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PSBIM Harrison 21st Edition > GOLD guidelines 2023 > Flashcards

GOLD guidelines 2023 Flashcards

1
Q

The main environmental exposures leading to COPD are ____

A
  1. Tobacco smoking
  2. Inhalation of toxic particles and gases from household and outdoor air pollution
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2
Q

The most relevant (albeit rare) genetic risk factor for COPD

A

Mutation in SERPINA-1 gene —> alpha 1-antritypsin deficiency

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3
Q

Confirms the diagnosis of COPD

A

The presence of non-fully reversible airflow limitation (FEV1/FVC < 0.7 post-bronchodilation) measured by spirometry

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4
Q

-Individuals with (+) Structural Lung lesions, and/or physiologic abnormalities, WITHOUT airflow obstruction

-May or may not develop airflow obstruction

A

Pre-COPD

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5
Q

-Normal ratio (FEV1/FVC ≥ 0.7 after bronchodilation) but abnormal spirometry (FEV1 < 80% of reference, after bronchodilation)

-Associated with increased all-cause mortality

-Not always a stable phenotype

-Can transition to both normal and obstructed spirometry overtime

A

Preserved Ratio Impaired Spirometry (PRISm)

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6
Q

High prevalence of COPD seen in

A

-Smokers
-Ex-smokers
-≥40 years old

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7
Q

According to PLATINO, the highest prevalence of COPD is seen in

A

Age >60 years old

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8
Q

According to BOLD, global prevalence of COPD is ________

A

10.3%

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9
Q

Key environmental risk factor for COPD

A

Cigarette Smoking

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10
Q

Non-smoking COPD is more common in: ___

A
  1. Females
  2. Younger age groups
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11
Q

Characteristic of Non-smoking COPD

A
  1. Exhibits similar (or milder) respiratory symptoms and quality of life
  2. Lesser rate of decline in lung function over time
  3. Lower neutrophils and a trend towards higher eosinophil numbers in the airway sputum
  4. Similar spirometric indices
  5. Greater small airways obstruction (respiratory oscillometry and radiology)
  6. Less emphysema
  7. Similar defect in macrophage phagocytosis of pathogenic bacteria
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12
Q

In COPD, in smokers (vs non-smokers)

A

-Higher prevalence of respiratory symptom and lung function abnormality
-Greater annual rate of decline of FEV1
-Greater COPD mortality

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13
Q

Principal symptoms of impaired mucous clearance

A

Cough and dyspnea

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14
Q

Occupational exposures account for ____of either symptoms or functional impairment consistent with COPD.

A

10-20%

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15
Q

___ is responsible for ~50% of the attributable risk for COPD in low and middle income countries

A

Air pollution

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16
Q

In never smokers, _____ is the leading known risk factor for COPD

A

Air pollution

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17
Q

Chronic exposure to ___________, significantly impairs lung growth, accelerates lung function decline in adults, and increases the risk for COPD

A

PM 2.5 and Nitrogen Oxide

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18
Q

Accelerated telomere shortening

A

Marker of accelerated aging

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19
Q

Anthropometric mismatch of airway tree calibre relative to lung volume

A

Dysanapsis

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20
Q

-Related to initial mechanisms that eventually leads to COPD
-“biological”

A

Early COPD

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21
Q

-Can occur at any age
-May or may not progress at any time
-Used to describe the severity of airflow obstruction measured spirometerically

A

Mild COPD

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22
Q

-Directly relates to the chronological age of the patient
-Seen patients around 20-25 years old
-Associated with significant structural and functional lung abnormality

A

Young COPD

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23
Q

Adults diagnosed of asthma were found to have a _____ of acquiring COPD over time compared to those without asthma

A

12-fold higher risk

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24
Q

____ of asthmatic patients developed irreversible airflow limitation and reduced diffusing lung capacity

A

20%

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25
Q

Independent predictor of COPD and respiratory mortality in population studies

A

Airway Hyperresponsivess
(can exist without asthma diagnosis)

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26
Q

An indicator of risk of excess decline in lung function in patients with mild COPD

A

Airway hyperresponsiveness

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27
Q

Chronic cough and sputum production for at least 3 months per year for two consecutive years, in the absence of other conditions that can explain these symptoms

A

Chronic Bronchitis

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28
Q

Factors associated with increased prevalence of Chronic Bronchitis in COPD

A
  1. Male Sex
  2. Younger Age
  3. Greater pack-years of smoking
  4. More severe airflow obstruction
  5. Rural location and increased occupational exposure
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29
Q

Mucin (large glycoproteins) polymers lining the human airways

A
  1. MUC5AC (proximal airway surface goblet cells)
  2. MUC5B (surface secretory cells throughout the airways and submucosal gland)
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30
Q

Mucin polymer thats is associated more specifically with increased exacerbation frequency, increased symptoms and greater lung function decline

A

Sputum MUC5AC

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31
Q

In COPD, this mucin is markedly increased due to submucosal gland hyperplasia leading to airway occlusion

A

Sputum MUC5B

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32
Q

In adults <50 years old, _______ represents as an early marker for susceptibility to the long term risk of COPD and all-cause mortality

A

Chronic Bronchitis WITHOUT airflow limitation

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33
Q

Associated with accelerated FEV1 decline

A

Chronic bronchial infection
(particularly with Pseudomonas aeruginosa)

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34
Q

_________ is both a differential diagnosis or possible comorbidity for COPD

A

Tuberculosis

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35
Q

Due to Methylation disruptions in airway epithelium, these type of patients has increased risk of COPD

A

HIV patients

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36
Q

Inflammatory changes in COPD

A
  1. Increased numbers of macrophages in peripheral airways, lung parenchyma and pulmonary vessels
  2. Increased activated neutrophils
  3. Increased lymphocytes
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37
Q

Protease-mediated destruction of this major connective tissue component is an important feature of emphysema in COPD

A

Elastin

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38
Q

__________ related to the loss of elastic recoil, reduces inspiratory capacity, and is commonly associated with dynamic hyperinflation during exercise related to airflow limitation —> causing _______ and _______

A

Static Lung Hyperinflation

Exertional dyspnea
Limiting exercise capacity

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39
Q

Main mechanism of abnormal pulmonary gas exchange resulting to different degrees of arterial hypoxemia with or without hypercapnia

A

Ventilation/Perfusion mismatch

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40
Q

Pulmonary hypertension in COPD is caused by: _____ (2)

A

Intimal hyperplasia
Smooth muscle hypertrophy/hyperplasia

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41
Q

COPD Taxonomy: Childhood asthma

A

COPD-A (asthma)

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42
Q

COPD Taxonomy: Tobacco smoke, Maternal smoking, Vape, Cannabis

A

COPD-C (cigarette)

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43
Q

COPD Taxonomy: Early life events, Low birthweight, Premature birth

A

COPD-D (development)

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44
Q

COPD Taxonomy: Alpha-1 anti-trypsin deficiency

A

COPD-G (genetics)

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45
Q

COPD Taxonomy: Childhood infections, Tuberculosis-associated, HIV-associated

A

COPD-I (infections)

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46
Q

COPD Taxonomy: Household pollution, Ambient air pollution, Wildfire smoke, Occupational Hazards

A

COPD-P (pollution)

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47
Q

COPD Taxonomy: unknown cause

A

COPD-U (unknown)

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48
Q

Most characteristic symptom of COPD

A

Chronic Dyspnea

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49
Q

Cardinal symptom of COPD
Major cause of the disability and anxiety associated with COPD

A

Dyspnea

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50
Q

Often the first symptom of COPD

A

Chronic Cough

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51
Q

Large volume of sputum

A

Possible underlying Bronchiectasis

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52
Q

Purulent sputum

A

Increase in inflammatory mediators
Possible onset of bacterial infection

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53
Q

Ankle swelling in COPD may indicate ___

A

Presence of Cor pulmonale

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54
Q

Bronchodilation in Spirometry

A

Short-acting beta agonist
DOSE: 400 mcg
FEV1 measure after 10-15 min after

Short-acting anti-cholinergic
DOSE: 160 mcg
FEV1 measure after 30-45 minutes after

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55
Q

Initial Assessment in patients with COPD

A
  1. Severity of Airflow Limitation
  2. Nature and Magnitude of current symptoms
  3. Previous history of moderate and severe exacerbation
  4. Presence and type of other diseases (multimorbidity)
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56
Q

GOLD GRADING OF SEVERITY
Gold 1: Mild

A

FEV1 ≥ 80% predicted

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57
Q

GOLD GRADING OF SEVERITY
Gold 2: Moderate

A

50% ≤ FEV1 <80% predicted

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58
Q

GOLD GRADING OF SEVERITY
Gold 3: Severe

A

30% ≤ FEV1 <50% predicted

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59
Q

GOLD GRADING OF SEVERITY
Gold 4: Very Severe

A

FEV1 <30%

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60
Q

Episodes of acute respiratory symptom worsening often associated with increased local and systemic inflammation

A

Acute Exacerbation

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61
Q

The best predictor of having frequent exacerbations (defined as two or more exacerbations per year)

A

Previous history of exacerbations

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62
Q

A modifiable source of exercise intolerance by rehabilitation

A

Skeletal Muscle Dysfunction

63
Q

Lung volume study in COPD

A

increase in TLC, particularly during exercise

(Increase in both Static and Dynamic Hyperinflation)

64
Q

In COPD patients, DLCO values are predictive of increased symptoms, decreased exercise capacity, worse health status, increased risk of death (independent of severity of airflow obstruction)

A

DLCO <60%

65
Q

In smokers without airflow obstruction, DLCO value that is marker of emphysema, or sign of risk for developing COPD overtime

A

DLCO <80%

66
Q

Should be measured in any patient with dyspnea disproportionate to the severity of airflow obstruction

A

Single breath Carbon monoxide diffusing capacity of the lungs (DLco)

67
Q

Indications for Chest CT Scan

A
  1. COPD patients with persistent exacerbations
  2. Symptoms out of proportion to disease severity on lung function testing
  3. FEV1 less than 45% predicted with significant hyperinflation and gas trapping
  4. Those who meet criteria for lung cancer screening
68
Q

Indications for Endobronchial valve therapy

A
  1. Post-bronchodilator FEV1 of 15-45%
  2. Evidence of Hyperinflation
69
Q

Indications for Lung Volume Reduction Surgery

A
  1. Hyperinflation
  2. Severe Upper lobe predominant emphysema
  3. Low exercise capacity after Pulmonary rehabilitation
70
Q

Composite score that is a better predictor for subsequent survival than any single component

A

The BODE Index (BMI, Obstruction, Dyspnea, Exercise)

71
Q

Blood Eosinophil count at higher risk for exacerbation, and more likely benefit from preventive treatment with inhaled corticosteroids

A

≥ 300 cells/μL

72
Q

COPD Intervention that has the greatest capacity to influence the natural history of COPD.

A

Smoking Cessation

73
Q

Nicotine replacement therapy reliably increases long-term smoking abstinence rates. Medical contraindications to nicotine replacement therapy include _____

A

recent myocardial infarction or stroke

74
Q

Recommended Vaccinations for COPD

A

1. Influenza vaccine (annual)
2. Pneumococcal vaccine
-One dose PCV20
-One dose PCV15 followed by PPSV23
3. Tdap vaccine (if not vaccinated during adolescence)
4. Zoster vaccine ( >50 years old)
5. Covid 19 vaccine

75
Q

PHARMACOLOGY OF STABLE COPD

Medications that increase FEV1

A

Bronchodilators

76
Q

Effects of Bronchodilators

A
  1. Alters airway smooth muscle tone
  2. Reduce dynamic hyperinflation at rest and during exercise
  3. Improves exercise performance
77
Q

PHARMACOLOGY OF STABLE COPD

Central to the symptom management of COPD

A

Inhaled Bronchodilators

78
Q

Once daily LABA that improves breathlessness, health status and exacerbation rate

A

Indacaterol

79
Q

Side effects of beta-agonists

A
  1. Resting sinus tachycardia
  2. Potential to precipitate cardiac rhythm disturbances
  3. Exaggerated somatic tremor
80
Q

Main side effect of Inhaled Anticholinergic Drugs

A

Dry Mouth

81
Q

What drug improves the effectiveness of pulmonary rehabilitation in increasing exercise performance?

A

Tiotropium (LAMA)
(better exacerbation reduction than LABA)

82
Q

Bronchodilator

A

LABA and LABA are preferred over SAMA

83
Q

Non-selective phosphodiesterase inhibitors

A

METHYLXANTHINES
-metabolized by cytochrome P450
-clearance declines with age
-Improved inspiratory muscle function
-toxicity is dose-related
-adverse effect: atrial & ventricular arrhythmia, gran mal convulsions
-interacts with erythromycin but not azithromycin

84
Q

Lower blood and sputum eosinophils are associated with greater presence of ___

A
  1. Proteobacteria (Haemophilus)
  2. Increased bacterial infections
  3. Increase rate of pneumonia
85
Q

Independent of ICS use, blood eosinophil count of _____ is associated with increase risk of pneumonia

A

<2%

86
Q

Oral glucocorticoids in COPD

A

No evidence of benefits

87
Q

Drug that improves lung function and decreases exacerbation in patients who are in fixed dose LABA + ICS combinations

A

PDE4 inhibitor

88
Q

Antibiotic associated with increased incidence of bacterial resistance and hearing test impairment

A

Azithromycin

89
Q

Antibiotic therapy associated with reduced exacerbations over 1 year

A

Long term Azithromycin and Erythromycin therapy

90
Q

COPD patient on ICS with increased risk for pneumonia

A

currently smoke
aged ≥ 55 years
have a history of prior exacerbations or pneumonia
a body mass index (BMI) < 25 kg/m2
a poor MRC dyspnea grade
severe airflow obstruction
blood eosinophil count < 2%

91
Q

Indications to Add ICS to LABA + LAMA

A

History of Hospitalization for COPD exacerbation
≥ 2 exacerbations per year
Blood eosinophil count ≥ 300
History of concomitant asthma

92
Q

ICS is NOT recommended if

A

Repeated pneumonia events
Blood eosinophil count <100
History of mycobacterial infection

93
Q

______ reduces moderate and severe exacerbations treated with systemic corticosteroids in patients with chronic bronchitis, severe to very severe COPD, and a history of exacerbations.

A

Roflumilast (PDE4 inhibitors)

Note:
-Avoid in underweight patients (unexplained weight loss ~2 kg)
-Use in caution for patients with depression

94
Q

In COPD patients not receiving ICS, regular treatment with mucolytics may reduce exacerbations. In contrast, this drug, ______, may have significant effect on exacerbations irrespective of concurrent treatment with ICS

A

Erdosteine

95
Q

_____ may slow down progression of emphysema

A

IV augmentation therapy with Alpha 1-antitrypsin

(AATD and FEV1≤ 65)

96
Q

Anti-tussives

A

No conclusive role

97
Q

Vasodilators

A

Do not improve outcome
May worsen oxygenation
Contraindicated in Stable COPD

98
Q

Treatment goals for patient with chronic bronchitis

A

1) reducing the overproduction of mucus
2) decreasing mucus hypersecretion by reducing inflammation
3) facilitating elimination of mucus by increasing ciliary transport
4) decreasing mucus viscosity
5) facilitating cough mechanisms

99
Q

A comprehensive intervention based on thorough patient assessment followed by patient-tailored therapies that include, but are not limited to, exercise training, education, self-management intervention aiming at behavior change, designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adherence to health-enhancing behaviors

A

Pulmonary rehabilitation

100
Q

Optimum benefits of Pulmonary Rehabilitation in COPD

A

Achieved in programs lasting 6-8 weeks
No additional benefits from extending pulmonary rehabilitation to 12 weeks

Supervised exercise training at least twice weekly is recommended

101
Q

Vitamin supplementation that has been shown to improve antioxidant deficits, quadriceps strength, and serum total protein, without further improvement in quadriceps endurance.

A

Vitamin C
Vitamin E
Selenium
Zinc

102
Q

COPD-Nutrition

Associated with worse outcomes in COPD

A

Low BMI
Low fat free mass

103
Q

Other interventions that can improve feeling of breathlessness

A

Opiates
Neuromuscular Electrical Stimulation
Oxygen, even if non-hypoxemic (<92%)
Fans blowing air to face

104
Q

Appropriate Inhalation device

A

Dry powder inhalers
only if patient can make a forceful and deep inhalation

Metered-dose inhalers
Coordination between device triggering and inhalation and patients needs to be able to perform a slow and deep inhalation

105
Q

Proven to increase survival in patients with severe, resting hypoxemia

A

Long term administration of oxygen (>15 hours per day)

106
Q

Patients on long term oxygen therapy should maintain in-flight paO2 of ____

A

60 mmHg (6.7 kPA)

107
Q

COPD patients may travel (flights) without assessment if:

A

Resting Oxygenation is >95%
6-minute walk test oxygen saturation >84%

108
Q

In COPD exacerbation: the standard of care for decreasing morbidity and mortality in patients hospitalized with an exacerbation of COPD and acute respiratory failure

A

Noninvasive ventilation (NIV)

109
Q

Home NIV is beneficial in

A

COPD with persistent hypercapnia (pCO2 >53 mmHg)

110
Q

Giant bullectomy done if

A

Bulla occupies >1/3 of hemithorax, and compresses adjacent viable tissues

111
Q

Bilateral LVRS showed improved survival IN

A

Upper lobe emphysema
Low post-rehabilitation exercise capacity

112
Q

Lung transplant

A

Improved Quality of Life
No survival benefit (except for COPD with AATD)

113
Q

Endobronchial one-way valves (EBV)

A
  1. Lower number of exacerbations and episodes of respiratory failure
  2. Improved survival

(Evidence A)

114
Q

Bronchoscopic interventions

A

Advanced emphysema, bronchoscopic interventions reduced the end-expiratory lung volume AND improves exercise tolerance, Health status and Lung function at 6-12 months following treatment

Endobronchial valves (Evidence A)
Lung coils (Evidence B)
Vapor Ablation (Evidence B)

115
Q

When to repeat Spirometry in COPD

A

Anually

116
Q

Preferred over SAMA

A

LABA and LAMA

117
Q

Preferred initiating treatment with long acting bronchodilator

A

Combination therapy with LAMA + LABA

118
Q

Monotherapy with ICS

A

Not recommended

119
Q

INITIAL PHARMACOLOGIC TREATMENT
GOLD A

A

Bronchodilator (LABA or LAMA or SABA)

120
Q

INITIAL PHARMACOLOGIC TREATMENT
GOLD B

A

LAMA + LABA

121
Q

INITIAL PHARMACOLOGIC TREATMENT
GOLD E

A

LABA + LAMA

Consider adding ICS if blood eosinophil count ≥ 300

122
Q

When to add Roflumilast

A

FEV <50%
Chronic Bronchitis

123
Q

When to add Azithromycin (Long term)

A

Preferebly in previous smokers (currently not smoking)

124
Q

When to consider withdrawal of ICS

A

pneumonia or other considerable side-effects develop

125
Q

Indication for Long term oxygen therapy (LTOT)

A

paO2 below 55 mmHg or SO2 below 88%, with or without hypercapnia confirmed twice over 3 week period

paO2 between 55-60 mmHg, or SO2 88%, if there is evidence of pulmonary hypertension, peripheral edema suggesting congestive cardiac failure, or polycythemia (hematocrit > 55%).

126
Q

Goal of LTOT

A

Keep SO2 ≥90%

127
Q

After initiation of LTOT therapy

A

Recheck after 60 to 90 days to reassess if
1. Supplemental O2 is still needed
2. If prescribed supplemental oxygen is effective

128
Q

In patients with Severe COPD (progressive disease, BODE score 7-10) and not a candidate for LVRS, LUNG TRANSPLANTATION may be considered for referral if:

A

At least one

  1. History of hospitalization for exacerbation associated with acute hypercapnia with pCO2 >50 mmHg
  2. Pulmonary hypertension and/or cor pulmonale, despite oxygen therapy
  3. FEV1 <20% and either DLCO <20% or homogenous distribution of emphysema
129
Q

NON-PHARMACOLOGIC MANAGEMENT OF COPD

GOLD A

A

Smoking Cessation
Physical Activity
Vaccinations

130
Q

NON-PHARMACOLOGIC MANAGEMENT OF COPD

GOLD B AND E

A

Smoking cessation
Pulmonary Rehabilitation
Physical activity
Vaccination

131
Q

An event characterized by dyspnea and/or cough and sputum that worsen over < 14 days.

A

COPD Exacerbation

132
Q

What is the initial bronchodilators to treat an exacerbation.

A

Short-acting inhaled beta2-agonists, with or without short-acting anticholinergics

133
Q

In patients with severe exacerbations, ______ can improve lung function (FEV1), oxygenation and shorten recovery time including hospitalization duration.

A

Systemic corticosteroids

134
Q

Duration of treatment of Systemic Corticosteroids in Acute COPD exacerbation

A

5 days

135
Q

Methylxanthine in Exacerbation

A

Not recommended

136
Q

Usual recovery time of exacerbation

A

4-6 weeks

137
Q

Most frequent confounders in patients with COPD in exacerbation

A

Pneumonia
Pulmonary embolism
Heart failure

Less Frequent:
Pneumothorax
Pleural effusion
Myocardial infarction and/or cardiac arrhythmias

138
Q

What classifies patient as Severe ECOPD

A

Worsening acidosis
pH <7.35, pCO2 >45 mmHg

139
Q

Potential indications for possible Hospital Assessment

A

Severe symptoms
Acute respiratory failure
Onset of new physical signs
Failure pf an exacerbation to respond to initial medical management
Presence of serious comorbidities
Insufficient home support

140
Q

Management of Severe, Non-life threatening exacerbation

A

Administer O2
Start Bronchodilators
Consider Oral Corticosteroids
Consider Oral antibiotics if with signs of bacterial infection
Consider NIV

At all times
Monitor fluid balance
Consider subcutaneous heparin or LMW heparin for VTE prophylaxis
Identify and treat conditions

141
Q

Long-term prognosis following hospitalization for COPD exacerbation is poor, with a five-year mortality rate of about __-

A

50%

142
Q

Recommended dose of Oral Corticosteroids in Acute Exacerbation

A

Prednisone 40 mg OD x 5 days

143
Q

Indications for ICU admission during Acute exacerbation

A
  1. Severe dyspnea that responds inadequately to initial emergency therapy
  2. Changes in mental status
  3. Persistent or worsening hypoxemia (paO2 <40) and/or severe respiratory acidosis (pH <7.2) despite O2 and NIV
  4. Need for NIV
  5. Need for Vasopressors
144
Q

Indications for NIV in acute exacerbation

A

At least ONE

  1. Respiratory acidosis (pH ≤7.35, pCO2 ≥45)
  2. Severe dyspnea with clinical signs suggestive of respiratory muscle fatigue, increased work of breathing, use of accessory muscles of breathing, paradoxical motion of the abdomen, retraction of intercostal space
  3. Persistent hypoxemia despite Oxygen therapy
145
Q

Indications for IMV in acute exacerbation

A
  1. Unable to tolerate NIV or NIV failure
  2. S/P respiratory or cardiac arrest
  3. Diminished consciousness, psychomotor agitation, inadequately controlled by sedation
  4. Massive aspiration or Persistent vomiting
  5. Persistent inability to remove respiratory secretions
  6. Severe hemodynamic instability without response to fluids or vasoactive drugs
  7. Severe Ventricular or Supraventricular arrhythmias
  8. Life-threatening hypoxemia in patients unable to tolerate NIV
146
Q

After admission from ECOPD, when will you repeat spirometry?

A

12-16 weeks follow up
recheck FEV1

147
Q

Recommended lung CA screening in people with COPD due to smoking

A

Annual low-dose Chest CT scan

148
Q

Treatment with _____ improves heart failure in COPD patients

A

Beta 1-blocker

149
Q

COPD with Ischemic heart disease

A

Treatment of IHD should be according to guidelines irrespective of the presence of COPD

150
Q

Arrhythmia usually associated with COPD that is associated with lower FEV1

A

Atrial fibrillation

151
Q

Most frequently occurring comorbidity of COPD

A

Hypertension

152
Q

Risk factors for developing Lung Cancer

A

Age >55
>30 pack year smoker
(+) Emphysema on CT scan
FEV1/FVC <0.7
BMI <25
Family history of Lung CA

153
Q

Independent Risk factor for exacerbation of COPD

A

GERD

154
Q

___ is responsible for ~50% of the attributable risk for COPD in low and middle income countries

A

Air pollution

PSBIM Harrison 21st Edition (15 decks)

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