L19 - Obstructive Lung Diseases (COPD and Asthma) Flashcards
Prevelance of COPD now and in 2020
Ranking of COPD in terms of cause of death now and in 2020
World Health Organization predicts that by 2020 COPD will rise from its current ranking as the 12th most prevalent disease worldwide to the 5th; and from the 6th most common cause of death to the 3rd
COPD mortality is highest where worldwide?
Why?
In developing countries and asia
• Not only do to smoking, but also biomass fuels (indoor airpollution - common to indoor cooking)
Which is false regarding asthma effects in US society
A. 1 patients die of asthma every day
A. 39.5 million Americans have been diagnosed with asthma in their lifetime.
A. 13.2 million Americans had an asthma attack in 2011.
A. Economic cost from 2002 to 07 was $56.0 Billion dollars
A. 10
Demographics of asthma
more common in women and in blacks. About equal prevalence in kids and adults
Overall prevalence is rising
COPD or Asthma? • Increasing prevalence • Affects only adults • Increase mortality • High Health Care Cost
COPD
COPD or Asthma? • Increasing prevalence • Affects both children and adults • Decrease mortality • High Health Care Cost
Asthma
Describe fatal asthma
- People who die from asthma have abnormal lungs with mucus plugs (corks in the airway) - prevent air from getting into the lung
- Inhaled steroids prevent development of inflammation, which prevents development of mucus plugs
- The mucus plugs cause mortality in asthma
General asthma (not fatal) have normal looking lungs
• Clinical diagnosis defined by the presence of chronic productive cough for three months in each of two successive years in a patient in whom other causes of chronic cough have been excluded
• Chronic bronchitis:
• Emphysema:
Is a pathological term describing the abnormal permanent enlargement of airspaces distal to the terminal bronchioles, accompanied by destruction of their walls without “obvious fibrosis”.
Which is false about the pathologic features of asthmatic airways? A. goblet cell hypoplasia B. increased blood vessel numbers C. Smooth muscle hyperplasia D. Subepithelial fibrosis E. mucus gland hypertrophy F. reduced airway lumen area
A. Hyperplasia
Why is bronchial Wall Thickness important
• The degree of smooth muscle shortening required to produce airway closure is less in asthma patients than non-asthma patients (p
Which of the following does not increase to cause emphysema? A. neutrophil elastase B. alpha1-antitrypsin C. Cathepsins D. Matrix metalloproteinases (1,2,9,12)
B. This decreases
Which of the following does not decrease to cause emphysema?
A. Secretory leukoprotease inhibitor
B. elafin
C. Proteinase 3
D. Tissue inhibitors of matrix metalloproteinases
C. decreases
Describe the pathway of inflammatory mediators in asthma
Airway cell –> mediator –> physiological response
What is the diagnosis?
considered in current or former smokers (or in never smokers with other risk factors (noxious gases, ambient pollution and chronic respiratory infections)) who present with cough, sputum production, or dyspnea, with spirometric evidence of irreversible airflow obstruction
COPD
What is the diagnosis?
heterogeneous disease, usually characterized by chronic airway inflammation. It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable expiratory airflow limitation.
Asthma
Which is not a consequence of acute inflammation in asthma?
A. Altered airway physiology (inc airway hyperresponsiveness, inc airflow obstruction)
B. Acute inflammation
C. Resolution
B. Chronic inflammation
Does airway remodeling occur in mild asthma?
YES
COPD or Asthma?
A. sensitizing agent
B. airway inflammation with CD4 (+) T lymphocytes; eosinophils
C. reversible airflow limitation
D. younger, less likely to be smokers, intermittently symptomatic
ASTHMA
COPD or Asthma?
A. noxious agent
B. airway inflammation (CD8+ T lymphocytes, macrophages/neutrophils)
C. airflow limitation irreversible
D. older, smokers, persistent, dyspnea, less responsive to inhalers
COPD
What is the spirometry value of COPD patients?
FEV1/FVC ration
T/F Both spirometric evidence of airflow obstruction and clinical symptoms are necessary for the diagnosis of COPD
T
WHich is false regarding GOLD COPD definition?
A• COPD is a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients
B• Its pulmonary component is characterized by airflow limitation that is fully reversible
C• Exacerbations and comorbidities contribute to the severity of the disease
B. is NOT fully reversible
Which is not a systemic effect of COPD?
A• Cachexia,
B• Osteoporosis,
C• Hypercapnia-induced peripheral edema,
D• Neuro-psychiatric disorders, such as oxygen-related cognitive impairment and depression,
E• Excessive polycytemia
F• Weight loss
G• Venous thromboembolic disease (VTE)
H• Pulmonary Hypertension
I• Hormonal abnormalities (insulin, growth hormone, testosterone, and glucocorticoids)
J• Atherosclerosis
F• Sleep disorders are actually a systemic effect, not weight loss
These symptoms are found with COPD or asthma?
- Coughing (especially at night) - circadian rhythm of lungs (airways at night get smaller)
- Wheezing
- Chest tightness
- Shortness of breath
Asthma
What are some triggers of asthma?
- Night-time: gastroesophageal reflux?
- During/after exercise: exercise-induced asthma?
- Seasonal: allergic asthma?
- Coughing after laughing or crying?
- Exposure to triggers at home, school, work?
What are key findings in asthma physical exam?
• Chest
• Physical examination of the chest may be normal.
• Wheeezing or prolonged expiration during forced expiration.
○ (Wheezing and prolongation of expiratory phase does not correlate with the degree of airway obstruction measured by spirometry)
• Hyperinflation of the lungs
○ e.g. hyperresonance, diminished breath sounds
• Use of accessory muscles of respiration
What are non-pulmonary signs of asthma on physical exam?
- Non-Pulmonary (asthma)
- Skin Signs: Atopic Dermatitis
- Nasal Signs: Mucosal swelling, Polyps, Increased secretions
COPD or asthma? Pulmonary function test - Spirometry: obstructive - Lung volume: air trapping/hyperinflation - DLCO: reduced
COPD
- DLCO = diffusion capacity
- Will be normal or increased bc doesn’t affect lung parenchyma (due to more blood flow)
- In COPD it will be reduced
COPD or asthma? Pulmonary function test - spirometry: obstructive or normal - lung volume: normal to air trapping and/or hyperinflation - DLCO: normal or increased
Asthma
- DLCO = diffusion capacity
- Will be normal or increased bc doesn’t affect lung parenchyma (due to more blood flow)
- In COPD it will be reduced
What is this test?
• Measure FEV1 at each dose.
• When FEV1 drops to 20% - you stop
• If this happens at 5th does or lower = asthma
• If test is neg (never drop) - the person is very unlikely to have asthma
• This is a very sensitive test.
Methacholine challenge test to diagnose asthma
What percent of peak flow variation is diagnostic of asthma?
- If variation is beyond 20% = reactive airway disease (asthma)
- Useful for occupational asthma - check peak flows at work and when off work
Which is false regarding the natural history of COPD?
A. Smokers increase the rate at which they lose lung function over time
B. If you quit smoking, you can regain (increase) lung function
C. Never smokers typically have higher lung function than smokers over time
B. you can NOT, but the rate of loss will be that of as if you did not smoke after quitting
What are the 3 stages in the natural history of asthma?
- acute response (bronchoconstriction, mediator release, edema, secretions, cough)
- Chronic inflammation (cell recruitment, epithelial damage, early structural changes)
- Airway remodeling (cell proliferation, increased ECM)
List some genetic and environmental exposure risk factors that increase risk for COPD.
Do they influence lung growth in childhood?
Genetic: MMP12 SNP AA
Environmental: Smoking
Host characteristics (such as genetic makeup) and environmental exposures (such as smoking) influence lung growth in childhood and adolescence and determine the rate of decline in lung function in adulthood • Decline dependent of lung function you were able to reach when you were young.
T/F COPD can overlap with other syndromes such as chronic bronchitis, emphysema, and asthma
True - there are various subsets of COPD
T/F Pulmonary function tests are sufficient to diagnose emphysema
False - it is possible to have low FEV1 (which seems like emphysema) but now emphysema. Or normal FEV1, but imaging shows emphysema
Imaging (CT) and PFT are key
COPD or asthma?
- to stop the natural history you can:
1. stop smoking
2. tx asthma during childhood
COPD
COPD or asthma?
- to stop the natural history you can:
1. avoid triggers
2. use inhaled steroids (if in persistant stage)
asthma
COPD severity classification by GOLD criteria is based on these 3 components
- airflow obstruction
- risk of exacerbations
- symptoms (mMRC or CAT score)
Asthma classification is by…
Day and night symptoms
Describe an acute COPD exacerbation
Feels like a heart attack
COPD therapy is based on …
- GOLD classification
- PFT
- exacerbations
Which is false regarding the therapeutic management of COPD?
A. Reduce exacerbations
B. Disease control
C. LABA alone can be used
D. ICS are only used in combination with LABA
E. Smoking cessation is key in the treatment of COPD (prevent progression of disease)
C. LAMA & LABA alone can be used
Which is false regarding the therapeutic management of asthma?
A. Reduce exacerbation
B. Disease control
C. LABA alone is contraindicated
D. Limited data on LAMA use in asthma
E. ICS is not used in asthma therapy
E. • ICS are the cornerstone of asthma therapy
Define:
- SAMA
- SBA
- LAMA
- LABA
- ICS
- SAMA = Short acting muscarinic agent
- SABA = Short acting beta against
- LABA = Long activating broncodilator
- LAMA = long acting muscarinic agent
- ICS = inhaled corticosteroids
What kind of treatment ALONE is a contraindicated in asthma?
LABA
3 nonpharm therapies in COPD
- Oxygen therapy for patients with oxygen saturation ≤ 88% or ≤ 89% with evidence of cor pulmonale
- Vaccination (Influenza and Pneumonia)
- Pulmonary Rehabilitation
- PDE-4 inhibitor (phosphodiesterase inhibitor)
* Indicated in patients with frequent exacerbations, chronic bronchitis and FEV1
Roflumilast
For COPD exacerbations
- Unclear mechanism of action: Immunomodulation, antibiotics, change of airway microbiome
- Given at 250 mg daily
- Can interact with other drugs
- QT prolongation on EKG
- Potential hearing impairment
Azithromycin
For COPD exacerbations
Which is not a new therapy in COPD treatment?
A. Targeting of different cytokines by using monoclonal antibodies (anti IL-13, IL-5, IL-8, IL-5 receptor, CCL-2)
B. Targeting different signal transduction pathways (anti p38, MAPK, NF-KB)
C. Classifying patients based on cell count differential (neutrophils vs eosinophils) and targeting therapies against these cells
All are new therapies
• Binds free circulating IgE
Decreases symptoms and exacerbations
Omalizumab
Treatment of asthma
• Inhibits IL-5, results in decrease eosinophilia.
• Increase quality of life, decrease exacerbations, decrease need for prednisone
Administered IV or subq can reduce exacerbations
Mepolizumab
Treatment of asthma
