COPD (wk 8)

Question 1

slide 3

Question 2

slide 3

Answer 2

sldie 3

Question 3

slide 3

Question 4

early slide

Question 5

early slide

Question 6

Describe the burden of disease of COPD

Answer 6

-~6% of Americans; mortality slowly decreasing
-0.1% die secondary COPD
-Higher rates in Native American and Alaska Native populations
-Globally ~10%

Question 7

What are the risk factors for COPD?

Answer 7

1) Smoking is by far the single biggest risk factor, vaping, e-cigarette, Cannabis
2) Age > 45
3) Genetic: Alpha-1 antitrypsin deficiency (AATD)
4) Environmental pollutants
5) RTI: childhood infections, MTB, HIV
6) Childhood asthma: COPD-Asthma overlap
7) Native American & Alaska Native populations
-Socioeconomic and high smoking rates

Question 8

Is screening asymptomatic pts for COPD recommended? Explain

Answer 8

Treatment of COPD is directed at symptom control, not curative, so screening asymptomatic patients is not recommended
-Advise smokers to quit or cut back
-Do not screen patient
-Evaluate symptomatic patients

Question 9

Who should be evaluated for COPD?

Answer 9

1) Dyspnea that is:
-Progressive over time
-Worse with exercise
-Persistent
2) Recurrent Wheeze
3) Chronic cough: may be intermittent & may be non-productive
4) Recurrent lower RTI
5) History of risk factors
-Tobacco smokers, environmental smoke, occupational (dusts, vapors, gases, etc.)
-Host factors: genetics, developmental, PMHx (childhood asthma, RTI, LBW, Preemie)

Question 10

Describe the presentation of COPD using OLDCARTS

Answer 10

1) Onset: slowly progressive, older adults
2) Duration: persistent, non-reversible
3) Timing: chronic with exacerbations – often associated with RTI
4) Location: pulmonary system
5) Character: progressive dyspnea (DOE or at rest) and productive cough
6) Aggravating: activity, smoking, respiratory tract infections
Alleviating: rest, reduced or quit smoking
7) Risk factors: smoking history (increased PYH increased risk), Alpha-1 AT (especially younger age), older adult with smoking history
8) Associated Symptoms: frequent RTI, cachexia or obesity, cyanosis, dependent edema

Question 11

COPD PE:
1) What will VS be like?
2) What about general PE?
3) What might you see on an abd. exam?

Answer 11

1) May be normal or increased HR and RR & dyspneic at rest
2) Normal to frequent productive cough, pink to cyanotic, cachectic to obese, comfortable at rest or anxious and dyspneic
3) Paradoxical breathing

Question 12

COPD PE:
1) What will breath sounds be like?
2) What would a chest exam be like?
3) What may the lower extremities show?
4) What about the skin?

Answer 12

1) Decreased to wheezing, crackles (“junky”).
2) May demonstrate normal to barrel chest, hyperresonance on percussion, accessory muscles, pursed lip breathing.
3) May demonstrate dependent pitting edema (usually bilat.)
4) May be pink to cyanotic

Question 13

1) How do bronchitis predominant (blue bloaters) typically present?
2) What will you see on exam?
3) What drives their breathing?
4) What is important to remember regarding these pts?

Answer 13

1) As obese, chronic productive cough +/- wheezing, relatively comfortable at rest, significant DOE
2) EXAM: Obese, crackles and wheezing on chest auscultation (junky sounding), cyanotic, peripheral edema
CO2 retainers/O2 driven….. Retained CO2 resets chemoreceptors, chronic respiratory acidosis leads to dusky (blue) skin color
May become apneic with supplemental oxygen!! as their respiratory drive is O2 driven

Question 14

1) How do emphysema predominant (pink puffers) typically present?
2) What will you see on exam?
3) What drives their breathing?
4) What is important to remember regarding these pts?

Answer 14

1) Present with significant SOB at rest = anxious, pursed lipped breathing, 2–3-word sentences, cachectic appearing, minimal coughing
Exam: labored breathing - tachypnea, accessory muscles, barrel chested, pink skin (increased rate and depth of breathing – minute ventilation), diminished BS on auscultation (referred upper airway sounds)
CO2 responsive/driven
Very responsive to CO2 retention, CO2 chemoreceptors drives hyperventilation resulting in increased minute ventilation resulting in pink skin, responds to supplemental oxygen as their respiratory drive is CO2 driven

Question 15

What are some intrathoracic DDXs for chronic cough?

“won’t ask us this”

Answer 15

1) COPD – slowly progressive, h/o tobacco use or other risk factors, spirometry
2) Asthma – episodic, worse @ night, AR, begins in kids, spirometry
3) Lung cancer – h/o smoking, constitutional symptoms, hemoptysis
4) MTB – any age, endemic region, CXR findings, culture,
Bronchiectasis – large volume purulent sputum, associated with bacterial RTI, HRCT shows bronchial dilation
5) Left heart failure – CXR enlarged heart, pulmonary edema, spirometry demonstrates restriction vs. obstruction
6) Interstitial lung disease – restrictive pattern on spirometry, HRCT
7) Cystic fibrosis – children, sweat chloride test, genetics
Idiopathic cough

Question 16

What are some extrathoracic DDXs for chronic cough?

“won’t ask us this”

Answer 16

Chronic allergic rhinitis
Postnasal drip (PND)
Upper airway cough syndrome
GER
Medications (ACEi, amiodarone)

Question 17

1) Obstruction in middle aged or older adults is indicated by what FEV1/FVC ratio?
2) What does FEV1% predicted demonstrate with SABAs?

Answer 17

1) <0.7 or 70%
2) DOES NOT demonstrate improvement as in asthma

Question 18

1) When would you need to get

Answer 18

1) CXR or high-resolution chest CT to exclude lung masses
2) ECG in patients with ? Cor pulmonale or CHF
Pulse oximetry at rest, exertion, and during sleep to evaluate need for home oxygen (Medicare requirement)
Alpha-1 Antitrypsin deficiency screening – COPD Dx in Caucasian < 45 y/o or FHx of COPD

Question 19

1) Is a COPD exam diagnostic?
2) What might a CXR show?

Answer 19

1) EXAM: Rarely diagnostic
2) Often normal
-Lungs: Hyperinflation, Widened AP diameter, Flattened diaphragm
-Narrow heart
-Bullae

Question 20

Who should you give a Alpha-1 Antitrypsin Deficiency test to?

Answer 20

-GOLD recommends testing all patients Dx with COPD (but not always done)
-Particularly, young patients Dx with COPD should be tested for A1AT def

Question 21

List the 4 GOLD categories for severity of airflow obstruction based on FEV1

Answer 21

1) GOLD 1: Mild, FEV1 >/= 80% predicted
2) GOLD 2: Moderate, 50% </= FEV1 <80% predicted
3) GOLD 3: Severe, 30% </= FEV1 <50% predicted
4) GOLD 4: Very severe, FEV1 <30% predicted

Question 22

What are the 2 validated clinical tools to evaluate Sx?

Answer 22

MMRC (modified medical research counsel) dyspnea scale
OR
CAT (COPD assessment test)

Question 23

1) What does the Modified Medical Research Council (mMRC) Dyspnea Scale measure? Why is this useful?
2) How does it grade this?

Answer 23

1) Measure breathlessness
Key symptom in many
Patients with COPD

Symptoms grade:

Low = 0-1
High = 2+

Question 24

1) What does the CAT assessment measure?
2) How is it scored?

Answer 24

1) Multidimensional symptoms scale
2) Low < 10; High = 10+

Question 25

What are the Tx goals of COPD?

Answer 25

1) Reduce symptoms Relieve symptoms Improve exercise tolerance Improve health status 2) Reduce risk Prevent/slow disease progression Prevent/treat exacerbations Reduce mortality

Question 26

What 7 things should be included in an initial COPD assessment?

Answer 26

1) FEV1 – GOLD 1-4 2) Symptoms – CAT or mMRC 3) Exacerbation history 4) Smoking status – smoking cessation intervention in all patients (EBM grade A) 5) Blood eosinophil count 6) Alpha-1 AT 7) Comorbidities

Question 27

What should you include in COPD initial management?

Answer 27

1) Smoking cessation 2) Vaccination 3) Active lifestyle and exercise 4) Initial Rx 5) Patient self management education -Risk factors -Inhaler technique -Breathlessness -Written action plan 6) Manage comorbidities

Question 28

List the 5 As of smoking cessation

Answer 28

Ask Advise to stop or cut back on smoking Assess willingness to quit or cut back Assist with FDA approved smoking cessation Rx Arrange follow up

Question 29

1) What is a risk factor for lung cancer and COPD? 2) What increases risk of lung cancer above this?

Answer 29

1) Smoking 2) COPD

Question 30

Smoking + COPD = ______x risk of lung cancer over smokers w/o COPD

Answer 30

4.5x

Question 31

What vaccinations are recommended?

Answer 31

1) Yearly influenza 2) Covid-19 3) Pneumonia – PCV 20 or 21 4) RSV age 60+ 5) Tdap 6) Zoster vaccine 50+

Question 32

GOLD guidlines: 1) How to Tx group A? 2) Group B? 3) Group C?

Answer 32

1) Any bronchodilator 2) LABA + LAMA 3) LABA + LAMA (may add ICS if blood eos >/=300)

Question 33

What do you do if a pt has both asthma and COPD?

Answer 33

Tx the predominant Sx. 1) If wheezing is the worst Sx, treat them like an asthma pt. 2) If coughing, sputum production, and SOB that’s persistent and progressive is the main Sx, treat as COPD

Question 34

What are you treating in COPD? (i.e. what's the main goal?)

Answer 34

Symptoms and risk

Question 35

1) When are dry powder inhalers appropriate? 2) When are metered-dose inhalers and soft mist inhalers appropriate?

Answer 35

1) Only if the pt can make a forceful and deep inhalation 2) When pt can perform a slow and deep inhalation. Give them a spacer device if needed for metered inhalers.

Question 36

What is the COPD management cycle?

Answer 36

1) Review: Sx (dyspnea), exacerbations 2) Assess: Inhaler techinque & adherence + non-pharm Txs 3) Adjust: Escalate, switch inhaler device or molecules, de-escalate

Question 37

pulmonary rehabilitation: 1) What is it? 2) Who is it appropriate for? 3)

Answer 37

Multidisciplined structured program in exercise training, education, nutritional counseling and behavior/mental health support Appropriate for patient groups B & E Cochrane review: improved dyspnea, fatigue, emotional well bearing, & sense of control over disease Functional benefits: increase of 6-minute walk test ~ 44 meters Improved QOL and exercise capacity maintained for 12 months

Question 38

1) What does regular use of ICSs do to COPD pts? When might ICSs be used in this population? 2) Are oral corticosteroids appropriate for COPD pts?

Answer 38

1) Increases risk of pneumonia, especially in severe COPD ICS added if patient also has features of asthma 2) Long term use has significant side effects without any evidence of benefits

Question 39

41

Answer 39

In patients with chronic bronchitis, severe COPD, and h/o exacerbations: Roflumilast (Daliresp) – PDE-4i Improves lung function and reduces severe exacerbations Decreases pulmonary inflammation via inhibiting breakdown of intracellular cyclic adenosine monophosphate (c-AMP)

Question 40

41

Answer 40

NOTE: PDE-5i - inhibits breakdown of intracellular c-GMP which relaxes smooth muscle in vessels and leads to increased blood flow in penis and lungs

Question 41

Are prophylactic antibiotics appropriate for COPD? Explain

Answer 41

1) Daily long-term macrolides (azithromycin or clarithromycin) for 6-12 months: Decrease exacerbations over 1 year NNT 8 to prevent 1 exacerbation over 50 weeks Resistance is a concern 2) Use of tetracycline and fluroquinolones show no benefit and increase harm

Question 42

What group of drugs is recommended as add on (adjunct therapy) after optimizing inhaler therapy if needed? Give an example

Answer 42

Phosphodiesterase-4 inhibitors (PDE-4i) -like Roflumilast (Daliresp)

Question 43

1) Do mucolytics help? 2) Are antitussives recommended?

Answer 43

1) Regular use decease exacerbations in select patients Who benefits … difficult to characterize 2) Not recommended long term as they have no evidence of benefit

Question 44

43

Answer 44

Methylxanthines (Theophylline) MOA – acts as non-selective PDE-4i or bronchodilator Not generally recommended due to: Low therapeutic ratio Low toxicity threshold Significant interaction with other medications

Question 45

Biologics

Answer 45

Moderate to severe COPD and h/o exacerbations, chronic bronchitis, and higher blood eosinophile counts Dupilumab reduces exacerbations, improves lung function and QOL

Question 46

1) What is not recommended for COPD? 2) What doesn't have good evidence?

Answer 46

1) Statins are not recommended for COPD Leukotriene modifies have not been studied adequately in COPD

Question 47

45

Answer 47

Long term oxygen therapy recommended in COPD patients with severe resting hypoxia PaO2 - 55 mmHg or less or SpO2 of 88% or less, measured after breathing room air 30 minutes Used at least 15 hours/day Target SpO2 is 88-92% Decreases mortality

Question 48

45

Answer 48

If tissue hypoxia is noted (HCT 55% or greater, Cor pulmonale, or secondary pulmonary hypertension), then COPD patients benefit even if PaO2 > 55 mmHg or SpO2 > 88% Does not improve outcomes or QOL in exertional hypoxia Nocturnal oxygen therapy does not appear to improve outcomes in patients w/ isolated nocturnal hypoxia such as sleep apnea

Question 49

46

Answer 49

Group 1 SaO2 /= 89% or Decrease of SaO2 > 5% associated with symptoms reasonably attributed to hypoxemia (mental confusion, insomnia, nocturnal restlessness. Exercise Rx for O2 use – during exercise SaO2 /= 89% and evidence that oxygen during exercise improves hypoxemia Group 2 SaO2 =89% + dependent edema suggestive of CHF or P pulmonale on ECG (P wave > 3mm) or HCT > 56%

Question 50

47

Answer 50

Lung volume reduction Expensive, associated with high mortality Candidates – severe upper lobe emphysema and low exercise capacity Increased survival rates vs. Rx only after 12 months Lung transplant Severe COPD Increases health status and lung capacity without affecting survival Bronchoscopy interventions to decrease end expiratory volume Increase exercise tolerance, health status, and lung function @ 6-12 months Refer pulmonologist prior to surgery

Question 51

*not on exam* What are some factors that improve prognosis?

Answer 51

BMI - 21 or less FEV1 % predicted 6 min walk test mMRC dyspnea scale

Question 52

COPD comorbidities: 1) What is common? 2) What condition shares smoking tobacco as a major risk factor with COPD?

Answer 52

1) CVD 2) Lung cancer

Question 53

List some COPD comorbidities besides CVD and lung cancer

Answer 53

Osteoporosis Depression/anxiety Sleep disturbances GERD – increased risk of exacerbation

Answer 54

Annual LDCT for screening ages 50-80 and 20 PYH smoking, currently smoking or have quit less than 15 years. Stop when quit > 15 years, or reach 85 y/o

Question 55

Exacerbation of COPD (ecopd): What is it characterized by?

Answer 55

Characterized by acute changes in the cardinal symptoms of COPD: 1) Increased severity and frequency of cough 2) Increased sputum production – volume and/or changes in color 3) Increased dyspnea

Question 56

List 3 conditions that often cause ECOPD

Answer 56

Respiratory treat infection (RTI), PE, HFR

Question 57

Copd exacerbationscontributors/triggers: 1) What are the more frequent triggers? 2) What are the less frequent?

Answer 57

1) RTI Pulmonary emboli – Well’s Score clinical probability (DVT, Fx, cancer, surgery, etc.) D-dimer, CTA Hear failure (HF) – CXR, BNP, Echo

Question 58

When it comes to RTI causes of COPD, how common is each of the most popular ones?

Answer 58

H. Influenza 13-50% M. catarrhalis 9-21% S. pneumoniae 7-26% Pseudomonas aeruginosa 1-13%

Question 59

52

Answer 59

Thorough clinical assessment Look for symptoms & signs of CAP, HF, PE Assess: Symptoms: severity of dyspnea, cough Signs: tachypnea, tachycardia, sputum volume/color, respiratory distress with accessory muscle use. Pulse ox, labs, CRP, ABG Appropriate environment of care Establish trigger

Question 60

Describe the HPI of ECOPD using OLDCARTS

Answer 60

Onset, Duration, Timing: symptoms – cough, sputum, dyspnea - acutely increased over baseline Location: respiratory tract Character: productive cough, large sputum volume, +/-change in color, may be blood tinged Aggravating: recent RTI Alleviating: n/a Associated symptoms: etiology specific (**CAP**, HF, PE)

Question 61

ECOPD 1) When should you observe? 2) What would the VS be? 3) What do you need to rule out?

Answer 61

1) Observation: acute respiratory distress, productive cough VS: tachypnea, tachycardia, Fever?, hypoxia/cyanotic 3) r/o URI, sinusitis, AOM w. good HEENT exam

Question 62

Respiratory ECOPD

Answer 62

Respiratory: mild to severe respiratory signs In general, would expect to hear diffuse wheezing or other adventitious sounds Mild: RR < 22, HR < 95, resting SaO2 <92% RA, CRP < 10 mg/L (if obtained) Moderate: 3/5 of the following RR 24+, HR 95+, resting pulse ox < 92% RA, ABG (if obtained) may show hypoxia (PaO2 < 60 mmHg) &/or hypercapnia (PaCO2 > 45 mmHg) but no acidosis Severe: dyspnea, RR, HR, SaO2 same as moderate; ABG shows onset/worsening hypercapnia (PaO2 > 45 mmHg) and acidosis (Ph < 7.35)

Question 63

~ 80% or ECOPD can be treated as outpatient, sometimes after initial treatment in clinic or ER Mild to moderate ECOPD

Question 64

What are some potential indications for ECOPD admission?

Answer 64

Severe exacerbation Acute respiratory failure Failure to respond to therapy Presence of serious comorbidities – HF, new arrhythmias, etc. Insufficient home support

Question 65

What are the goals of ECOPD Tx?

Answer 65

1) Reverse airflow limitation with short acting bronchodilators and systemic glucocorticoids 2) Treat infection as this is most common etiology 3) Exclude DDX – PE, HF, etc. 4) Ensure appropriate oxygenation 5) Avert intubation and mechanical ventilation

Question 66

How do you manage severe, but not life threatening, ECOPD?

Answer 66

1) Administer supplemental oxygenation 2) Bronchodilators 3) Consider OCS 4) Consider antibiotics when RTI suspected 5) Consider non-invasive mechanical ventilation – CPAP, BiPAP 6) Monitor fluid balance 7) Consider SQ heparin (Lovenox) 8) ID and manage comorbid conditions

Question 67

What bronchodilators do you need to use for ECOPD?

Answer 67

SABA +/- SAMA initial therapy Inhaler or nebulizer Once stable consider using LAMA + LABA

Question 68

ECOPOral corticosteroids (OCS)

Answer 68

Systemic glucocorticoids (PO nearly equivalent to IV) – improve lung function, oxygenation, and shorten recovery Prednisone 40-60 mg (or equivalent) QD x 5 days Monitor for side effects: hyperglycemia, fluid retention, hypertension

Answer 69

Empiric antibiotics - check Sanford ID guide for recommendations Commonly used: macrolides (azithromycin, clarithromycin), 2nd/3rd generation cephalosporin (cefuroxime, cefpodoxime, cefdinir), Augmentin, or respiratory fluoroquinolone (levofloxacin or moxifloxacin)

Question 70

ECOPD

Answer 70

Reassess in 2-3 days If improved, continue Rx for 3-5 more days (~ 7 days) If not improved, evaluate Rx plan (bronchodilators, steroids, Gram stain/culture, comorbid conditions (PE, HF, Pneumothorax, pneumonia, etc.)

Question 71

What do you need to screen ECOPD pts for?

Answer 71

Influenza, covid-19 and treat with appropriate specific antiviral therapy in addition to above therapy

Question 72

Non-pharmacological ECOPD Txs: 1) Which is better, titrated O2 or high flow O2?

Answer 72

Titrated oxygenation decreases mortality when compared to high flow oxygen Non-invasive mechanical ventilation 1st mode of ventilation used in COPD with acute respiratory failure (CPAP, BiPAP) Improves gas exchange, reduces work of breathing and need for intubation, decreases hospitalization duration and improves survival

Answer 73

Chest physiotherapy no benefit Resistance training improves dyspnea and QOL Early pulmonary rehab in hospitalized patients improves dyspnea

Question 74

Sum up ECOPD Tx

Answer 74

Assess, initiate treatment, determine cause, reassess and disposition (environment of care) Short acting bronchodilators Systemic corticosteroids for ~ 5 days Antibiotics when indicated for 5-7 days Supplemental oxygen PRN Consider non-invasive mechanical ventilation as 1st mode early Acute respiratory failure

Question 75

How do you Tx mild, moderate, and severe ECOPD pharmacologically? (grading is arbitrary)

Answer 75

Mild – SABA +/- SAMA only Moderate – SABA +/- SAMA and OCS +/- antibiotics Severe – requires admission or ER visit, may be associate with respiratory failure

Question 76

Asthma COPD overlap syndrome (ACOS): 1) Is this term still used? 2) What indicates the presence of COPD? 3) What indicates both COPD and asthma?

Answer 76

This term is not longer encouraged in the GOLD 2023 update If patient has significant airflow limitations based on post bronchodilator FEV1/FVC ratio = COPD If also has significant reversibility, patient may have both COPD and Asthma Treat based on predominant diagnosis