Final Flashcards
What are the 2 global governing bodies responsible for molding our understanding, evaluation, and treatment of asthma?
GINA - Global Initiative for Asthma
NAEPP - National Asthma Education and Prevention Program
Describe GINA
Global Initiative for Asthma
Global in scope
Comprehensive guidelines for children and adults
Annual updates
Describe NAEPP
National Asthma Education and Prevention Program
National in scope
Comprehensive guidelines for children and adults
Updates annually
Why is it difficult to diagnose asthma?
Differing definitions
Differing manifestations, triggers, intensities ect
Subtypes of the disease are defined differently by different authorities
What is the GINA definition of asthma?
Asthma is a heterogeneous disease usually characterized by chronic airway inflammation
What airway characteristics are usually associated with asthma?
Airway hyperresponsiveness
Airway inflammation
What symptoms does GINA say define asthma?
Wheeze, shortness of breath, chest tightness, and cough that vary over time and intensity
Together with variable expiratory airflow limitation
Where does asthma lie on the dyspnea pyramid?
Bottom, lungs
Airways
What are asthma phenotypes?
Recognizable clusters of demographic, clinical or pathological characteristics
Keep in mind that these do not correlate strongly with specific pathological processes or treatment responses
What are the “Big Six” categories that encompass disease management?
Presentation
Definition
Epidemiology
Etiology/pathophysiology
Diagnosis
Management
What are questions you should be thinking about when considering patient presentation?
What does the patient look like coming through the door?
What are characteristic signs and symptoms
What history of present illness do we see?
What are the clinical manifestations that we can observe?
What is the difference between a definition of a disease and a diagnosis of a disease?
A definition defines what the disease is
Diagnosis is confirming that the patient has the disease
When considering the rarity, occurrence, and populations at risk for a disease, what category are we considering?
Epidemiology
What questions should we be asking when considering the epidemiology of a disease?
Is the condition common or rare?
Is this condition seen frequently? Rarely?
Does this conditions appearance correlate to a season?
What populations are at risk for this disease?
If we are thinking about the disease in regards to its frequency, seasonal correlation, and affected populations, we are thinking about the diseases
Epidemiology
When we are studying how a disease develops, what conditions lead to the disease and how the disease sabotages the body, we are discussing…
Etiology or pathophysiology
When considering pathophysiology, we must consider the following questions
How does the disease develop
What conditions give rise to the disease
How does the disease sabotage your body?
Give an example of how incidence can be communicated
How many new cases per hundred thousand people in the country/state/region over a year
In some cases it can be how many new cases per state per day, like with COVID
Define incidence in relation to epidemiology
How many new cases in a given number in a given population in a given length of time
What questions must we ask when attempting to diagnose a disease?
How do we confirm the presence of the disease
What are the appropriate tests to conduct to determine the presence of the disease?
What testing will help us isolate this condition as the patients root problem and rule out other problems?
Define prevalence in relation to epidemiology
How many people in the population have the condition
How would one select tests in order to diagnose a disease
Assess clinical manifestations
Consider typical tests and what they might reveal
ABG
Pulmonary function tests
Lab tests
Chest imaging
Survey the tests AVAILABLE and select the tests LIKELY TO BE PRODUCTIVE
We cant test everyone for everything
What is the prevalence of asthma?
7.8% in 2020
Why do we need to be thoughtful with our test selection?
Some tests will not give us useful information ie an STD panel when the patient has asthma
Want to eliminate the potential for false positives, the more tests run, the higher the chances are that a test is done incorrectly
Erroneous tests? IN THIS ECONOMY??
What do we need to consider when managing the disease post diagnosis?
How the disease is treated
What are the contributions respiratory therapy could make to the treatment
What are the two forms of disease management?
Acute management
Chronic management
How many people in the USA suffer from asthma?
Over 25 million
How many people suffer from asthma worldwide?
262 million
Where do most asthma related deaths occur?
Low and lower income countries where underdiagnosis and undertreatment is a challenge
Give examples of host factors that could contribute to an individuals likelihood to have asthma
Genetics
Gender
Obesity
What are environmental risk factors for asthma?
Allergens
Outdoors and indoors air pollutants
Infections
Occupational sensitizers
Tobacco smoke
Active or passive smoke
Diet
What muscle is affected by asthma?
Smooth muscle of bronchial airway
What does the smooth muscle of the bronchial airways do during an asthma exacerbation?
Constrict = bronchospasm
Describe secretions associated with asthma
Excessive production of whitish bronchial secretions
What portion of the immune system can be responsible for the thickening of the bronchial walls?
Inflammatory cells, usually eosinophils (white blood cells) infiltrate airway mucosa and cause inflammation
hat are other potential risk factors for asthma?
Drug use
Food additives and preservatives
Exercise induced bronchoconstriction
Gastroesophageal reflex
Nocturnal breathing disturbances
Emotional stress
Perimenstrual asthma
Allergic bronchopulmonary aspergillosi
Repeated exacerbations resulting in bronchial wall inflammation can lead to what?
Fibrosis
In severe cases, remodeling
Secretions created during an asthma exacerbation can lead to what?
Mucous plugging
Hyperinflation of the alveoli = air trapping
In severe cases, atelectasis
How do eosinophils cause inflammation?
They release granulocytes which contain granules of chemical mediators that are toxic to invaders but also cause cellular damage
What are Charcot-Leiden crystals a sign of?
They are a sign of degranulation of eosinophils
Describe remodeling in regards to bronchial smooth muscle
Bronchiole smooth muscle in healthy airways is thin and strap-like. In airways where there have been repeated asthma exacerbations, the muscle experiences hypertrophy becoming thick and wide resulting in the narrowing of the airway
Basically the muscle hit the gym in the worst possible way
Describe remodeling in terms of the bronchial walls
Eosinophils infiltrate the airway mucosa and degranualate causing inflammation
Airways become inflamed and collect fluid
What two factors does GINA consider to be the foundation for an asthma diagnosis?
History of variable respiratory symptoms
Confirmed variable expiratory airflow limitation
What symptoms does GINA consider when looking at a potential asthma diagnosis?
Wheeze
Shortness of breath
Chest tightness
Cough
What qualities does the wheeze have to have to be indicative of asthma?
Polyphonic quality
Start and stop independently
Vary in tone and duration
Appear during expiration
What does it mean that the wheezes are polyphonic, start and stop independently, and vary in tone and duration?
It means that multiple different airways are producing the wheeze independently. A wheeze coming from one specific airway would not have a polyphonic quality, would have predictable starts and stops, and would not vary in tone and duration
A wheeze can be a symptom of another disease process. What is the defining factor surrounding the symptoms of asthma?
Variability in symptoms
What kind of variations can be expected with asthma related symptoms?
Multiple symptoms
Symptoms vary over time
Symptoms vary in intensity
Symptoms are often worse at night or upon waking
Symptoms are often triggered by exercise, laughter, allergens, cold air
Spirometry can be used to confirm what diagnostic criteria for asthma?
Variable expiratory airflow limitation
How does a forced vital capacity serve as a diagnostic tool for asthma?
Forcing the breath provokes any expiratory flow resistance to reduce the volume of air exhaled
Describe forced vital capacity
Take the biggest breath you can
Blow air out through mouthpiece as hard and as long as possible till lungs are empty
Take big breath on mouth piece
What measurements should be examined when performing a forced vital capacity?
FEV1
FEF 25-75%
PEFR
What is FEV1?
Forced expiratory volume over 1 second
Is smaller in patients with restrictive diseases because flow out of the lungs is resisted
What is FEF 25-75%?
Forced Expiratory Flow
Average flow rate generated by the patient during the middle 50% of the FVC measurement
What is PEFR?
Peak Expiratory Flow rate
The maximum flow rate generated during the FVC exhalation
If FEV1 improves after administering a bronchodilator, what does this indicate?
That the airway limitation is reversible
What are the markers for improvement with a positive bronchodilator responsiveness test?
An increase in FEV1 of greater than 12% or…
An increase in FEV1 volume of greater than 200 mL
T/F: People with normal lung function do not experience variability in PEFR over the course of a day
False. People with normal lung function experience variability in PEFR
People with asthma experience EXAGGERATED variability
Do people experience changes in PEFR on a diurnal basis? How would you test this?
Yes
Measure PEFR in the morning and evening checking for variability. Individuals with asthma will have a larger range of variability than those without
Describe the process for testing anti inflammatories on a potential asthma patient
Test lung function
Treat patient for 4 weeks with anti-inflammatories
Retest lung function
Improvement = asthma likely
What measurements would indicate antiinflammatory treatment success? By what degree?
FEV1
Increase in FEV1 by more than 12% or more than 200 mL
Describe the positive exercise challenge test
Test patient lung function
Have patient exercise
Test for decreased lung function, decrease could be because of asthma
What kind of test utilizes irritants to test lung function?
Bronchial provocation test
Methacholine challenge test
What is the goal of the bronchial provocation/methacholine challenge test?
Provoke symptoms by administering an irritant and determine how much irritant is required to cause symptoms
What irritants can be used to provoke symptoms for the bronchial challenge test?
Methacholine
Standaradized hyperventilation
Hypertonic saline
Mannitol
What would constitute a positive result with the bronchial challenge test?
A decrease in FEV1 from baseline by 20% or more
The bronchial challenge test can have the procedure altered. Explain how this is done and what it can reveal
Patients are given increase amounts of irritants until their FEV1 drops 20% or more
Healthy patients will be able to tolerate a much greater amount of irritant than patient who potentially have asthma
T/F: Allergy tests can be useful for the diagnosis of asthma
True-ish. They can be a portion of an asthma diagnosis but they are not sufficient alone to diagnose asthma. They are more useful for the management of asthma than the diagnosis
T/F: A high eosinophil count has no relation to asthma
False. A high eosinophil count is associated with severe asthma
What exhaled gas can be used to determine whether or not the airways are experiencing eosinophilic airway inflammation?
The fractional concentration of exhaled nitric oxide
An increase in the fractional concentration of exhaled nitric oxide can mean what?
Eosinophilic airway inflammation
Why is differential diagnosis important when attempting to diagnose asthma?
Multiple disease processes have the same signs and symptoms as asthma and a misdiagnosis could be fatal for a patient. Therefore it is important to keep potential diagnostic options open until they are eliminated via testing
During a physical examination, what vital signs could indicate or support the potential diagnosis that a patient is suffering from asthma?
Tachypnea
Tachycardia
Increased blood pressure
What muscular movements could support or indicate that a patient is potentially suffering from asthma?
Accessory muscles of inspiration
Accessory muscles of expiration
Pursed lip breathing
Substernal intercostal retractions
T/F: increased anteroposterior chest diameter could be a sign of asthma
True….apparently
T/F: Sputum production is not associated with asthma
False. Asthmatics can produce a white frothy sputum
A condition where blood pressure decreases during inspiration and increases during expiration is called what
Pulsus paradoxus
Describe pulsus paradoxus
Decreased blood pressure during inspiration
Increased blood pressure during expiration
How much does systolic blood pressure decrease by during inspiration in healthy individuals
2-4 mmHg with normal inhalation
How much can blood pressure decrease by during inspiration in people suffering an asthma exacerbation
> 10 mmHg
A pneumothorax could cause a patients pulse to feel…
Thready (weak)
When performing a chest assessment, what might you notice in a patient suffering from asthma?
Expiratory prolongation
Decreased tactile and vocal fremitus
Hyperresonant percussion note
Diminished breath sounds
Diminished heart sounds
Wheezing
Crackles
Why would asthma cause a decrease in the FEV1 and the PEFR?
Asthma is a obstructive disease that prevents patients from completely exhaling due to inflamed, damaged or narrowed airways
You conduct a pulmonary function test on a patient that is suspected to have asthma. What flow measurements would be the most significantly affected by the disease? How?
Decreased FEV1 (Forced expiratory volume over 1 second)
Decreased PEFR (Peak expiratory flow rate)
You conduct a pulmonary function test on a patient that is suspected to have asthma. What capacity measurements would be the most significantly affected by the disease?
FRC
TLC
Why would the FRC and TLC be increased on a patient who is suffering from asthma?
Asthma is a obstructive disease that prevents patients from completely exhaling due to inflamed, damaged or narrowed airways resulting in more air remaining in the lungs after exhalation
A patient is brought in to the ER during the early stages of a moderate asthma exacerbation. You run an ABG on them. What would you expect to see?
Decreased PaCO2
Increased pH
Decreased PaO2
Decreased oxygen saturation
You perform an ABG on a patient and the results show decreased PaCO2, increased pH, decreased HCO3-, decreased PaO2, and decreased oxygen oxygen saturation. At the point when the ABG was drawn, would the patient be described as compensating or decompensating?
Compensating. Low PaCO2 indicates hyperventilation
A sputum sample is sent to the lab. The lab reports back that the sample contains Charcot-Leyden crystals. What does this indicate?
The presence of Charcot-Leyden crystals demonstrates that eosinophils have degranulated and caused inflammation due to an allergic reaction
What could you expect to see in a sputum sample from a patient suffering from asthma
Eosinophils
Charcot-leydon crystals
Cast of of mucus from small airways (curschmanns spirals)
IgE
What would you expect to find on a chest radiograph of an individual having an asthma exacerbation?
Translucent (dark) lung fields
Depressed or flattened diaphragm
What are GINA’s goals for managing asthma?
Control the symptoms
Reduce the risk of exacerbations
What are the steps GINA recommends when treating asthma?
Review
Assess
Adjust
hat does GINA recommend during the review phase?
Symptoms
Exacerbations
Side effects
Lung function
Comorbidities
Patient satisfaction
What does GINA focus on during the assessment phase?
Confirmation of a diagnosis if necessary
Symptom control and modifiable risk factors
Comorbidities
Inhaler technique and adherence
Patient preferences and goals
After the review and assessment phase, GINA recommends a phase of adjustment to optimize the treatments and outcomes. What does this consist of?
Treatment of modifiable risk factors and comorbidities
Non pharmacological strategies
Asthma medication adjustments
Education and skills training
What is the difference between controller medications and reliever medications?
Controller medications are referred to as background medications that are intended to keep symptoms from arising. Reliever medications are intended to rapidly stop symptoms once they begin
What is the goal of a controller medication?
Prevent symptoms from arising
Reduce risk of exacerbation and compromised lung function
If activated, what do leukotrienes cause?
Bronchoconstriction
Inflammatory cell recruitment
Increased vascular permeability
Secretion production
What is track 2 of the GINA recommendation for asthma treatment?
SABA as a reliever
What is track 1 of the GINA recommendation for asthma treatment?
ICS-formoterol as reliever
Why is track 1 of the GINA recommendation for asthma using ICS-formoterol as a reliever?
ICS-formoterol have been found to reduce the risk of exacerbations relative to relying on a SABA
What constitutes an “add-on medication”?
Controller medications at higher dosages
What are the drugs that make up advair?
Fluticasone and salmeterol
How can we prevent the leukotrienes from causing respiratory distress
Leukotriene receptor antagonist
What are the drugs that make up symbicort?
Budesonide and formoterol
List the common ICS-LABA combinations that constitute a reliever and a controller medication (Brand Names)
Advair
Symbicort
Dulera
Breo Ellipta
What are the drugs that make up dulera?
Mometasone and formoterol
What are the drugs that make up Breo Ellipta?
Fluticasone and vilanterol
What are the brand names for albuterol?
Proventil
Ventolin
List commonly used SABA medications that are relievers
Albuterol
Levalbuterol
Pirbuterol
What are the brand names for Pirbuterol?
Maxair
What are the brand names for Levalbuterol?
Xopenex
Xopenex HFA
Historically, LAMAs have been associated as relief for _______ patients but now are being used for higher levels of control for ________
COPD
Asthma
What are the brand names for tiotropium bromide?
Spiriva
Spiriva respimat
What is the brand name for Aclidinium bromide?
Tudorza Pressair
What is the brand name for Glycopyrrolate
Seebri NEohaler
What is the brand name of montelukast?
Singulair
What is the brand name for Umeclinium bromide?
Incruse Ellipta
What is the generic name of Singulair?
Montelukast
According to GINA, what constitutes severe asthma?
Asthma that is uncontrolled despite adherence with optimized high dose ICS-LABA therapy and treatment of contributory factors, or worsens when high dose treatment is decreased
3-10% of people with asthma have severe asthma
What is considered moderate asthma?
Moderate asthma is defined as asthma that is well controlled with low or medium dose ICS-LABA in either track 1 or track 2 of the GINA recommendation for treatment
What is one of the issues associated with classifying asthma?
The classification has evolved over time so health professionals who have been in the field longer are generally less aware of the changes in diagnosis and classification
How is asthma severity classified now?
Classification is based on how much medication is required to control symptoms and exacerbations. Because of this, classifications of an individual’s level of asthma is done retrospectively
Describe how asthma has been classified in the past
Asthma was classified by the type of symptoms present without analyzing the quality of the symptoms or level of treatment required to control the symptoms
What is the diagnostic criteria for severe asthma?
Asthma that remains uncontrolled despite optimized treatment with high dose ICS-LABA medications
Asthma that requires high dose ICS-LABA to prevent it from becoming uncontrolled
In short, lots of meds to be able to even potentially control
Describe difficult to treat asthma
Asthma that is uncontrolled despite medium or high dose ICS LABA or that requires a high dose treatment to maintain good symptom control and reduce risk of exacerbations.
In many cases, asthma may be difficult to treat because of MODIFIABLE factors such as incorrect inhaler technique, poor adherence, smoking, comorbidities or incorrect diagnosis
Describe moderate asthma
Asthma that is well controlled at Step 3 or Step 4 of the GINA treatment guide
Asthma that is well controlled with low or medium dose ICS formoterol
Why is the term “mild asthma’ generally avoided?
Mild asthma is frequently used to describe individuals who do not have frequent exacerbations, however the term undercuts the potential severity of exacerbations and leads individuals to believe that they do not need to be prepared or have medication on hand in case of an exacerbation
How do individuals suffering from a mild or moderate exacerbation present clinically?
Talk in phrases
Prefers sitting to laying down
Not agitated (potentially)
RR increased
No use of accessory muscles
HR 100-120
O2 sat on air = 90-95%
PEF > 50% predicted
How do individuals suffering from a severe asthma exacerbation present clinically?
Talk in words
Tripoding
Agitated
RR > 30/min
Accessory muscle use
HR > 120
O2 sat < 90% on air
PEF </= 50% predicted
What therapies are appropriate for a patient with a moderate/mild asthma exacerbation?
SABA
Consider iprtropium bromide (SAMA)
Control O2 to maintain 90-95% O2 sat
Oral corticosteroids
What therapies are appropriate for a patient with a severe asthma exacerbation?
What therapies are appropriate for a patient with a severe asthma exacerbation?
Under what conditions would intubation be considered for a patient suffering from a severe asthma exacerbation?
Following ABCs, assess for drowsiness, confusion or silent chest. If these conditions are present, consult the ICU, Start SABA and O2 and prepare patient for intubation
What is the purpose of administering IV magnesium?
Associated with calcium channel blocker in smooth muscle of the airway
Translation: reduces bronchoconstriction (maybe. Evidence mixed)
How would heliox be used when treating a patient with a severe exacerbation?
Used for nebulizer treatments in hopes of reducing airway resistance
Helium takes the place of nitrogen
Controversial. Also we’re running out of helium. What will we use to make balloon animals?? Think of the unemployed clowns! Wait. Fuck clowns. USE IT ALL
Describe the RR and HR of an emphysema patient during an exacerbation
Tachypnic
Tachycardic
Describe the RR and HR of a chronic bronchitis patient during an exacerbation
Tachypnic
Tachycardic
You are sent in to assess a patient with COPD. They present as a stocky male who is slightly blue in color and is breathing slowly with a prolonged expiration. What is the colloquial name for this patient? And how would you describe their COPD?
Blue bloater
Chronic bronchitis
T/F: a chronic cough that tends to be more severe upon waking is characteristic of a emphysema patient
False. A chronic cough that tends to be more severe in the mornings is characteristic of a chronic bronchitis patient
What is the typical body type (or habitus) of a emphysema patient?
Thin, underweight
What is the body type (or habitus) of a chronic bronchitis patient
Stocky, overweight
Describe the differences in sputum production and quality between a emphysema patient and a chronic bronchitis patient
Emphysema patient = very little mucus
Chronic bronchitis = copious and purulent
Describe the respiratory pattern of an emphysema patient
Prolonged expiration
Tachypnic
Dyspneic, even at rest
Hypoventilation in late stage
Describe the respiratory pattern of a chronic bronchitis patient
Prolonged expiration
Low RR
Describe the A/P diameter of emphysema patients
Classic sign of emphysema is barrel chest
Why do emphysema patients develop barrel chest?
Emphysema results in the weakening and destruction of alveolar walls which results in air trapping and distention of the rib cage
T/F: patients with chronic bronchitis do not present with barrel chest
False. Patients with chronic bronchitis do present with barrel chest, but not as commonly as emphysema patients
Describe the accessory muscle usage of a patient with emphysema
Accessory muscles are actively used, especially during exacerbations
Describe the accessory muscle use of a bronchitis patient
Less common than with emphysema patients, tend to use abdominal muscles for expirations. Accessory muscle use in chronic bronchitis patients is more common in the end stages of the disease
You auscultate a patient with COPD and hear wheezes, crackles, and rhonchi. What does this tell you about this patients type of COPD
That is likely chronic bronchitis
When palpating the chest of a patient, you noticed decreased tactile fremitus, decreased chest expansion, and somehow you notice that the point of maximal impulse (PMI) has shifted to the epigastric area (dont ask me how, you just do). These signs support that the patient has which kind of COPD?
Emphysema
What the fuck even is bronchitis?
Inflammation of the bronchial tubes resulting in coughing and increased secretion production
What would you notice when performing a chest palpation on an emphysema patient?
Decreased tactile fremitus
Decreased chest expansion
PMI (point of maximal impulse) has shifted, usually to the epigastric area
Why would the point of maximal impulse shift in a patient with emphysema?
Air trapping has put so much pressure on the heart that it has shifted the apex
An enlarged or tender liver may be indicative of what kind of COPD?
Chronic bronchitis
A patient with emphysema would have what type of resonance when performing chest percussions? Why?
Hyperresonance
Air trapping
Pitting edema is caused by what and is common in which kind of COPD?
Right heart failure
Chronic bronchitis
Jugular vein distention is caused by what and is common in what type of COPD?
Right heart failure
Chronic bronchitis
What is hoovers sign?
Inward movement of the lower rib cage during inspiration rather than outward in healthy individuals
T/F: Hoovers sign is common in chronic bronchitis patients
False. Hoovers sign is common in emhysema patients and uncommon in chronic bronchitis patients
What is the definition of COPD?
A preventable and treatable disease state characterized by airflow limitation that is not always fully reversible
T/F: digital clubbing is present in both emphysema and chronic bronchitis patients
True.
What is the primary cause of COPD?
Cigarette smoking
How does cigarette smoke result in COPD?
Smoke causes repeated inflammatory responses leading to emphysema and chronic bronchitis
T/F: COPDs effects are limited to the lungs
False. COPD has significant systemic effects
What is the definition of chronic bronchitis?
A productive cough for 3 months in each of 2 successive years in a patient in which other causes of a productive cough have been excluded
What is the definition of emphysema?
Emphysema is defined pathologically as the presence of permanent enlargement of the air spaces distal to the terminal bronchioles accompanied by the destruction of the bronchiole walls without obvious fibrosis
What is the GOLD definition of COPD?
Cigarette smoking
T/F: COPDs effects are limited to the lungs
False. COPD has significant systemic effects
How does cigarette smoke result in COPD?
Smoke causes repeated inflammatory responses leading to emphysema and chronic bronchitis
What is the definition of emphysema?
Emphysema is defined pathologically as the presence of permanent enlargement of the air spaces distal to the terminal bronchioles accompanied by the destruction of the bronchiole walls without obvious fibrosis
What is the definition of chronic bronchitis?
A productive cough for 3 months in each of 2 successive years in a patient in which other causes of a productive cough have been excluded
What is the GOLD definition of COPD?
A heterogeneous lung condition characterized by chronic respiratory symptoms such as dyspnea, cough, sputum and having a shit time in general due to abnormalities of the airways (bronchitis, bronchiolitis) and/or alveoli (emphysema) that cause persistent often progressive airflow obstruction
Bronchitis and bronchiolitis affect the…
Airways
Emphysema affects the….
Alveoli
Describe mucous production in a patient with chronic bronchitis
Excessive production and accumulation
Partial or total mucous plugging of the airways
Describe what happens to the walls of the peripheral airways in a patient with chronic bronchitis and what it results in
Chronic inflammation causes thickening of the walls of the peripheral airways
Describe panlobar emphysema
Emphysema that affects the whole acinus
In the late stages of chronic bronchitis, mucus buildup can result in what?
Mucus plugs causing air trapping and hyperinflation of the alveoli
Describe centrilobar emphysema
The emphysema is limited to the respiratory bronchioles and the proximal alveoli which are weakened and enlarged. More distal alveoli are relatively unaffected
What happens to the lungs in a patient with emphysema?
Permanent enlargement or destruction of air spaces distal to the terminal bronchioles (alveoli)
Destruction of the AC membrane
Weakening of the distal airways, primarily the respiratory bronchioles
What is the most clinically significant element of emphysema?
It destroys the alveoli and damages the AC membrane resulting in less surface area for gas exchange
Describe the change in compliance in a patient with emphysema
The compliance is increased due to the destruction of the elastic tissues
Which capacities are affected by emphysema and how are they affected?
ERV and TLC are increased
How many people in the US have COPD?
10-15 million estimated, could be as high as 20 million
How many deaths occur annually due to COPD in the US?
138k
Describe the cellular changes that take place in a patient with COPD
Fewer ciliated cells
More goblet cells
Appearance of squamous metaplasia
Which is more common, chronic bronchitis or emphysema?
Chronic bronchitis
Where is alpha1-atritrypsin made?
The liver
What does alpha1-atritrypsin do?
Blocks the neutrophil elastase which can break down connective tissue in the lungs
How many individuals in the US are estimated to have a alpha1-atritrypsin deficiency?
80-100k
What connection does COPD have to socioeconomic status?
COPD has been linked to poverty
Poor housing, lack of occupational choice, lack of education, poor nutrition, crowding and lack of control over living conditions have all been associated with increased risk of developing COPD
How do we diagnose COPD?
Spirometry
What happens to FEV1 in patients with COPD?
FEV1 is significantly reduced
What clinical indicators would support a diagnosis of COPD?
Dyspnea that is progressive over time, worse with exercise, and persistent
Chronic cough (intermittent and may or may not be productive)
History of risk factors
What history of risk factors would support a diagnosis of COPD?
Exposure to tobacco smoke
Smoke from other sources
Occupational dusts, vapors, fumes, gases, chemicals
Host factors
What component of PFT is used to discern whether or not a patient has COPD?
FEV1
Measuring the FEV1 and FVC is step one of diagnosing a patient with COPD.
What is the next step?
Take the ratio of FEV1/FVC
If FEV1/FVC < 70%, the patients has that dog in them aka COPD
What host factors would support a diagnosis of COPD?
Genetic factors
Developmental abnormalities
Low birthweight
Premature birth
Childhood respiratory infections
A GOLD grade of 1 means that the patient
Has mild COPD
FEV1 >= 80% predicted
A GOLD grade of 2 means that the patient
Has moderate COPD
50% < FEV1 < 80% predicted
A GOLD grade of 3 means that the patient
Has severe COPD
30% < FEV1 < 50% predicted
A GOLD grade of 4 means that the patient
Should really get their affairs in order
Has VERY severe COPD
FEV1 < 30% predicted
What is the problem with the GOLD grading level?
It suffers from the same problem as the BMI, it assumes that the average population trend applies to the individual.
How do we solve the problem associated with the GOLD scale?
Integrate it into a flowchart that also takes into account exacerbations and whether or not hospitalization occurred due to a COPD exacerbation
Integrate patient surveys to determine whether or not COPD is affecting their day to day lives
The three criteria used to diagnose the severity of COPD are:
The GOLD grade
The number of exacerbations per year and whether or not they led to hospitalization
Patients mMRC scores
Patients CAT scores
What are mMRC scores?
Scores derived from a patient survey that aims to determine how much COPD is affecting their day to day lives
For example, if a patient only gets breathless during strenuous exercise or if they are unable to leave the house due to breathlessness
What is the CAT assessment?
A patient survey that aims to gauges how much COPD affects a patients day to day life in specific scenarios such as sleeping, activity limitation or energy levels by asking the patients whether or not they are upset by potential limitations
Kind of subjective
COPD Assessment Tool
What lung volumes and capacities does air trapping increase?
Residual volume
Functional residual capacity
Total lung capacity
What is the primary pathological feature of emphysema?
Air trapping
What would you expect to see on an ABG from a COPD patient?
Increased PaCO2
Normal pH
What lung volumes and capacities does emphysema reduce?
Inspiratory reserve volume inspiratory capacity
Vital capacit
Why can COPDers maintain a normal pH despite increased PaCO2?
The kidneys compensate for respiratory acidosis by producing bicarbonate to maintain a normal pH
What would you expect from a sputum culture of an emphysema patient?
Normal culture
What would you expect from a sputum culture of a chronic bronchitis patient?
Strep
Influenza
What would a chest xray of chronic bronchitis patient look like?
Lungs may be clear with only large bronchi affected
Occasionally translucent or depressed diaphragms
Right sided heart failure
What would a chest xray of a emphysema patient look like?
Translucent
Depressed or flatted diaphragms
Long narrow heart
Increased retrosternal space
Occasional right sided congestive heart failure
What does the DLCO test examine?
The diffusing capacity of the lungs for carbon monoxide
What would the diffusion capacity of a chronic bronchitis patient look like? An emphysema patient?
Chronic bronchitis = normal
Emphysema patient = decreased
What can the DLCO test identify?
Disorders involving thickened capillary membranes
Disrupted AC membrane due to its destruction by emphysema
What do the hematocrit and hemoglobin levels look like in an emphysema patient?
Normal in the early to moderate stage
Elevated in late stage
What do the hematocrit and hemoglobin look like in a chronic bronchitis patient?
Elevated = polycythemia
What are the goals of treatment for stable COPD according to GOLD?
Reduce symptoms
Reduce risk of exacerbations
What are basic steps that can be taken to help treat COPD
Smoking cessation
Vaccinations
Risk factor management
Inhaler technique
Pulmonary rehab
Written action plan
According to GOLD, what do patients in Group E and B receive as treatment?
LABA + LAMA
According to gold, what do patients in group A receive as treatment?
A bronchodilator
According to GOLD, what do patients in Group E and B receive as treatment?
LABA + LAMA
What should be assessed before concluding an aerosolized therapy is insufficient?
Inhaler technique
What is the definition of a COPD exacerbation in 2023
An event characterized by
increased dyspnea and/or cough and sputum that worsens in <14 days which may be accompanied by
tachypnea and/or tachycardia and is often associated with increased local and systemic inflammation cause by infection, pollution, or
other insult to the airways
Long term administration of oxygen is effective at increasing survival for what kind of COPD patient
Severe chronic resting arterial hypoxia
What is GOLDs stance on non-invasive positive pressure ventilation?
NPPV may improve hospitalization free survival in selected patients after recent hospitalization, particularly in those with pronounced daytime persistent hypercapnia
How does GOLD recommend patients presenting with a COPD exacerbation be treated?
LABA + LAMA
ICS
If those are ineffective, roflumilast or azithromycin
What does GOLD recommend for COPD patients who do not respond appropriately to initial pharmacological therapy?
Increase dosage or frequency
Combine SABAs and anticholinergics
Consider long acting bronchodilators
Consider oral steroids
Consider oral antibiotics
Consider non invasive mechanical ventilation
What age of onset favors asthma? COPD?
Asthma < 20 years
COPD >40 years
What pattern of respiratory symptoms favor asthma? COPD?
Asthma = variation in symptoms
COPD = persistent symptoms
What kind of lung function between symptoms favors asthma? COPD?
Asthma = lung function normal between symptoms
COPD = lung function abnormal between symptoms
What kind of airflow limitation is consistent with asthma? COPD?
Asthma = variable air flow limitation
COPD persistent airflow limitation post bronchodilator
What patient history favors asthma?
Asthma = Family history of asthma
COPD = heavy particulate or irritant exposure
A diagnosis of ACOS would be supported by the patient developing symptoms at what age?
Usually over 40, but may have had symptoms as a child or early adult
What kind of respiratory patterns would be indicative of ACOS?
Exertional dyspnea are persistent but variability may be prominent
What kind of symptom changes do we see over time with asthma? COPD?
Asthma = no worsening of symptoms over time
COPD symptoms slowly worsen over time
What does a chest ray of an asthmatic look like? COPDer?
Asthma = normal
COPD = hyperinflation
What kind of lung function between symptoms might be indicative of ACOS?
Persistent airflow limitation
What kind of lung function characteristics might be indicative of ACOS?
Airflow limitation that is not fully reversible, but often with current or historic variability
What kind of past or family history might be indicative of ACOS?
History of dr diagnosed asthma, allergies, family history of asthma or a history of particulate exposure
What kind of changes over time would be indicative of ACOS?
Symptoms are significantly reduced with treatment but will progress over time and require higher levels of treatment
What chest x ray would be indicative of ACOS?
Hyperinflation similar to COPD
A patient who has had 2 or more moderate exacerbations in the past year leading to hospitalization would receive what classification on the GOLD ABE assessment tool?
E
A patient who has had 0-1 moderate exacerbations in the past year that did not lead to hospitalization and who has a mMRC score of 3 and a CAT score of 28 would receive what classification on the GOLD ABE assessment tool?
B
