COPD - Exam 1 Flashcards
What are the 3 classic respiratory symptoms associated with COPD? What are the 2 pathophys categories?
dyspnea, cough and sputum
Chronic bronchitis
Emphysema
_____ and extensive _______ are key physiologic makers of COPD. Name 4 factors that can cause narrowing of the small airways
Airflow obstruction
airway destruction
Immune cells, molecules, mucus, fibrotic tissue
smoking increasing ________ causes alveolar tissue damage. What is the happening in chronic bronchitis?
neutrophil elastase
inflammation of the bronchus leading to narrowing
overweight
cyanotic
elevated hemoglobin
peripheral edema
rhonchi
wheezing
What am I?
chronic bronchitis
older and thin
severe dyspnea
quiet chest
hyperinflation on xray
What am I?
emphysema
Weight gain
Weight loss
Activity limitation (including intercourse)
Wheezing +/- chest tightness
Syncope
Anxiety / depressive symptoms
What am I?
Is weight gain or loss associated with worse prognosis?
COPD
weight loss is worse because the body is working very hard to breathe, resulting in weight loss
What are COPD risk factors?
Family hx
smoking hx
environment
hx of childhood pulm infections
HIV
TB
asthma
What will mild COPD present like? moderate/severe?
mild: PE is often normal; may pick up on prolonged expiration, faint end-expiratory wheeze with forced expiration
Lung hyperinflation
Decreased breath sounds, wheezes
Crackles at lung bases
Distant heart sounds
Increased AP diameter
Describe wheezing. What phase is it heard in?
a continuous musical sound heard in the expiratory phase
Describe fine crackles (Rales). What phase are they heard in?
brief and discontinuous, high pitched and popping noise.
both inspiration and expiration
What do early inspiration fine crackles indicate? late inspiration?
chronic bronchitis
pneumonia, CHF or atelectasis
Tripod posturing
Use of accessory muscles for breathing
Expiring through pursed lips
Hoover’s sign
cyanosis
nail clubbing is possible but rare
End-stage Disease / Chronic Respiratory Failure
What is Hoover’s sign?
lower intercostal interspace retraction during inspiration
**pt must take shirt off to see
What is the timeframe and criteria to be considered chronic bronchitis? What is a common complication?
Productive cough >3 months for 2 consecutive years
cor pulmonale (right sided heart failure)
**Who is screened for COPD? what is the questionnaire called? What score do you need to have to indicate COPD?
Only screen adults who present with at least 1 of the 3 cardinal symptoms OR if they have a gradual decline in activity with risk factors for COPD
CAPTURE Questionnaire
CAPTURE scores 2-4 are indicative of clinically significant COPD
What is COPD defined as? What are some additional labs you would want to order?
COPD is defined by irreversible or partially reversible airflow limitation after bronchodilator administration as tested using spirometry
Pulse oximetry every visit
Labs - CBC, BMP, TSH, BNP/NT-proBNP, serum alpha-1 antitrypsin
CXR
**When you give a pt who has asthma a bronchodilator, what happens?
asthma conditions significantly improve! vs COPD have only slight to no improvement
What is FEV and FVC?
FEV₁ - Forced Expiratory Volume in 1 second
aka how much you can push out of your lungs in 1 second
FVC - Forced Vital Capacity - amount of air moved in 1 breath
**What is the spirometry results criteria that indicate an obstructive lung condition?
_____ is not necessary for routine assessment of COPD but is great for assessing the severity of emphysema
DLCO
DLCO ______ in proportion to severity of disease
decreases as the disease gets worse
Draw the Dr. Sheppard? graph how how to tell if something is met/resp acid/alk based on ABG values
What ABG values would you expect to find in mild COPD? moderate/severe COPD?
mild: Low pO₂ and normal pCO₂
moderate/severe: worsening pO₂ and elevated pCO₂
What is base excess in arterial blood gas? Base excess _____ in metabolic alkalosis and ______ in metabolic acidosis
the amount of acid or base required to restore a liter of blood to its normal pH at a PaCO2 of 40 mmHg
increases
decreases (or becomes more negative)
T/F: imaging is needed for making the diagnosis of COPD
FALSE!! imaging is not required but you can consider CXR and chest CT w/o
When would imaging be indicated when working a pt up for COPD?
Dyspnea/cough etiology is unclear
Rule out complicating process during acute exacerbations
Evaluate for comorbidities
What will a CXR on a pt with emphysema look like? chronic bronchitis?
Hyperinflation
Flattened diaphragm
Increased retrosternal air space
Long, narrow heart shadow
like to be normal unless comorbities/complications
**What is COPD staging based on? What is the organization that sets the guidelines?
Airflow limitations
Symptom severity
Exacerbations
Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria
**What are the airflow limitations in COPD staging?
After the pt’s GOLD category is determined, what do you do next?
calculate mMRC and CAT score
mMRC - assesses severity of breathlessness
CAT - assesses multitude of symptoms present
What does mMRC stand for? What does it assess?
Modified Medical Research Council Dyspnea Scale (mMRC
mMRC - assesses severity of breathlessness
What does CAT stand for? What does it assess?
COPD Assessment Test (CAT)
CAT - assesses multitude of symptoms present
What is the scale range for mMRC?
0-4 -> 0=very mild and 4= severe
What does the CAT stand for? What does it assess? What is the scoring range?
COPD Assessment Test (CAT)
CAT - assesses multitude of symptoms present
0-40-> 0 is mild and 40 is severe
**draw the entire graph for GOLD assessment COPD staging
What are the 3 goals for COPD management?
Improve symptoms
Decreased number of exacerbations
Improve patient functioning and quality of life
What are some non-pharm COPD management?
SMOKING CESSATION!! +/- behavioral counseling
vaccinate!!!
healthy BMI/lose weight
Vit D supplementation
regular, progressive exercise
oxygen therapy
pulm rehab
What vaccines are recommended for all COPD pts?
- Influenza
- COVID-19
- PCV-20 OR PCV-13 followed by PCV-23
- Tdap
- Zoster in patients >50
- New RSV vaccine
______ deficiency is associated with ______ and hospitalization for COPD exacerbations
vit D
reduced lung function
When is oxygen therapy helpful in COPD?
Proven to increase survival in patients with severe chronic resting arterial hypoxemia
pO2 ≤ 55 mmHg on ABG
O2 sat ≤ 88%
pO2 >55 <60 + RHF or erythrocytosis
Severe hypoxemia with exertion
What GOLD stages of COPD is pulm rehab indicated for? What are the components of pulm rehab?
Indicated for COPD class B and E
components:
exercise training
promotion of healthy behavior
psychological support
What are the 2 categories of short-acting bronchodilators? Long-acting?
Short-acting Beta Agonists (SABA)
Short-acting Muscarinic Antagonists (SAMA)
Long-acting Beta Agonists (LABA)
Long-acting Muscarinic Antagonists (LAMA)
Tachycardia
Tremor
Cardiac arrhythmia
jittery
Are SE of _____ medication.
What must you do before you prescribe one?
What are the medications in this category?
SABA
education your pt on the possible SE!!
Albuterol (Proventil, Ventolin, Proair)
Levalbuterol (Xopenex)
Dry mouth
dry eyes
metallic taste
prostatic symptoms
Are SE of _____ medication.
What are the medications in this category?
SAMA
Ipratropium Bromide (Atrovent)
Tachycardia
Tremor
Headache
Are all SE of ____ medication
What are the meds in this class?
LABA
Arformeterol
Salmeterol
Formeterol
Which LABA only comes in NEB form?
Arformeterol
Dry mouth
constipation
urinary retention
Are all SE of ____ medication
What drugs are in this class?
LAMA
QD:
Tiotropium
Umeclidinium
Revefenacin
BID:
Aclidinium
Glycopyrrolate
Olodaterol /Tiotropium
Vilanterol/Umeclidinium
Formoterol/Glycopyrrolate
Formoterol/Aclidinium
What drug class?
LABA + LAMA
Salmeterol/Fluticasone propionate
Vilanterol/Fluticasone furoate
Formoterol/Budesonide
What drug class?
LABA + ICS
Fluticasone furoate/Umeclidinium/ Vilanterol
Beclometasone/Formoterol/ Glycopyrronium
Budesonide/Formoterol/ Glycopyrrolate
What drug class?
LABA + LAMA + ICS
**Draw the chart for initial pharm management for COPD based on GOLD category
What is the textbook answer for follow-up pharm management for COPD?
if one med is working, do NOT stop. if s/s are not well controlled need to add another medication to regime
What factors strongly favor adding on ICS to med regime? What factors favor use? What factor go AGAINST use?
look at eosinophil count!!
What is the proper technique for how to use an inhaler?
uncap
shake the inhaler 10-15 times
take a deep breath and breathe out all the way
hold the inhaler upright
hold the inhaler in your mouth above your tongue and between your teeth
seal lips around the inhaler
press down on the inhaler and breath in as much as you can
hold your breath for 5-10 seconds
slowly breathe out
When is it indicated to remove ICS therapy?
pneumonia
inappropriate indication for ICS when it was first prescribed
lack of response
well controlled s/s can try deescalation with close f/u
What drug class is Roflumilast (Daliresp)? What is the indication? What are the SE?
phosphodiesterase-4 (PDE-4) inhibitor
reduce exacerbations in severe COPD
psych reaction: anxiety, depression, insomnia avoid if possible in pts with mental health history
What drug class is theophylline (Theobid)? What is the indication? Need to be cautious when prescribing to ______ because of ______
non-specific phosphodiesterase inhibitor
refractory COPD
liver impaired pts
toxicity can occur
_____ MOA suppresses cytokine release and inhibits pulmonary neutrophil infiltration → reduces inflammation, pulmonary remodeling and mucociliary malfunction
Roflumilast (Daliresp)
_______ MOA relaxes smooth muscle → suppresses airway response to noxious stimuli → increased diaphragm contraction force
Theophylline (Theobid)
What is the follow-up recommendation for COPD pts? How often should spirometry be performed?
1-3 months following initial diagnosis and initiation of therapy
Patients can be followed every 3-6 months once stabilized
at least annually
What are risk factors for acute COPD exacerbations?
Advanced age
Chronic productive cough
Duration of COPD
History of prior antibiotic therapy
COPD-related hospitalization within past year
Comorbid conditions (CAD, CHF, DM)
Respiratory infections (trigger ~70% of exacerbations)
What does decreased mental status tell us on a pt who presents with an acute COPD exacerbation?
hypercapnia or hypoxemia
What are some acute COPD exacerbation management options?
Adjust bronchodilator therapy
Consider spacers / nebulizer therapy
Consider oral glucocorticoid therapy
Antibiotics for increased cough, sputum production, and purulence
CPAP machine
When should abx be considered in a COPD exacerbation? Which ones?
Antibiotics for increased cough, sputum production, and purulence
Macrolide (azithromycin, clarithromycin)
2nd or 3rd gen cephalosporin (cefuroxime, cefdinir)
Amoxicillin-clavulanate (Augmentin)
Respiratory fluoroquinolone (levofloxacin, moxifloxacin)
What is the target oxygen range for supplemental oxygen in COPD? Why would it be bad for the number to be above target range?
88-92%
too much oxygen can decrease the body’s natural respiratory drive which can led to a build up of CO2
What is the inpatient therapy for COPD exacerbation?
supplemental O2
reverse obstruction
IV abx: Levaquin, ceftriaxone, pip/taz
order pulm rehab
______ an enzyme naturally produced by the liver and migrates to the lungs via the blood. What is it’s job?
Alpha-1 Antitrypsin (AAT)
ATT protects the lungs from neutrophil (elastase) damage
What are the 2 pathophysiologic processes related AAT deficiency?
ATT deficiency in the lungs leads to loss of elastin in the alveolar wall and early onset emphysema
An accumulation of ATT in the liver leads to destruction of hepatocytes and liver disease
Same as emphysema in COPD at much younger age
Symptoms of chronic hepatitis, cirrhosis, or hepatocellular carcinoma
Symptoms of panniculitis → inflammation of subcutaneous tissue
What am I?
AAT deficiency: Alpha-1 Antitrypsin Deficiency
What is panniculitis?
Hot, painful, red nodules or plaques characteristically on the thigh or buttocks
What factors would make you think to order AAT diagnostic testing? What will the test show?
In patients <45
Non-smokers or minimal smoking (<10-15 years)
FH of emphysema and/or liver disease
Adult onset asthma that does not respond to bronchodilators
Panniculitis or unexplained liver disease
low serum AAT levels
What is the tx for Alpha-1 Antitrypsin Deficiency?
Refer to provider specializing in disease
Possible infusion of donor AAT
Aggressive lifestyle modifications
Pharmacotherapy, O2 therapy, vaccinations as indicated in COPD
Prompt management of acute respiratory infections
Pulmonary rehab
What is bronchiectasis? What causes it? What is the result?
An irreversible focal or diffuse dilation and destruction of the bronchial walls
infection plus impaired draining/obstruction with impaired host defense
Often results from recurrent inflammation or infection of the airways
What does bronchiectasis lead to? **What is the PE finding that leads you to this dx? What will their lungs sound like?
Leads to inflammation, mucosal edema, cratering, ulceration, and neovascularization of airway
**Copious, foul-smelling, thick, purulent sputum is characteristic
Rales/rhonchi/wheezing on exam
Why do you need to order an CXR if you suspect bronchiectasis? **What is the CXR finding clinical pearl related to bronchiectasis? What do they reflect?
to rule out pneumonia
**“tram tracks” are characteristic and reflect dilated airways
dilated airways
What will Bronchiectasis look like on imaging?
CT shows bronchial wall thickening and dilated airways
Ballooned or “honeycomb” appearance
What 2 additional tests do you need to order for bronchiectasis?
sputum culture and bronchoscopy
Why do you need to order a bronchoscopy in bronchiectasis?
assess for underlying mass or foreign body in focal disease
What is the tx for bronchiectasis?
SMOKING CESSATION!! +/- behavioral counseling
vaccinate!!!
healthy BMI/lose weight
Vit D supplementation
regular, progressive exercise
oxygen therapy
pulm rehab
abx for acute exacerbations: Amoxicillin, Amoxicillin-clavulanate, Doxycycline, TMP-SMX
mucolytic therapy, bronchodilators, chest physiotherapy (vest that vibrates to break up mucous in chest so they can cough it out)
surgical resection
lung transplant
When is long-term abx indicated for bronchiectasis? When is a lung transplant indicated?
Consider long-term antibiotics for pts with ≥ 3 exacerbations/year
indicated when FEV₁ <30% predicted
What are the risk factors for obstructive sleep apnea?
Increasing age, male, obesity, smoking, craniofacial or upper airway abnormalities
Comorbid conditions such as pregnancy, ESRD, CHF, COPD, hx of stroke (CVA)
What is the pathophys behind obstructive sleep apnea?
Recurrent, functional collapse of pharyngeal airway during sleep → reduced airflow → intermittent disturbances in gas exchange and fragmented sleep
What are the 2 OSA questionnaires? What test is first line to dx OSA?
Berlin Questionnaire
STOP-BANG
In-laboratory polysomnography (sleep study
What is the dx criteria for OSA?
≥5 obstructive respiratory events (apneas, hypopneas, or respiratory-related arousals) per hour of sleep plus one or more of the following: (long list)
OR
≥15 or more predominantly obstructive respiratory events per hour of sleep, regardless of associated symptoms or comorbidities
What is the management of OSA?
Weight loss is paramount!!!
Continuous positive airway pressure (CPAP)
oral appliances (mouth piece that hold the jaw forward)
upper airway surgery to create a bigger hole in the back of the throat
hypoglossal nerve stimulation
