COPD DSA Flashcards
COPD is characterized by __________, with the predominant conditions being _________.
- Airway obstruction that is not fully reversible
- Chronic bronchitis and emphysema
Chronic bronchitis is described as ____
Productive cough for 3 months in each 2 successive years in a patient where other causes of sputum production have been excluded.
What is emphysema?
Permanent enlargement of airspaces distal to terminal bronchioles, with destruction of bronchiolar walls without fibrosis. During expiration, airways colapse.
Both emphysema and chronic bronchitis are result in what?
- Peripheral airway obstruction
- Parenchymal destruction
- Pulmonary vascular abnormalities that decrease gas exchange and cause hypoxemia, hypercapnia and cor pulmonae.
What should we focus on differentiated from COPD?
Other conditions that limit airflow and are not fully reversible: Bronchiectasis, CF and bronchiolitis.
-Asthma
What are risk factors for developing COPD?
- a1-antitrypsin deficiency => too much elastase => destroys elasin => early onset COPD
- Genes involves in detoxifying cigg smoking
- 3. Developmental risk factors (LBW)
80-90% of the risk of developing COPD is attributable to ___________.
Cigarette smoking
How does smoking cessation affect your lungs?
1. Decreases FEV1
2. Reduces mortality
Who do we screen for COPD?
- Not done for asymptomatic patient.
-
Screen the following patients for AAT deficiency
- Early-onset COPD (younger that 45 YO)
- Strong family hx of lung/liver disease.
How many pack/years smoking hx, age, and maximum laryngeal height are the most predictive of COPD?
- >40 pack-year smoking hx
- ≥45 y/o
- Maximum laryngeal height ≤4 cm
Cardiac exam of pt with COPD may show what?
-
Cor pulmonale
- ↑ intensity of the pulmonic sound, persistently split S2
- Parasternal lift due to RVH
-
Cor pulmonale
How is COPD confirmed and staged?
- Spirometry using the GOLD criteria
All patients who have unexplained dyspnea and cough should be evaluated for what?
α1-AT deficiency
Using the GOLD criteria for staging COPD what are the characteristics of stage I through stage IV?
- I (mild) = FEV1 ≥80% of predicted w/ or w/o chronic sx (cough and sputum)
-
II (moderate) =
- FEV1 is 50 - 80% of predicted w/ or w/o chronic sx (cough and sputum)
-
II (moderate) =
-
- III (severe) =
- FEV1 is 30-50% of predicted w/ or w/o chronic sx (cough and sputum)
-
IV (very severe) =
- FEV1 is less than 30% of predicted or
- FEV1 <50% of predicted + chronic respiratory failure
-
IV (very severe) =
- *All have FEV1/FVC <70%
What confirms the prescence of a non-reversible airflow obstruction?
- FEV1 less than 80% post-bronchodilator
- Forced vital capacity ratio (FEV1/FVC) less than 70%
What else can be used to detect the severity of COPD?
BODE index.
What does the BODE index entail and what is it used to evaluate?
Higher score means what?
Risk for hospitalization, long-term prognosis in COPD patients
- BMI
- Airflow Obstruction
- Dyspnea
- Exercise capacity (the 6-minute walk distance)
Higher score => greater risk of death.
For patient with GOLD I: mild COPD what is the standard tx?
Short-acting bronchodilator when needed.
For patient with GOLD II: moderate COPD what is the standard tx?
- Short acting bronchodilator +
- Regular treatment with 1 or more long-acting bronchodilators + pulmonary rehab
For patient with GOLD III: severe COPD what is the standard tx?
- If repeated excerbation; add ICS (but never take alone).
- With or without either roflumiast or theophylline
For patient with GOLD IV: very severe COPD what is the standard tx?
- Add long-term oxygen therapy if chornic respiratory failure
- Consider surgery
What are the 3 types of bronchodilators are used to treat patients with stable COPD?
1. B agonists
2. Anticholinergic agents
3. Methylxanthines (therophylline)
What are the difference between short and long-acting B agonists?
- Short-acting B agonists (albuterol and levalbuterol) are rescue meds that act in a few minutes and last 4-6 hours.
-
Long-acting B agonists (salmeterol, formoterol and arformoterol) have a more sustain and predictable imrpovement on lung.
- Given every 12 hours alone, with other bronchodilators or w inhaled glucocorticoids.
Mot comon side effect of B-ago?
Increased HR & tremor
What anticholinergic drugs are used as bronchodilators?
- Short-acting inhaled agents (ipatropium)
- Long-acting inhaled agents (tiotropium)
When are anticholinergics recommened?
Combined with short or long-acting B AGO and/or theophylline,
bc they are less potent.
Tiotropium should not be given with _______.
Short-acting anticholinergic drugs
What is the primary SE for anticholinergic agents?
Use with caution in what patients?
- Dry mouth
- Urinary obstruction and narrow-angle glaucoma
What is theophylline and when is it used?
- Nonspecific PDE inhibitor that increases cAMP in smooth muscle of airway and inhibits intracellular Ca2+ release.
- Trial for 1-2 months by adding to inhaled bronchodilators and glucocorticoids.
What is Roflumilast and when is it used?
- Oral PDE-inhibitor used in select patients with severe COPD to reduce risk for exacerbations.
Which drug used in tx of COPD is NEVER used alone in COPD?
Inhaled glucocorticoids
How can we improve the actions of inhaled glucocorticoids and long-acting bronchodilators?
TAKE TOGETHER; reduce exacerbations and improve health.
Use of inhaled glucocortoids should be monitored in who?
-Elderly patients d/t osteopenia, cataracts, hyperglycemia and pneumonia
When should oxygen therapy for 15 hours a day be given to a patient with COPD?
Stage 4 COPD;
- Arterial PO2 < 55 mmHg
- O2 sat less than 88% with or without hypercapnia.
What treatment improves quality of life in patients with moderate => severe symptoms that persist depite medical management?
Pulmonary rehabilitation
What 3 surgical interventions may improve sx’s of COPD in highly selected pt’s?
- Bullectomy
- Lung volume reduction surgery
- Lung transplantation
What are COPD exacerbations?
- Sudden change in patients baseline dyspnea, cough and or sputum production that is beyond day-to-day variations due to infection or air polluation.
Exacerbations are classified as: mild, moderate and severe.
How do we treat each?
-
Mild to moderate exacerbations: treat at home
- Mild: short-acting bronchodilators
- Moderate: short-acting bronchodilators + systemic glucocorticoids and/or ABX.
-
Severe: treat at hospital w oxygen therapy
*
How are severe exacerbations defined as?
Loss of alertness or a combo of 2 or more of the following
- Dyspnea at rest
- RR over 25/min
- Pulse rate over 110/min
- Use of accessory respiratory muscles
What is the goal of hospital therapy for COPD exacerbations?
-
O2 therapy
* -check by measuring arterial blood gas levels 30-60 min after O2 therapy.
Treatment of COPD is stepwise and largely based on what?
PFT’s
Why is there significant benefit in using ABX in patients with moderate and severe COPD exacerbations?
Bacteria are often recovered:
- - S. pneumoniae
- - M. catarrhalis
- - H. influenzae
How do we treat bacterial infections seen in COPD exacerbations?
- Cephalosporin + macrolide
- Monotherapy with fluoroquinolone
Sputum gram stain or culture is not necessary.
What other patients qualify for O2 therapy?
- Hematocrit is more than 55%
- Arterial pO2 less than 59 mmHg
- O2 sat less than 89% if pt has pulmonary HTN, cor pulmonale, edema
