Clinical Approach

Question 1

Define COPD

Answer 1

Group of diseases characterized by an obstructive ventilatory defect

Question 2

Two groups of COPD

Answer 2

1. Chronic bronchitis
2. Emphysema

Question 3

3rd leading cause of death in the USA

Answer 3

COPD

(10 year mortality 50%)

Question 4

3 Obstructive airway disease

Answer 4

1. asthma (reversible)
2. COPD (partially reversible)
3. emphysema

Question 5

Risk factors for COPD (6)

(LO!!!)

Answer 5

1. smoking (80-90%)
2. pollution, dust, chemicals
3. infections
4. allergy/asthma
5. white elderly male
6. alpha-1 antitrypsin deficiency (<1%)

(ask "have you EVER smoked?")

Question 6

COPD is a progressive airflow limiting disease with an abnormal _______ response to noxious gases.

Answer 6

inflammatory (i.e. CD8, MF, neutrophils, IL-8, TNF-a)

Question 7

Define chronic bronchitis

Answer 7

cough w/sputum (3 tbsp) for 3 months out of 2 consecutive years WITHOUT any discernible cause

Question 8

COPD symptoms (3)

Answer 8

1. dyspnea on exertion
2. productive cough
3. acute chest illness

(usually begins in the 5th decade of life)

Question 9

COPD physical signs on auscultation (2)

Answer 9

1. diminished breath sounds
2. rhonchi/wheeze

(can be misdx as asthma; pts prefer this dx)

Question 10

COPD: physical findings (visual inspection)

Answer 10

1. barrel shaped chest
2. horizontal ribs
3. peripheral cyanosis w/elevated JVP
4. Hoover sign (indrawing of lower intercostal spaces during inspiration)
5. low, flat diaphragm

Question 11

COPD: physical findings in the physical examination (2)

Answer 11

1. hyperresonance to percussion
2. prolonged expiratory phase
3. pursed lip breathing

Question 12

Pathophysiology of COPD (6)

(LO!!!)

Answer 12

1. mucus production
2. reduced mucociliary clearance (cough & sputum)
3. loss of elastic recoil
4. increased smooth muscle
5. pulmonary hyperinflation
6. hypoxemia and/or hypercapnia

Question 13

Structures damaged by COPD (3)

(LO!!!)

Answer 13

1. peripheral airways
2. lung parenchyma
3. pulmonary vasculature

Question 14

Describe the early inflammatory changes of COPD (3)

(LO!!!)

Answer 14

1. Increased number of goblet cells
2. Mucous gland hyperplasia
3. Fibrosis, narrowing of peripheral airways

Question 15

In COPD, the repeated cycles of injury and repair of the peripheral airways leads to _______.

Answer 15

scarring, narrowing and fixed obstruction/collapse of airways

(inflammation→ edema, mucus hypersecretion adds to obstruction)

Question 16

Define lung parenchyma

Answer 16

Respiratory bronchioles and alveoli

(aka acinus)

Question 17

Smoking is more likely to cause damage to the ____ lobes, whereas alpha 1 antitrypsin causes damage to the _____ lobes.

Answer 17

• upper
• lower

Question 18

In COPD, all lung parenchyma damage is due to an overproduction of ______ is in response to ______.

Answer 18

• endogenous proteinases
• repeated and prolonged inflammation

Question 19

What is the cause for peripheral airway collapse in COPD?

Answer 19

Destruction of alveolar attachments to the outer wall

(damage to alveoli→loss of elastic recoil)

Question 20

How does cigarette smoke cause damage to the pulmonary vasculature (3)?

Answer 20

1. Causes endothelial dysfunction
2. thickening of the intima
3. increase smooth muscle cells and tone

(chronic hypoxemia→ further vasoconstriction)

Question 21

How can COPD lead to pulmonary hypertension (2)?

Answer 21

1. Increase afterload of the right ventricle
2. Increase viscosity (erythrocytosis) in the right ventricle

(Cor pulmonale (RV Failure) is the end result)

Question 22

In COPD, gas exchange problems occur when the FEV₁ is less than _____

Answer 22

1 L

Question 23

Proximal acinar (centrilobular/centriacinar) emphysema is an inflammation of proximal acinus due to tobacco abuse (or coal workers pneumoconiosis). Smoke gets trapped early in the bronchioles and proximal acinus, leading to _____.

Answer 23

Elastase production increases proximally, destroying elastin

Question 24

Panacinar emphysema involves the ______.

Answer 24

Entire acinar complex affected due to alpha-1-antitrypsin deficiency.

(Elastase increase (normally inhibited by alpha-1) destroys elastin throughout the acinus)

Question 25

Distal acinar emphysema (aka paraseptal) occurs ______

Answer 25

distally near the septum or pleura (blebs).

(Mostly upper lobes; a/w spontaneous pneumothorax)

Question 26

Irregular emphysema is unclassified, mixed or scarring due to ______.

Answer 26

chronic infections in an irregular pattern.

(Rarely significant airflow obstruction)

Question 27

Answer 27

COPD

(note the horizontal ribs, increased intercostal space, narrow cardiac shadow/vertical heart, increased translucency)

Question 28

Answer 28

emphysema due to tobacco

Question 29

Which is COPD? Which is normal?

Answer 29

Question 30

Spirometry findings of COPD

Answer 30

1. decreased FEV₁
2. FEV₁/FVC < 60%

Question 31

What is indicated by this graph?

Answer 31

severe irreversible airway obstruction

(compare to normal below)

Question 32

What is the utility of an arterial blood gas in COPD?

Answer 32

Provides clues to acuteness and severity of disease exacerbation

(spirometry dx COPD; ABG gives snapshot)

Question 33

Patients with COPD have mild to moderate hypoxemia without ______.

Answer 33

hypercapnia (they have a higher tolerance for CO₂)

(until disease progresses)

Question 34

pH of ____ usually indicates acute respiratory compromise

Answer 34

7.3

(near normal, thanks Kidneys!)

Question 35

Chronic hypoxia leads to increasing pulmonary artery pressure w/resultant _________.

Answer 35

cor pulmonale and pulmonary hypertension

Question 36

COPD therapy to prolong life (6)

Answer 36

1. smoking cessation
2. vaccinate
3. oxygen
4. pulmonary rehab
5. Lung Volume Resection Surgery (LVRS)
6. lung transplant (chronic bronchitis)

Question 37

COPD tx (symptomatic) (2)

Answer 37

1. MDI (SABA, LABA, anticholinergics SAMA/LAMA)
2. Corticosteroids

Question 38

Treatment recommendations

Answer 38

SABA/SAMA

Question 39

Fill in the blank and give treatment recommendations (3)

Answer 39

1. LABA/LAMA
2. pulmonary rehab
3. SABA/SAMA

Question 40

Fill in the blank and give treatment recommendations (4)

Answer 40

1. LABA/LAMA
2. SABA/SAMA
3. Pulmonary Rehab
4. inhaled glucocorticoids if repeated exacerbations

Question 41

Fill in the blank and give treatment recommendations (6)

Answer 41

1. • one short-acting bronchodilator
2. inhaled glucocorticosteroids (repeated exacerbations)
3. treat complications
4. pulmonary rehab
5. long-term O₂ therapy
6. surgical consult

Question 42

Sx of acute COPD exacerbation (4)

Answer 42

1. worsening hypoxia
2. dyspnea
3. cough & sputum
4. infection

(⅓ have no obvious cause)

Question 43

Acute COPD exacerbation treatment

Answer 43

1. SABA/SAMA
2. IV steroids
3. IV broad spectrum ABX (if infection suspected)
4. OMM/RT
5. mechanical ventilation

(diuresis if chronic bronchitis or cor pulmonale)

Question 44

What is the difference between COPD & bronchiectasis

Answer 44

bronchiectasis produces copious amounts of sputum

(similar disease)