GOLD guidelines 2023 Flashcards
The main environmental exposures leading to COPD are ____
- Tobacco smoking
- Inhalation of toxic particles and gases from household and outdoor air pollution
The most relevant (albeit rare) genetic risk factor for COPD
Mutation in SERPINA-1 gene —> alpha 1-antritypsin deficiency
Confirms the diagnosis of COPD
The presence of non-fully reversible airflow limitation (FEV1/FVC < 0.7 post-bronchodilation) measured by spirometry
-Individuals with (+) Structural Lung lesions, and/or physiologic abnormalities, WITHOUT airflow obstruction
-May or may not develop airflow obstruction
Pre-COPD
-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
Preserved Ratio Impaired Spirometry (PRISm)
High prevalence of COPD seen in
-Smokers
-Ex-smokers
-≥40 years old
According to PLATINO, the highest prevalence of COPD is seen in
Age >60 years old
According to BOLD, global prevalence of COPD is ________
10.3%
Key environmental risk factor for COPD
Cigarette Smoking
Non-smoking COPD is more common in: ___
- Females
- Younger age groups
Characteristic of Non-smoking COPD
- Exhibits similar (or milder) respiratory symptoms and quality of life
- Lesser rate of decline in lung function over time
- Lower neutrophils and a trend towards higher eosinophil numbers in the airway sputum
- Similar spirometric indices
- Greater small airways obstruction (respiratory oscillometry and radiology)
- Less emphysema
- Similar defect in macrophage phagocytosis of pathogenic bacteria
In COPD, in smokers (vs non-smokers)
-Higher prevalence of respiratory symptom and lung function abnormality
-Greater annual rate of decline of FEV1
-Greater COPD mortality
Principal symptoms of impaired mucous clearance
Cough and dyspnea
Occupational exposures account for ____of either symptoms or functional impairment consistent with COPD.
10-20%
___ is responsible for ~50% of the attributable risk for COPD in low and middle income countries
Air pollution
In never smokers, _____ is the leading known risk factor for COPD
Air pollution
Chronic exposure to ___________, significantly impairs lung growth, accelerates lung function decline in adults, and increases the risk for COPD
PM 2.5 and Nitrogen Oxide
Accelerated telomere shortening
Marker of accelerated aging
Anthropometric mismatch of airway tree calibre relative to lung volume
Dysanapsis
-Related to initial mechanisms that eventually leads to COPD
-“biological”
Early COPD
-Can occur at any age
-May or may not progress at any time
-Used to describe the severity of airflow obstruction measured spirometerically
Mild COPD
-Directly relates to the chronological age of the patient
-Seen patients around 20-25 years old
-Associated with significant structural and functional lung abnormality
Young COPD
Adults diagnosed of asthma were found to have a _____ of acquiring COPD over time compared to those without asthma
12-fold higher risk
____ of asthmatic patients developed irreversible airflow limitation and reduced diffusing lung capacity
20%
Independent predictor of COPD and respiratory mortality in population studies
Airway Hyperresponsivess
(can exist without asthma diagnosis)
An indicator of risk of excess decline in lung function in patients with mild COPD
Airway hyperresponsiveness
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
Chronic Bronchitis
Factors associated with increased prevalence of Chronic Bronchitis in COPD
- Male Sex
- Younger Age
- Greater pack-years of smoking
- More severe airflow obstruction
- Rural location and increased occupational exposure
Mucin (large glycoproteins) polymers lining the human airways
- MUC5AC (proximal airway surface goblet cells)
- MUC5B (surface secretory cells throughout the airways and submucosal gland)
Mucin polymer thats is associated more specifically with increased exacerbation frequency, increased symptoms and greater lung function decline
Sputum MUC5AC
In COPD, this mucin is markedly increased due to submucosal gland hyperplasia leading to airway occlusion
Sputum MUC5B
In adults <50 years old, _______ represents as an early marker for susceptibility to the long term risk of COPD and all-cause mortality
Chronic Bronchitis WITHOUT airflow limitation
Associated with accelerated FEV1 decline
Chronic bronchial infection
(particularly with Pseudomonas aeruginosa)
_________ is both a differential diagnosis or possible comorbidity for COPD
Tuberculosis
Due to Methylation disruptions in airway epithelium, these type of patients has increased risk of COPD
HIV patients
Inflammatory changes in COPD
- Increased numbers of macrophages in peripheral airways, lung parenchyma and pulmonary vessels
- Increased activated neutrophils
- Increased lymphocytes
Protease-mediated destruction of this major connective tissue component is an important feature of emphysema in COPD
Elastin
__________ 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 _______
Static Lung Hyperinflation
Exertional dyspnea
Limiting exercise capacity
Main mechanism of abnormal pulmonary gas exchange resulting to different degrees of arterial hypoxemia with or without hypercapnia
Ventilation/Perfusion mismatch
Pulmonary hypertension in COPD is caused by: _____ (2)
Intimal hyperplasia
Smooth muscle hypertrophy/hyperplasia
COPD Taxonomy: Childhood asthma
COPD-A (asthma)
COPD Taxonomy: Tobacco smoke, Maternal smoking, Vape, Cannabis
COPD-C (cigarette)
COPD Taxonomy: Early life events, Low birthweight, Premature birth
COPD-D (development)
COPD Taxonomy: Alpha-1 anti-trypsin deficiency
COPD-G (genetics)
COPD Taxonomy: Childhood infections, Tuberculosis-associated, HIV-associated
COPD-I (infections)
COPD Taxonomy: Household pollution, Ambient air pollution, Wildfire smoke, Occupational Hazards
COPD-P (pollution)
COPD Taxonomy: unknown cause
COPD-U (unknown)
Most characteristic symptom of COPD
Chronic Dyspnea
Cardinal symptom of COPD
Major cause of the disability and anxiety associated with COPD
Dyspnea
Often the first symptom of COPD
Chronic Cough
Large volume of sputum
Possible underlying Bronchiectasis
Purulent sputum
Increase in inflammatory mediators
Possible onset of bacterial infection
Ankle swelling in COPD may indicate ___
Presence of Cor pulmonale
Bronchodilation in Spirometry
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
Initial Assessment in patients with COPD
- Severity of Airflow Limitation
- Nature and Magnitude of current symptoms
- Previous history of moderate and severe exacerbation
- Presence and type of other diseases (multimorbidity)
GOLD GRADING OF SEVERITY
Gold 1: Mild
FEV1 ≥ 80% predicted
GOLD GRADING OF SEVERITY
Gold 2: Moderate
50% ≤ FEV1 <80% predicted
GOLD GRADING OF SEVERITY
Gold 3: Severe
30% ≤ FEV1 <50% predicted
GOLD GRADING OF SEVERITY
Gold 4: Very Severe
FEV1 <30%
Episodes of acute respiratory symptom worsening often associated with increased local and systemic inflammation
Acute Exacerbation
The best predictor of having frequent exacerbations (defined as two or more exacerbations per year)
Previous history of exacerbations
A modifiable source of exercise intolerance by rehabilitation
Skeletal Muscle Dysfunction
Lung volume study in COPD
increase in TLC, particularly during exercise
(Increase in both Static and Dynamic Hyperinflation)
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)
DLCO <60%
In smokers without airflow obstruction, DLCO value that is marker of emphysema, or sign of risk for developing COPD overtime
DLCO <80%
Should be measured in any patient with dyspnea disproportionate to the severity of airflow obstruction
Single breath Carbon monoxide diffusing capacity of the lungs (DLco)
Indications for Chest CT Scan
- COPD patients with persistent exacerbations
- Symptoms out of proportion to disease severity on lung function testing
- FEV1 less than 45% predicted with significant hyperinflation and gas trapping
- Those who meet criteria for lung cancer screening
Indications for Endobronchial valve therapy
- Post-bronchodilator FEV1 of 15-45%
- Evidence of Hyperinflation
Indications for Lung Volume Reduction Surgery
- Hyperinflation
- Severe Upper lobe predominant emphysema
- Low exercise capacity after Pulmonary rehabilitation
Composite score that is a better predictor for subsequent survival than any single component
The BODE Index (BMI, Obstruction, Dyspnea, Exercise)
Blood Eosinophil count at higher risk for exacerbation, and more likely benefit from preventive treatment with inhaled corticosteroids
≥ 300 cells/μL
COPD Intervention that has the greatest capacity to influence the natural history of COPD.
Smoking Cessation
Nicotine replacement therapy reliably increases long-term smoking abstinence rates. Medical contraindications to nicotine replacement therapy include _____
recent myocardial infarction or stroke
Recommended Vaccinations for COPD
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
PHARMACOLOGY OF STABLE COPD
Medications that increase FEV1
Bronchodilators
Effects of Bronchodilators
- Alters airway smooth muscle tone
- Reduce dynamic hyperinflation at rest and during exercise
- Improves exercise performance
PHARMACOLOGY OF STABLE COPD
Central to the symptom management of COPD
Inhaled Bronchodilators
Once daily LABA that improves breathlessness, health status and exacerbation rate
Indacaterol
Side effects of beta-agonists
- Resting sinus tachycardia
- Potential to precipitate cardiac rhythm disturbances
- Exaggerated somatic tremor
Main side effect of Inhaled Anticholinergic Drugs
Dry Mouth
What drug improves the effectiveness of pulmonary rehabilitation in increasing exercise performance?
Tiotropium (LAMA)
(better exacerbation reduction than LABA)
Bronchodilator
LABA and LABA are preferred over SAMA
Non-selective phosphodiesterase inhibitors
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
Lower blood and sputum eosinophils are associated with greater presence of ___
- Proteobacteria (Haemophilus)
- Increased bacterial infections
- Increase rate of pneumonia
Independent of ICS use, blood eosinophil count of _____ is associated with increase risk of pneumonia
<2%
Oral glucocorticoids in COPD
No evidence of benefits
Drug that improves lung function and decreases exacerbation in patients who are in fixed dose LABA + ICS combinations
PDE4 inhibitor
Antibiotic associated with increased incidence of bacterial resistance and hearing test impairment
Azithromycin
Antibiotic therapy associated with reduced exacerbations over 1 year
Long term Azithromycin and Erythromycin therapy
COPD patient on ICS with increased risk for pneumonia
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%
Indications to Add ICS to LABA + LAMA
History of Hospitalization for COPD exacerbation
≥ 2 exacerbations per year
Blood eosinophil count ≥ 300
History of concomitant asthma
ICS is NOT recommended if
Repeated pneumonia events
Blood eosinophil count <100
History of mycobacterial infection
______ reduces moderate and severe exacerbations treated with systemic corticosteroids in patients with chronic bronchitis, severe to very severe COPD, and a history of exacerbations.
Roflumilast (PDE4 inhibitors)
Note:
-Avoid in underweight patients (unexplained weight loss ~2 kg)
-Use in caution for patients with depression
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
Erdosteine
_____ may slow down progression of emphysema
IV augmentation therapy with Alpha 1-antitrypsin
(AATD and FEV1≤ 65)
Anti-tussives
No conclusive role
Vasodilators
Do not improve outcome
May worsen oxygenation
Contraindicated in Stable COPD
Treatment goals for patient with chronic bronchitis
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
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
Pulmonary rehabilitation
Optimum benefits of Pulmonary Rehabilitation in COPD
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
Vitamin supplementation that has been shown to improve antioxidant deficits, quadriceps strength, and serum total protein, without further improvement in quadriceps endurance.
Vitamin C
Vitamin E
Selenium
Zinc
COPD-Nutrition
Associated with worse outcomes in COPD
Low BMI
Low fat free mass
Other interventions that can improve feeling of breathlessness
Opiates
Neuromuscular Electrical Stimulation
Oxygen, even if non-hypoxemic (<92%)
Fans blowing air to face
Appropriate Inhalation device
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
Proven to increase survival in patients with severe, resting hypoxemia
Long term administration of oxygen (>15 hours per day)
Patients on long term oxygen therapy should maintain in-flight paO2 of ____
60 mmHg (6.7 kPA)
COPD patients may travel (flights) without assessment if:
Resting Oxygenation is >95%
6-minute walk test oxygen saturation >84%
In COPD exacerbation: the standard of care for decreasing morbidity and mortality in patients hospitalized with an exacerbation of COPD and acute respiratory failure
Noninvasive ventilation (NIV)
Home NIV is beneficial in
COPD with persistent hypercapnia (pCO2 >53 mmHg)
Giant bullectomy done if
Bulla occupies >1/3 of hemithorax, and compresses adjacent viable tissues
Bilateral LVRS showed improved survival IN
Upper lobe emphysema
Low post-rehabilitation exercise capacity
Lung transplant
Improved Quality of Life
No survival benefit (except for COPD with AATD)
Endobronchial one-way valves (EBV)
- Lower number of exacerbations and episodes of respiratory failure
- Improved survival
(Evidence A)
Bronchoscopic interventions
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)
When to repeat Spirometry in COPD
Anually
Preferred over SAMA
LABA and LAMA
Preferred initiating treatment with long acting bronchodilator
Combination therapy with LAMA + LABA
Monotherapy with ICS
Not recommended
INITIAL PHARMACOLOGIC TREATMENT
GOLD A
Bronchodilator (LABA or LAMA or SABA)
INITIAL PHARMACOLOGIC TREATMENT
GOLD B
LAMA + LABA
INITIAL PHARMACOLOGIC TREATMENT
GOLD E
LABA + LAMA
Consider adding ICS if blood eosinophil count ≥ 300
When to add Roflumilast
FEV <50%
Chronic Bronchitis
When to add Azithromycin (Long term)
Preferebly in previous smokers (currently not smoking)
When to consider withdrawal of ICS
pneumonia or other considerable side-effects develop
Indication for Long term oxygen therapy (LTOT)
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%).
Goal of LTOT
Keep SO2 ≥90%
After initiation of LTOT therapy
Recheck after 60 to 90 days to reassess if
1. Supplemental O2 is still needed
2. If prescribed supplemental oxygen is effective
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:
At least one
- History of hospitalization for exacerbation associated with acute hypercapnia with pCO2 >50 mmHg
- Pulmonary hypertension and/or cor pulmonale, despite oxygen therapy
- FEV1 <20% and either DLCO <20% or homogenous distribution of emphysema
NON-PHARMACOLOGIC MANAGEMENT OF COPD
GOLD A
Smoking Cessation
Physical Activity
Vaccinations
NON-PHARMACOLOGIC MANAGEMENT OF COPD
GOLD B AND E
Smoking cessation
Pulmonary Rehabilitation
Physical activity
Vaccination
An event characterized by dyspnea and/or cough and sputum that worsen over < 14 days.
COPD Exacerbation
What is the initial bronchodilators to treat an exacerbation.
Short-acting inhaled beta2-agonists, with or without short-acting anticholinergics
In patients with severe exacerbations, ______ can improve lung function (FEV1), oxygenation and shorten recovery time including hospitalization duration.
Systemic corticosteroids
Duration of treatment of Systemic Corticosteroids in Acute COPD exacerbation
5 days
Methylxanthine in Exacerbation
Not recommended
Usual recovery time of exacerbation
4-6 weeks
Most frequent confounders in patients with COPD in exacerbation
Pneumonia
Pulmonary embolism
Heart failure
Less Frequent:
Pneumothorax
Pleural effusion
Myocardial infarction and/or cardiac arrhythmias
What classifies patient as Severe ECOPD
Worsening acidosis
pH <7.35, pCO2 >45 mmHg
Potential indications for possible Hospital Assessment
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
Management of Severe, Non-life threatening exacerbation
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
Long-term prognosis following hospitalization for COPD exacerbation is poor, with a five-year mortality rate of about __-
50%
Recommended dose of Oral Corticosteroids in Acute Exacerbation
Prednisone 40 mg OD x 5 days
Indications for ICU admission during Acute exacerbation
- Severe dyspnea that responds inadequately to initial emergency therapy
- Changes in mental status
- Persistent or worsening hypoxemia (paO2 <40) and/or severe respiratory acidosis (pH <7.2) despite O2 and NIV
- Need for NIV
- Need for Vasopressors
Indications for NIV in acute exacerbation
At least ONE
- Respiratory acidosis (pH ≤7.35, pCO2 ≥45)
- 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
- Persistent hypoxemia despite Oxygen therapy
Indications for IMV in acute exacerbation
- Unable to tolerate NIV or NIV failure
- S/P respiratory or cardiac arrest
- Diminished consciousness, psychomotor agitation, inadequately controlled by sedation
- Massive aspiration or Persistent vomiting
- Persistent inability to remove respiratory secretions
- Severe hemodynamic instability without response to fluids or vasoactive drugs
- Severe Ventricular or Supraventricular arrhythmias
- Life-threatening hypoxemia in patients unable to tolerate NIV
After admission from ECOPD, when will you repeat spirometry?
12-16 weeks follow up
recheck FEV1
Recommended lung CA screening in people with COPD due to smoking
Annual low-dose Chest CT scan
Treatment with _____ improves heart failure in COPD patients
Beta 1-blocker
COPD with Ischemic heart disease
Treatment of IHD should be according to guidelines irrespective of the presence of COPD
Arrhythmia usually associated with COPD that is associated with lower FEV1
Atrial fibrillation
Most frequently occurring comorbidity of COPD
Hypertension
Risk factors for developing Lung Cancer
Age >55
>30 pack year smoker
(+) Emphysema on CT scan
FEV1/FVC <0.7
BMI <25
Family history of Lung CA
Independent Risk factor for exacerbation of COPD
GERD
___ is responsible for ~50% of the attributable risk for COPD in low and middle income countries
Air pollution
