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Pulm > COPD - Exam 1 > Flashcards

COPD - Exam 1 Flashcards

1
Q

What are the 3 classic respiratory symptoms associated with COPD? What are the 2 pathophys categories?

A

dyspnea, cough and sputum

Chronic bronchitis
Emphysema

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2
Q

_____ and extensive _______ are key physiologic makers of COPD. Name 4 factors that can cause narrowing of the small airways

A

Airflow obstruction

airway destruction

Immune cells, molecules, mucus, fibrotic tissue

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3
Q

smoking increasing ________ causes alveolar tissue damage. What is the happening in chronic bronchitis?

A

neutrophil elastase

inflammation of the bronchus leading to narrowing

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4
Q

overweight
cyanotic
elevated hemoglobin
peripheral edema
rhonchi
wheezing

What am I?

A

chronic bronchitis

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5
Q

older and thin
severe dyspnea
quiet chest
hyperinflation on xray

What am I?

A

emphysema

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6
Q

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?

A

COPD

weight loss is worse because the body is working very hard to breathe, resulting in weight loss

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7
Q

What are COPD risk factors?

A

Family hx
smoking hx
environment
hx of childhood pulm infections
HIV
TB
asthma

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8
Q

What will mild COPD present like? moderate/severe?

A

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

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9
Q

Describe wheezing. What phase is it heard in?

A

a continuous musical sound heard in the expiratory phase

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10
Q

Describe fine crackles (Rales). What phase are they heard in?

A

brief and discontinuous, high pitched and popping noise.

both inspiration and expiration

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11
Q

What do early inspiration fine crackles indicate? late inspiration?

A

chronic bronchitis

pneumonia, CHF or atelectasis

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12
Q

Tripod posturing
Use of accessory muscles for breathing
Expiring through pursed lips
Hoover’s sign
cyanosis
nail clubbing is possible but rare

A

End-stage Disease / Chronic Respiratory Failure

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13
Q

What is Hoover’s sign?

A

lower intercostal interspace retraction during inspiration

**pt must take shirt off to see

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14
Q

What is the timeframe and criteria to be considered chronic bronchitis? What is a common complication?

A

Productive cough >3 months for 2 consecutive years

cor pulmonale (right sided heart failure)

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15
Q

**Who is screened for COPD? what is the questionnaire called? What score do you need to have to indicate COPD?

A

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

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16
Q

What is COPD defined as? What are some additional labs you would want to order?

A

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

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17
Q

**When you give a pt who has asthma a bronchodilator, what happens?

A

asthma conditions significantly improve! vs COPD have only slight to no improvement

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18
Q

What is FEV and FVC?

A

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

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19
Q

**What is the spirometry results criteria that indicate an obstructive lung condition?

A
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20
Q

_____ is not necessary for routine assessment of COPD but is great for assessing the severity of emphysema

A

DLCO

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21
Q

DLCO ______ in proportion to severity of disease

A

decreases as the disease gets worse

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22
Q

Draw the Dr. Sheppard? graph how how to tell if something is met/resp acid/alk based on ABG values

A
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23
Q

What ABG values would you expect to find in mild COPD? moderate/severe COPD?

A

mild: Low pO₂ and normal pCO₂

moderate/severe: worsening pO₂ and elevated pCO₂

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24
Q

What is base excess in arterial blood gas? Base excess _____ in metabolic alkalosis and ______ in metabolic acidosis

A

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)

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25
Q

T/F: imaging is needed for making the diagnosis of COPD

A

FALSE!! imaging is not required but you can consider CXR and chest CT w/o

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26
Q

When would imaging be indicated when working a pt up for COPD?

A

Dyspnea/cough etiology is unclear

Rule out complicating process during acute exacerbations

Evaluate for comorbidities

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27
Q

What will a CXR on a pt with emphysema look like? chronic bronchitis?

A

Hyperinflation
Flattened diaphragm
Increased retrosternal air space
Long, narrow heart shadow

like to be normal unless comorbities/complications

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28
Q

**What is COPD staging based on? What is the organization that sets the guidelines?

A

Airflow limitations
Symptom severity
Exacerbations

Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria

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29
Q

**What are the airflow limitations in COPD staging?

A
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30
Q

After the pt’s GOLD category is determined, what do you do next?

A

calculate mMRC and CAT score

mMRC - assesses severity of breathlessness
CAT - assesses multitude of symptoms present

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31
Q

What does mMRC stand for? What does it assess?

A

Modified Medical Research Council Dyspnea Scale (mMRC

mMRC - assesses severity of breathlessness

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32
Q

What does CAT stand for? What does it assess?

A

COPD Assessment Test (CAT)

CAT - assesses multitude of symptoms present

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33
Q

What is the scale range for mMRC?

A

0-4 -> 0=very mild and 4= severe

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34
Q

What does the CAT stand for? What does it assess? What is the scoring range?

A

COPD Assessment Test (CAT)

CAT - assesses multitude of symptoms present

0-40-> 0 is mild and 40 is severe

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35
Q

**draw the entire graph for GOLD assessment COPD staging

A
36
Q

What are the 3 goals for COPD management?

A

Improve symptoms
Decreased number of exacerbations
Improve patient functioning and quality of life

37
Q

What are some non-pharm COPD management?

A

SMOKING CESSATION!! +/- behavioral counseling

vaccinate!!!

healthy BMI/lose weight

Vit D supplementation

regular, progressive exercise

oxygen therapy

pulm rehab

38
Q

What vaccines are recommended for all COPD pts?

A
  1. Influenza
  2. COVID-19
  3. PCV-20 OR PCV-13 followed by PCV-23
  4. Tdap
  5. Zoster in patients >50
  6. New RSV vaccine
39
Q

______ deficiency is associated with ______ and hospitalization for COPD exacerbations

A

vit D

reduced lung function

40
Q

When is oxygen therapy helpful in COPD?

A

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

41
Q

What GOLD stages of COPD is pulm rehab indicated for? What are the components of pulm rehab?

A

Indicated for COPD class B and E

components:
exercise training
promotion of healthy behavior
psychological support

42
Q

What are the 2 categories of short-acting bronchodilators? Long-acting?

A

Short-acting Beta Agonists (SABA)
Short-acting Muscarinic Antagonists (SAMA)

Long-acting Beta Agonists (LABA)
Long-acting Muscarinic Antagonists (LAMA)

43
Q

Tachycardia
Tremor
Cardiac arrhythmia
jittery

Are SE of _____ medication.
What must you do before you prescribe one?
What are the medications in this category?

A

SABA

education your pt on the possible SE!!

Albuterol (Proventil, Ventolin, Proair)
Levalbuterol (Xopenex)

44
Q

Dry mouth
dry eyes
metallic taste
prostatic symptoms

Are SE of _____ medication.
What are the medications in this category?

A

SAMA

Ipratropium Bromide (Atrovent)

45
Q

Tachycardia
Tremor
Headache

Are all SE of ____ medication

What are the meds in this class?

A

LABA

Arformeterol
Salmeterol
Formeterol

46
Q

Which LABA only comes in NEB form?

A

Arformeterol

47
Q

Dry mouth
constipation
urinary retention

Are all SE of ____ medication
What drugs are in this class?

A

LAMA

QD:
Tiotropium
Umeclidinium
Revefenacin

BID:
Aclidinium
Glycopyrrolate

48
Q

Olodaterol /Tiotropium
Vilanterol/Umeclidinium
Formoterol/Glycopyrrolate
Formoterol/Aclidinium

What drug class?

A

LABA + LAMA

49
Q

Salmeterol/Fluticasone propionate
Vilanterol/Fluticasone furoate
Formoterol/Budesonide

What drug class?

A

LABA + ICS

50
Q

Fluticasone furoate/Umeclidinium/ Vilanterol
Beclometasone/Formoterol/ Glycopyrronium
Budesonide/Formoterol/ Glycopyrrolate

What drug class?

A

LABA + LAMA + ICS

51
Q

**Draw the chart for initial pharm management for COPD based on GOLD category

A
52
Q

What is the textbook answer for follow-up pharm management for COPD?

A

if one med is working, do NOT stop. if s/s are not well controlled need to add another medication to regime

53
Q

What factors strongly favor adding on ICS to med regime? What factors favor use? What factor go AGAINST use?

A

look at eosinophil count!!

54
Q

What is the proper technique for how to use an inhaler?

A

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

55
Q

When is it indicated to remove ICS therapy?

A

pneumonia

inappropriate indication for ICS when it was first prescribed

lack of response

well controlled s/s can try deescalation with close f/u

56
Q

What drug class is Roflumilast (Daliresp)? What is the indication? What are the SE?

A

phosphodiesterase-4 (PDE-4) inhibitor

reduce exacerbations in severe COPD

psych reaction: anxiety, depression, insomnia avoid if possible in pts with mental health history

57
Q

What drug class is theophylline (Theobid)? What is the indication? Need to be cautious when prescribing to ______ because of ______

A

non-specific phosphodiesterase inhibitor

refractory COPD

liver impaired pts

toxicity can occur

58
Q

_____ MOA suppresses cytokine release and inhibits pulmonary neutrophil infiltration → reduces inflammation, pulmonary remodeling and mucociliary malfunction

A

Roflumilast (Daliresp)

59
Q

_______ MOA relaxes smooth muscle → suppresses airway response to noxious stimuli → increased diaphragm contraction force

A

Theophylline (Theobid)

60
Q

What is the follow-up recommendation for COPD pts? How often should spirometry be performed?

A

1-3 months following initial diagnosis and initiation of therapy

Patients can be followed every 3-6 months once stabilized

at least annually

61
Q

What are risk factors for acute COPD exacerbations?

A

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)

62
Q

What does decreased mental status tell us on a pt who presents with an acute COPD exacerbation?

A

hypercapnia or hypoxemia

63
Q

What are some acute COPD exacerbation management options?

A

Adjust bronchodilator therapy

Consider spacers / nebulizer therapy

Consider oral glucocorticoid therapy

Antibiotics for increased cough, sputum production, and purulence

CPAP machine

64
Q

When should abx be considered in a COPD exacerbation? Which ones?

A

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)

65
Q

What is the target oxygen range for supplemental oxygen in COPD? Why would it be bad for the number to be above target range?

A

88-92%

too much oxygen can decrease the body’s natural respiratory drive which can led to a build up of CO2

66
Q

What is the inpatient therapy for COPD exacerbation?

A

supplemental O2

reverse obstruction

IV abx: Levaquin, ceftriaxone, pip/taz

order pulm rehab

67
Q

______ an enzyme naturally produced by the liver and migrates to the lungs via the blood. What is it’s job?

A

Alpha-1 Antitrypsin (AAT)

ATT protects the lungs from neutrophil (elastase) damage

68
Q

What are the 2 pathophysiologic processes related AAT deficiency?

A

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

69
Q

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?

A

AAT deficiency: Alpha-1 Antitrypsin Deficiency

70
Q

What is panniculitis?

A

Hot, painful, red nodules or plaques characteristically on the thigh or buttocks

71
Q

What factors would make you think to order AAT diagnostic testing? What will the test show?

A

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

72
Q

What is the tx for Alpha-1 Antitrypsin Deficiency?

A

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

73
Q

What is bronchiectasis? What causes it? What is the result?

A

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

74
Q

What does bronchiectasis lead to? **What is the PE finding that leads you to this dx? What will their lungs sound like?

A

Leads to inflammation, mucosal edema, cratering, ulceration, and neovascularization of airway

**Copious, foul-smelling, thick, purulent sputum is characteristic

Rales/rhonchi/wheezing on exam

75
Q

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?

A

to rule out pneumonia

**“tram tracks” are characteristic and reflect dilated airways

dilated airways

76
Q

What will Bronchiectasis look like on imaging?

A

CT shows bronchial wall thickening and dilated airways
Ballooned or “honeycomb” appearance

77
Q

What 2 additional tests do you need to order for bronchiectasis?

A

sputum culture and bronchoscopy

78
Q

Why do you need to order a bronchoscopy in bronchiectasis?

A

assess for underlying mass or foreign body in focal disease

79
Q

What is the tx for bronchiectasis?

A

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

80
Q

When is long-term abx indicated for bronchiectasis? When is a lung transplant indicated?

A

Consider long-term antibiotics for pts with ≥ 3 exacerbations/year

indicated when FEV₁ <30% predicted

81
Q

What are the risk factors for obstructive sleep apnea?

A

Increasing age, male, obesity, smoking, craniofacial or upper airway abnormalities

Comorbid conditions such as pregnancy, ESRD, CHF, COPD, hx of stroke (CVA)

82
Q

What is the pathophys behind obstructive sleep apnea?

A

Recurrent, functional collapse of pharyngeal airway during sleep → reduced airflow → intermittent disturbances in gas exchange and fragmented sleep

83
Q

What are the 2 OSA questionnaires? What test is first line to dx OSA?

A

Berlin Questionnaire
STOP-BANG

In-laboratory polysomnography (sleep study

84
Q

What is the dx criteria for OSA?

A

≥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

85
Q

What is the management of OSA?

A

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

86
Q
A

Pulm (11 decks)

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