Lecture 5 - COPD Flashcards
T/F
COPD is a common, preventable and treatable disease
T
T/F
COPD is fully reversible and progressive
F
Not reversible
COPD is associated with an abnormal response?
Inflammatory response of the lung to noxious particles or gases
COPD is caused primarily by what?
by cigarette smoking, air pollution: wood burning + other biomass fuels also identified as risk factors
T/F
COPD includes asthma
F
In obstruction disease yes, not in copd
What are the dx symptoms of copd?
- cough
- sputum
- dyspnea
- hx of exposure to risk factors for the disease
what are the risk (8) factor of copd?
Exposure to particles:
Tobacco smoke
Environmental and occupational exposure to particulate matter, i.e. pollution
Host factors:
Genes (alpha-1-antitripsin deficiency)
Hyperresponsiveness
Other factors: Respiratory infections, asthma, TB Lung Growth and Development Gender, age>65 years, socioeconomic status Nutrition
What are FEV1/FVC and FEV1 values for stage I - IV of COPD
All: fev1/fvc <0.70 FEV1 I (mild): FEV1: 80+% II (moderate): 50< <80 III (severe): 30< <50 IV (very sev): <30 OR <50 +chronic resp failure
What are the s/s in stage I copd?
Chronic cough & sputum production may be present (not always).
Individuals usually unaware that lung function is abnormal.
What are the s/s in stage II copd?
SOB on exertion
Cough & sputum sometimes present.
Patients typically seek medical attention because of chronic respiratory symptoms or exacerbation of their disease.
What are the s/s in stage III copd?
Greater SOB, decr exercise capacity, fatigue, repeated exacerbations
-> decrHRQoL.
What are the s/s in stage IV copd?
May lead to cor pulmonale (R heart failure) : incr jugular venous pressure; pitting ankle edema.
Decrease HRQoL - exacerbations may be life threatening.
What are the extra pulmonary s/s of copd?
Weight loss: cachexia
Skeletal muscle dysfunction decreased muscle mass and increased weakness - apoptosis and/or muscle disuse decrease proportion of type I fibers increase proportion of type II fibers decrease oxidative enzyme activity
What are the factors (5) contributing to extra-pulmonary effects in COPD
Negative nutritional balance Oral corticosteroids Physical inactivity Hypoxemia: oxidative stress Systemic inflammation
What are the co-morbid conditions (8)
MI, angina Osteoporosis, bone fractures Respiratory infection, lung Ca Depression Diabetes Sleep-disorders Anemia Glaucoma
How is emphysema anatomically defined (2) ?
Permanent enlargement of the airspaces distal to the terminal bronchioles
Destructive changes of the alveolar walls and without obvious fibrosis.
The destruction of interstitial lung tissue supporting the lung and bronchi results in what (5)?
Airway collapse during expiration Air trapping distally Increased FRC Decreased lung elastic recoil Uneven distribution of ventilation
T/F in COPD the air is trapped proximally?
F distally
The centriacinar touches A) acinus B) LL C) alveolar ducts & sacs D) UL E) superior segment
Centrilobular (centriacinar): resp bronchioles, ULs and superior segments LLs
The panacinar touches A) acinus B) LL C) alveolar ducts & sacs D) UL E) superior segment
Panlobular (panacinar): acinus, LLs
The paraseptal touches A) acinus B) LL C) alveolar ducts & sacs D) UL E) superior segment
Paraseptal: alveolar ducts and sacs, LLs
When the spaces are greater than ?? cm (may go to ?? cm) called bullae, and called bullous emphysema.
When the spaces are greater than 1 cm (may go to 10 cm) called bullae, and called bullous emphysema.
Emphysema: what are the findings with auscultations?
decreased breath sounds
prolonged expiratory phase
no adventitious breath sounds
Comment on characteristics of emphysema concerning:
Body
Cough
Respiration and chest observation
Thin
No cough or a mildly productive cough
Very dyspneic
Use accessory muscles of breathing
Paradoxical indrawing of the lower margins of the rib cage
Hyperinflated
Barrel-shaped chest- ie. increased anterior to posterior chest diameter
Emphysema: comment on FEV1 RV TLC FRC RV TLC DLCO
↓ FEV1 - related to the dynamic airway compression
↑ RV
↑ TLC - due to the decreased elastic recoil
↑ FRC
↑ RV/TLC
↓ DLCO
What are x-rays findings on emphysema?
Lungs are large and hyperinflated.
Low set diaphragm and vertical heart.
Presence of blebs and paucity of vascular markings in the outer
third of the film.
What ar th finings in ABGs?
↓ or normal PaO2
Normal PaCO2 – hyperventilation
*** V/Q inequalities play a lesser role in emphysema as destruction of the alveolar walls may impair both regional ventilation and perfusion.
Arterial hypoxemia may occur during exercise
What is the clinical definition of chronic bronchitis?
” Chronic or recurrent productive cough on most days for a minimum of 3 months per year for 2 consecutive years.”
What is the description/pathology of Chron bronc
Chronic swelling and inflammation of the bronchi and bronchioles.
Pathology:
↑ size of tracheobronchial mucous glands
Goblet cell hyperplasia
↓ number of cilia
What causes Airflow obstruction primarily (4)?
Narrowing of airways:
- Mucous hypersecretion
- Loss of ciliated epithelial cells
- Chronic inflammatory changes
- Edema
Airflow obstruction primarily due to a narrowing of the airway lumen and results in (3)
↑ WOB due to increased airflow resistance
Uneven distribution of ventilation
↓ arterial oxygenation
What are the characteristics of chron bronch concerning: body UE/face observations Breathing Other diseases?
Often stocky Cyanotic Nail clubbing Chronically productive cough Frequent bouts of upper respiratory tract infections Less dyspnea than in emphysema Crackles & wheezes on auscultation Signs of (R) heart failure i.e. edematous feet and ankles Cardiomegaly on CXR
Chron bronch. What can we observe in ABGs
Hypoxemia (↓ PaO2 to 40 and 50 mm Hg)
Hypercapnia (PaCO2 > 45 mm Hg)
Chron bronch. What can we observe in FEV1 TLC VC RV DLCO
↓ FEV1
TLC and VC usually normal
RV may be slightly ↑
normal DLCO
Chron bronch. what can we observe in x-rays?
“Dirty lung” because of recurrent infection with scarring, the bronchovascular structures have irregular contours. This is the only sign of bronchitis in chest x-ray.
Cardiomegaly on CXR
What does decreased PaO2 do locally?
Hypoxic vasoconstriction - to prevent blood from going to the areas that are underventilated.
Pulmonary hypertension
i.e. increased pulmonary artery pressure
What are the medical intervention for COPD
Smoking cessation
Annual influenza vaccine
O2 therapy, non invasive mechanical ventilation
Medications (Bronchodilators, Steroids, Combination therapies, Theophylline, Antibiotics for acute exacerbation, cortico)
Surgical intervention (Lung reduction, Transplantation)
What are the intervention in physio?
Education Pulm rehab Reducin dyspnea Airway mucus clearance Alv ventilation and V/Q matching
What’s the definition of an acute exacerbation of COPD?
an acute event characterized by a worsening in the patient’s baseline dyspnea, cough, and/or sputum and beyond normal day-today variations, that may warrant a change in regular medication in a patient with underlying COPD.
Definition of asthma
- Chronic inflammatory disorder of the lungs
- characterized by airway hyperresponsiveness 7
- resulting in variable airway obstruction
- recurrent symptoms of wheezing, dyspnea, chest tightness and coughing.
how do we know that asthma is reversible?
> 12% ↑ in FEV1 or PEFR after bronchodilator administration.
Sustained improvement in symptoms and lung function with corticosteroids
what are the host factors (3) that influence the dvlp of asthma
Genetic: family history
Obesity: more frequent & more difficult to control,
Sex: ♂ = higher incidence in children; ♀ = higher in adults
what are the environnemental factors (7) that influence the dvlp of asthma
Allergens
Infections (viral)
Occupational exposure to dust or fumes
Tobacco smoke: Active and passive
Air pollution: gas & biomass fuels for heating & cooling
Diet: higher incidence in infants fed cow`s milk and soy protein than breast milk
Stress, Exercise
What are the histological findings in asthma?
Hypertrophy and spasm of smooth muscle
Increase in mucous glands
Inflammation of the airways with oedema
How is the clinical dx done
Episodic symptoms - incidental allergen exposure, seasonal variability, intermittent rhinitis
Family history
Atopic disease: hereditary hypersensitivity to certain allergens (positive skin-prick tests to common environmental allergens)
Measurement of lung function (spirometry and PEF) – helps confirm the diagnosis
- reversibility
- variability
Methacholine-histamine challenge test
T/FConcerning atopic disease: many people are atopic but not asthmatic
T
Reversibility of asthma implies what?
Pre- post-bronchodilator spirometry: 12-15% incre FEV1
More sustained improvement over days or weeks with treatment such as inhaled steroids.
Variability of asthma implies what?
how is it measured
Diurnal (within-day) variability in symptoms and lung function over time i.e. difference between min and max daily PEF value as a % of the daily mean PEF value .
PEF measured with a peak flow meter
Methacholine or histamine challenge tests:
measurement Test results expressed as the provocative mass (or dose) of the agonist causing a 25% fall in the FEV1 (PC25)
Methacholine or histamine challenge tests:
measurement of airway responsiveness
Test results expressed as the provocative concentration (or dose) of the agonist causing a 20% fall in the FEV1 (PC20)
What implies a controlled asthma on: daytime s/s limit of activ noctural s/s need for rescue lunf fct (pef-fev1)
daytime s/s: 2-/week limit of activ: none noctural s/s: none need for rescue: 2-/week lunf fct (pef-fev1): normal
What implies a partly controlled asthma on: daytime s/s limit of activ noctural s/s need for rescue lunf fct (pef-fev1)
daytime s/s: 3+/week limit of activ: yes noctural s/s:yes need for rescue: 3+/week lunf fct (pef-fev1): <80%
What implies a partly uncontrolled asthma on: daytime s/s limit of activ noctural s/s need for rescue lunf fct (pef-fev1)
3 or more features of partly controlled asthma present in any week
Medical treatement?
Education to improve self-management Avoidance and control of triggers Annual flu shot Weight control Medications (broncho, anti-inflam, antihistamin, antileukotriene) Breathing techniques: Relaxation and breathing control Improved breathing efficiency Exercise training: Dec exercise-induced asthma, Dec asthma attacks, inc conditioning, inc confidence
Definition bronchiectasis?
Irreversible dilatation of medium-sized bronchi and bronchioles from the destruction of the muscular and elastic properties of the lung.
Inflamed airways that are full of purulent sputum.
what is the usual cause of bronchiectasis?
Usually following a necrotizing infection - less often due to aspiration of a foreign body.
Where is bronchiectasis localized?
Localized to a few segments or a lobe of the lung.
More common in basal segments of the LL.
40-50% bilateral.
What is the physiopatho (6) of bronchiectasis?
Intense inflammation
Edema & ulceration of airway mucosa.
Epithelium replaced with hyperplastic non-ciliated mucus-secreting cells.
Destruction of the elastic & muscular airway structures.
Dilatation and fibrosis
Pooling of secretions = chronic infection = further damage & irritation
What are the s/s of bronchiectasis? Respiration UE Other mx on body structure/capacity
Chronic productive cough
Purulent sputum
Unpleasant tasting or foul-smelling sputum
Recurrent infections
Hemoptysis – erosion of bronchial arteries
25% have nail clubbing
Crackles, rhonchi, pleural rubs
Increased incidence of cor pulmonale
Weight loss, fatigue and decreased exercise tolerance may be present
Bronchiectasis: what is xpected on pulm fct FEV1 DLCO MVV RV
May show little of no abnormalities
More widespread disease
– ↓ FEV1, DLco, MVV & RV
Bronchiectasis, what is expected on chest x-rays
Non-specific/hyperinflation with focal areas of atelectasis.
High-resolution CT – dilatation of bronchi with or without bronchial thickening.
What is the med tx for bronchiec?
Antibiotics to control infection
Bronchodilators to maximize airflow
Annual influenza vaccine
Adequate hydration
What is the physio tx for bronchiec
Physiotherapy: Airway clearance techniques Postural drainage Active cycle breathing Autogenic drainage Manual techniques
Exercise training: strength and endurance training
Active lifestyle encouraged
