Lecture 5: COPD Flashcards
What are the two pathophysiologic categories of COPD?
- Chronic bronchitis
- Emphysema
What symptoms are characteristic of COPD?
- Dyspnea
- Cough
- Sputum production
- Airflow obstruction
How common is COPD?
- > 10 million in the US
- > 120k deaths annually
- 4th leading cause of death
High burden due to high resource utilization
What are the key physiologic markers of COPD?
- Airflow obstruction
- Extensive airway destruction
What disease is characterized primarily by alveolar destruction in COPD?
Emphysema
What disease is characterized by increased sputum production and obstruction of more central airways in COPD?
Chronic bronchitis
What is a blue bloater usually describing?
Obese male that is constantly coughing.
What does a classic emphysema patient look like?
- Barrel chest
- Older and thinner
- Hyperinflated diaphragm with flattened diaphragms.
- Quiet chest
- Severe dyspnea
What is the clinical diagnosis criteria for chronic bronchitis?
- Daily productive cough > 3+ months
- Must be in at least 2 consecutive years
What is the diagnostic criteria for emphysema?
Permanent enlargement and destruction of airspaces distal to terminal bronchioles.
Does not require a CXR, but CXR will be noticeably abnormal.
How does mild COPD often present on PE?
- Usually normal
- Maybe prolonged expiration or faint-end expiratory wheeze with forced expiration.
How does moderate/severe COPD typically present on PE?
- Lung hyperinflation (via percussion)
- Decreased breath sounds, wheezes (bilateral)
- Crackles at lung bases (bilateral)
- Distant heart sounds
- Increased AP diameter (closer to 1:1)
How do end-stage COPD patients typically present?
- Tripodding + calloused elbows
- Accessory muscle use
- Pursed lips
- Hoover’s sign (lower intercostal space retraction during inspiration)
- Cyanosis
- Nail clubbing (rare)
What are the abnormal PE findings most characteristic of chronic bronchitis?
- Coarse rhonchi/wheezing
- Hepatomegaly
- Increased JVP
- Peripheral edema
Suggestive of R-sided HF
What are the abnormal PE findings most characteristic of emphysema?
- Expiration with pursed lips
- Hyperresonant percussion
- Wheezing, rales
Who gets screened for COPD?
- 1 of the 3 cardinal symptoms.
- OR
- Gradual decline in activities with risk factors for COPD.
- CAPTURE questionnaire. (2-4 = clinically significant)
Cardinal symptoms:
Dyspnea
Sputum volume
Sputum production
What does COPD look like on spirometry in regards to BD administration?
COPD is defined by irreversible or partially reversible but limited airflow.
What labs/diagnostics are recommended in a patient with COPD?
- Pulse ox every visit
- CBC, BMP (or CMP), TSH, BNP/NT-proBNP, serum alpha-1-antitrypsin
- CXR (not required to diagnose COPD)
What PFT findings suggest obstructive disease?
- FVC > 80%
- FEV1/FVC < 0.7
- OR
- FVC < 80% with TLC > 80%
AKA they either breath out very slowly or they cant breath out a lot in general even though their lung capacity is fine overall.
When should DLco be considered in PFT testing?
- Severe FEV1
- Resting O2 <= 92%
- Exertional hypoxemia < 90% on 6MWT
- Severe dyspnea (mMRC >= 2)
Mainly to assess severity of emphysema.
Lower DLco decreases in proportion to severity of disease
What are ABGs specifically used for?
- Determining pH levels
- Determining metabolic vs respiratory acidosis/alkalosis
- Determining compensation for above
In COPD, what generally becomes elevated in ABGs the worse the COPD?
pCO2 should increase.
Worsening pO2.
What does negative base excess suggest on ABG? Positive?
- Negative = metabolic acidosis
- Positive = metabolic alkalosis
When is a CXR indicated for COPD workup?
- Dyspnea/cough etiology unknown
- R/o complicating process during acute exacerbations
- Comorbidity evaluation
What is characteristic of emphysema on CXR?
- Hyperinflation
- Flattened diaphragm
- Increased retrosternal air space
- Long, narrow heart shadow
How is COPD staged?
Global initiative for COPD (GOLD)
What is GOLD severity determined by and how many stages are there?
- Gold 1: Mild with FEV1 >= 80%
- Gold 2: Moderate with FEV1 50-80%
- Gold 3: Severe with FEV1 30-50%
- Gold 4: Very severe with FEV1 < 30%
Requires spirometry
What are the two ways to assess symptoms for COPD staging?
- mMRC: severity of breathlessness (0-4)
- CAT: assess multitude of symptoms present (0-40)
What are the GOLD ABE Assessment protocol steps?
- Spirometrically confirmed COPD
- GOLD assessment of obstruction
- Exacerbation history per year
- Assessment of symptoms/risk of exacerbations
Example: CAT of 22 with 1 moderate exacerbation without hospitalization is B.
Stage this patient
FEV1 60%, ➔ 1 exacerbation ➔ No hospitalizations ➔ mMRC 2
GOLD 2B
Stage this patient
FEV1 45%, ➔ 3 exacerbation ➔ No hospitalizations ➔ CAT 13
GOLD 3E
What are the primary goals of managing COPD?
- Improving symptoms
- Decreased number of exacerbations
- Improve quality of life and functioning
What pharmacological support is available for smoking cessation?
- NRT
- Bupropion (caution in eating disorders/seizure disorder)
- Varenicline (Chantix)
What is the role of oxygen in COPD management?
- Good in patients with severe, chronic, resting arterial hypoxemia.
- Careful with potential oxygen trapping in acute exacerbations.
In what classes of COPD is pulmonary rehabilitation indicated for?
Class B and E.
What does pulmonary rehab consist of?
- Exercise training
- Promotion of healthy behaviors
- Psychological support
What are the SABAs and their SEs?
- Albuterol and Levalbuterol.
- Tachycardia, tremor, cardiac arrhythmias
Rescue inhaler
What is the SAMA and its SEs?
- Ipratropium bromide
- Dry mouth/eyes, metallic taste, and prostatic symptoms.
What are the LABAs and their frequency of use?
- Arformeterol (NEB only, QD/BID)
- Salmeterol (BID)
- Formeterol (BID)
What are the LAMAs and their frequency of use?
- Tiotropium (Spiriva, QD)
- Umeclinidium (Incruse ellipta, QD)
- Revefenacin (Yupelri Neb, QD)
- Aclinidium (Tudroza Pressair, BID)
- Glycopyrrolate (Seebri Neohaler, BID)
What is the pharmacologic recommendation for Group A COPD? B? E?
- A: single BD
- B: LABA + LAMA
- E: LABA + LAMA (can add ICS if eosinophil > 300)
For followup of dyspnea, what should be the first step if the current medication regimen is not working?
Switch to a different inhaler combo.
What eosinophil count contraindicates ICS use in COPD?
Once it goes < 100, d/c ICS and use roflumilast or azithromycin.
When is ICS removal indicated in COPD?
- Pneumonia
- Inappropriately added
- Lack of response
- Can attempt trial descalation if tolerating well.
What is roflumilast’s MOA and drug class?
PDE-4 inhibitor to reduce inflammation and pulmonary remodeling.
Reduces exacerbations in severe COPD.
Who is roflumilast contraindicated in?
- Psychiatric patients
What is theophylline’s drug class and MOA?
- Drug class: non-specific phosphodiesterase inhibitor
- MOA: relaxes smooth muscle, which increases diaphragm contraction force.
Indicated in refractory COPD
What is the main concern regarding theophylline use?
Toxicity and hepatic impairment.
How often is COPD management/follow up?
- 1-3 months after initiating therapy.
- 3-6 months once stabilized
- Annual spirometry at minimum.
What is the concern with untreated COPD exacerbation?
Development of PNA
What historical findings characterize a COPD exacerbation?
- Worsening of symptoms over hours-days
- More rapid course of symptoms and increased respiratory compromise.
- Increased mucus production
- Hemoptysis
What PE findings might suggest acute COPD exacerbation?
- Wheezing and tachypnea
- Respiratory compromise
- Abnormal breathing
- Decreased mental status
What aspects of acute COPD exacerbation require changes in patient management?
- Severe symptoms
- Acute respiratory failure
- new PE findings (cyanosis, peripheral edema)
- Failure to respond to standard therapy
- Serious comorbidities (arrhythmias, CHF)
- Insufficient home support
What are the treatment options for acute COPD exacerbation management?
- Adjust BD therapy
- Spaces/nebs
- Oral glucocorticoid (5 days max)
- ABX for increased cough, sputum, or purulence.
- Non-invasive mechanical ventilation (BiPAP)
ABX treatment depends on exposure history.
What is the target spO2 level for acute COPD exacerbation patients admitted?
88-92% to prevent O2 trapping.
Do not over oxygenate if spO2 is fine.
What would prompt ICU admission for acute COPD exacerbation?
- Severe dyspnea unresponsive to initial treatment.
- Mental status changes
- Worsening hypoxemia w/ respiratory acidosis unresponsive to therapy.
- Invasive ventilation
- Hemodynamic instability.
What is the purpose of alpha-1 antitrypsin?
Protects the lungs from neutrophil (elastase) damage
Made in the liver, migrates via blood.
What are the two pathophysiologic processes of ATT1 deficiency?
- Loss of elastin in alveolar wall and early onset emphysema
- Accumulation of ATT in liver, leading to liver damage.
How does ATT1 deficiency present?
- Symptoms of chronic liver disease
- Young age with emphysema symptoms
- Panniculitis: inflammation of SubQ tissue, resulting in hot and painful nodules on the thigh or butt
What workup is recommended for suspect ATT1 deficiency?
- Low serum ATT1
- PFT
- CXR
How is ATT1 managed?
- Same as COPD + possible infusion of donor ATT.
- Smoking cessation
What is bronchiectasis?
- Irreversible focal or diffuse dilation and destruction of the bronchial walls
- Multifactorial etiology, generally inflammation of the airways.
How does bronchiectasis present typically?
- Chronic, daily productive cough
- Copious, foul-smelling, thick, purulent sputum.
- Rales/rhonchi/wheezing on PE.
- Increased sputum volume/production in acute exacerbations
What are tram tracks and what are they associated with?
- Dilated airways.
- Often associated with bronchiectasis.
What is a hallmark description of a CT chest for bronchiectasis?
Honeycomb/ballooned presence.
What are the most common risk factors associated with OSA?
- Age
- Male
- Obesity
- Smoking
- COPD
What is the pathophysiology of OSA?
- Recurrent and functional collapse of pharyngeal airflow in sleep.
- Reduced airflow = fragmented sleep and gas exchange disturbances.
What is the workup for OSA?
- Sleep apnea questionnaires (Berlin or STOP-BANG)
- In-lab polysomnography (FIRST LINE)
- Home sleep apnea test
- Overnight oximetry
What is the diagnostic criteria for OSA?
- 5+ obstructive respiratory events per hour of sleep + somnolence/snoring/gasping/HTN/CAD/CVA
- 15+ obstructive respiratory events per hour of sleep.
Either criteria
What are the primary treatments for OSA?
- Weight loss
- CPAP or APAP (mainstay)
- Oral appliances
- Upper airway surgery
- Hypoglossal nerve stimulationo