COPD Intro

Question 1

What IS COPD
A _____and _______disease
Characterized by __________ airflow limitation (obstruction)
Is not fully _______
Associated with an abnormal _________ of the lungs to noxious particles or gas.

Answer 1

treatable and preventable
progressive

reversible
abnormal inflamm response

Question 2

Chronic Bronchitis (CB)
Inflammation of bronchioles

Answer 2

● Defined clinically
● a chronic productive cough
● for at least 3 months in each 2 successive years
● other causes of chronic cough have been
excluded

Question 3

Emphysema (E)

Destruction of alveoli

Answer 3

● Defined anatomically
● Abnormal permanent enlargement of the
airspaces distal to the terminal bronchioles
● accompanied by destruction of their walls and
without obvious fibrosis

Question 4

Chronic Bronchitis (CB) pathophys

Chronic inflammation
understand

Answer 4

● Cigarette smoke damages epithelial cells
● Tissue damage attracts inflammatory cells 
release enzymes  damage epithelial cells and
stimulate goblet cells to ↑ in number and to ↑
mucus production
● Airway obstruction blockage by mucus,
inflammation, progressive scarring (fibrosis),
and/or narrowing (constriction) of the airways

Question 5

Emphysema (E) - Loss of elastic recoil

understand

Answer 5

● Cigarette smoke attracts inflammatory cells
(WBC, including neutrophils, lymphocytes, and
macrophages) into the lung
● Inflammatory cells release proteases
proteases dissolve the proteins in the alveolar
walls (septae) and thereby destroy the septae

Question 6

Screening: Identifying Patients with possible COPD
Spirometry is required to establish diagnosis

what is the starting question
5 questions?

Answer 6

Smoker or ex-smoker (or have history of occupational exposure to dust/chemicals) that is ≥ 40 years old

AND answer “yes” to 1 of any of the following:
- Regular cough “Do you cough regularly”
- Productive cough with sputum “Do you cough up phlegm regularly”
- SOB even from simple chores “Do even simple chores make you SOB?”
- Wheezes on exertion or at bedtime “Do you wheeze when you exert yourself or at night?”
- Frequent colds that persist longer than other people. “Do you get frequent colds that
persist longer than those of other people you know?

Question 7

what FEV1/FVC confirms persistent airflow limitation/obstruction

Answer 7

FEV1/FVC <0.70

Question 8

GOLD recommends assessment of 3 following factors for improving and managing COPD?

Answer 8

1. Assess lung function (degree of airflow limitation)
2. Assess frequency of exacerbations
3. Assess symptom severity (mMRC dyspnea scale*/CAT)

Question 9

1. Classification of airflow limitation severity (obstruction of air flow- degree of airflow limitation)

o FEV1/FVC < 0.70 = COPD
o GOLD GRADE: Based on post bronchodilator FEV1

what is classified as:
mild (GOLD 1)
moderate (GOLD 2)
severe (GOLD 3)
very severe (GOLD 4)

Answer 9

GOLD 1 FEV1> 80% predicted
GOLD 2 FEV1 > 50% - <80%
GOLD 3 FEV1> 30% - <50%
GOLD 4 FEV1< 30% predicted

Question 10

2. Assess risk of exacerbations

Answer 10

o A thorough review of exacerbation history in the last 12 months
o > 2 exacerbations in the last 12 months OR >1 leading to hospital admission
o 0 or 1 exacerbations not leading to hospital admission

Question 11

3. Assess symptoms

which 2 ways to do this?

Answer 11

a) MRC dyspnea scale - useful clinical measure that better reflects overall disease impact
b) COPD Assessment Test (CAT); Classification by over-all well being
- Includes 8 statements about symptoms and activities. Patient scores each statement on a scale of 0 to 5 and the impact of COPD is assessed by the cumulative score (0-20)

Question 12

ABC Tool for Assessment

A: low risk; less symptoms
MMRC?
CAT?
exacerbations per year?

Answer 12

either MMRC <0-1
or CAT <10

exacerbations per year: 0 or 1 not leading to hospital admission

Question 13

ABC Tool for Assessment

B: low risk; more symptoms
MMRC?
CAT?
exacerbations per year?

Answer 13

either MMRC >/= 2
or CAT >/= 10

exacerbations per year: 0 or 1 not leading to hospital admission

Question 14

ABC Tool for Assessment

C: high risk; less symptoms
MMRC?
CAT?
exacerbations per year?

Answer 14

either MMRC <0-1
or CAT <10

exacerbations per year: >/= 2 or >/= 1 leading to
hospital admission

Question 15

ABC Tool for Assessment

D: high risk; more symptoms
MMRC?
CAT?
exacerbations per year?

Answer 15

either MMRC >/= 2
or CAT >/= 10

exacerbations per year: >/= 2 or >/= 1 leading to
hospital admission

Question 16

asthma vs COPD

airway inflamm

Answer 16

asthma: eosinophilic
COPD: neutrophilic

Question 17

asthma vs COPD

response to ICS

Answer 17

a: Essential for optimal control
c: Helpful in patients with moderate to severe disease and frequent AECOPD

Question 18

asthma vs COPD

role of bronchodilators

Answer 18

a: as needed only
c: regular therapy usually necessary

Question 19

asthma vs COPD

role of exercise training

Answer 19

a: rarely formally used
c: essential therapy

Question 20

asthma vs COPD

end of life discussions

Answer 20

a: rarely necessary
c: often essential

Question 21

goals of therapy

see summary of goals table for more

Answer 21

Symptoms:
Alleviate breathlessness and other respiratory symptoms Symptoms
Improve exercise tolerance and daily activity
Improve health status

Risk:
Prevent disease progression
Reduce the frequency and severity of exacerbations
Treat exacerbations and complications of the disease
Reduce mortality

Question 22

Non-pharm

Smoking Cessation (reduce risk factors) (+/- pharmacologic interventions)

Answer 22

single most effective intervention to reduce the risk of developing COPD and only intervention shown to slow it’s progression

Question 23

Non-pharm

Education (Health Literacy)
read

Answer 23

o Tailor to individual patient
o Education alone does not improve exercise performance or lung function
o Plays a role in improving skills, ability to cope with illness, and health status
o Improves patient response to exacerbation

Question 24

Non-pharm

Rehabilitation

Answer 24

All COPD patients should be encouraged to maintain an active lifestyle:
▪ FITT: (frequency) 3-5 sessions/week, (intensity) to moderate SOB; (timing) 30- 45 min; (type of exercise) walk, cycle, swim

components: exercise, psychosocial support, nutrition counseling, occupational therapy, energy conversation strat, education

Question 25

Non-pharm

Benefits of Pulmonary rehab

Answer 25

▪ Reduce symptoms: dyspnea, exercise endurance, decrease fatigue
▪ Improve quality of life
▪ Reduced resource utilization
▪ Trend to reduced mortality compared to standard care

Question 26

Non-pharm

● Home Oxygen
when is it needed

Answer 26

Survival benefit conferred by supplemental O2 treatment in certain patients
◦ Stage IV patients with the following:
◦ PaO2 ≤ 7.3 kPa (55mmHg) or SaO2 ≤ 88% with or without hypercapnia
OR
◦ Pa O2 7.3 kPa – 8 kPa (60 mmHg) or SaO2 88% with evidence of pulmonaryhypertension, peripheral edema suggesting cardiac failure, or polycythemia (Hct >
55%)
◦ Goal is to maintain kPa > 8 and SaO2 at least 90% to preserve vital organ function

Question 27

Drugs to avoid in COPD

Answer 27

o Anti-tussives
o Sedating antihistamines
o Beta-blockers
o Opioids*
o Benzodiazepines*
*maybe used as part of end of life care

Question 28

non-pharm

vaccines
antibiotics

Answer 28

Vaccinations
o Annual influenza
▪ Reduces serious illnesses and death in COPD
o Pneumococcal x 1, repeat in 5 – 10 yrs
▪ Reduces incidence of CAP (community acquired pneumonia)

Antibiotics (area of controversy)
o continuous prophylactic use have NOT shown to reduce exacerbations
o Only use to treat infectious exacerbation of COPD and other infections