Module 4.2 - Obstructive Lung Disease Flashcards
What is COPD?
- It is the most common preventable and treatable disease characterized by persistent respiratory symptoms and airflow limitation that is not fully reversible
- COPD is a mixture of diseases including emphysema, chronic bronchitis and bronchospastic airway disease. All of these diseases are characterized by limitation of expiratory airflow. The airflow limitation is often progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases particularly cigarette smoke.
- Acute exacerbations are superimposed on chronic symptoms. COPD exacerbations account for the greatest proportion of the total COPD burden.
What are the 3 main causes of COPD?
-
Tobacco smoking – most common cause, including cigarettes, cigars and pipes. This includes ex-smokers.
- Cigarette smokers of one ppd > 40 years (of smoking) will have manifestations of COPD.
- Environmental pollutants – oxides of sulfur and nitrogen – incidence depends on duration and concentration of exposure
- Occupational exposure to inorganic chemicals – chlorine and fluorine exposure to organic chemicals; toluene
Higher in men overall than women
What are the 6 subjective findings found in a patient with COPD?
1. Cough, dry and occasionally productive – especially in the early morning – symptoms may be under reported by patients
2. Sputum production – usually clear in color but can become yellow, purulent and green. Change in sputum production and color should guide your management decisions
3. Dyspnea – especially exertional
**COPD should be considered in any patient who has the above three and/or history of exposure to risk factors of smoking or exposure. Age is a key distinguishing factor when considering Asthma vs COPD in your patient evaluation- the onset of asthma is generally in patients less than 30 years old**
4. Weight loss can be seen with progressive disease – patients experience early satiety and worsening dyspnea after food is consumed. The elderly are particularly sensitive to this
5. Fatigue
6. Chest tightness – due to slow changes in the diameter in the chest wall, possibly due to acute air retention within the thorax
What are the physical exam findings in a patient with COPD?
General
- Respiratory rate is normal or increased
- Mental status: alert and oriented
- Sitting position shows “emphysema stance” – chest forward, arms straightened. Upper body is lifted to allow greater expansion of the chest as gravity pulls the abdominal contents downward
- Possibly clubbing of nail beds
- Pursed-lip breathing
Chest
- Barrel configuration – increased anteroposterior diameter of chest
- Loss of muscle strength in elderly may accelerate this
- Use of accessory muscles with inspiration including sternocleidomastoids and intercostals
- Percussion: hyper resonance,lowposition ofdiaphragm
- Auscultation: diminished breath sounds bilaterally, prolonged expiration, rhonchi on inspiration and/or expiration, occasional wheezing on expiration
What is the main goal of an assessment for a patient with COPD?
The goals of an assessment for COPD are to determine:
- The level of airflow limitationt
- The impact of disease on the patient’s health status
- The risk of future events (such as exacerbations, hospital admissions or death) in order to guide therapy
What changes are seen in pulmonary function testing in patients with COPD?
- Expiratory flow rates are reduced
- Early disease: reduction in small airway flow rates.
- Late disease: reduction in FEV1. This is a measure of the potential for severe complications of the disease
What are the lung volume changes associated with COPD?
- Air trapping indicated by increased residual volume
- Hyperinflation indicated by increased total lung capacity
- Forced vital capacity (FVC) may be reduced by air trapping
- Reduction in FVC is, on a percentage of a normal basis, less than the percentage reduction in predicted expiratory airflow
What are the arterial blood gas (ABG) and pulse oximetry changes associated with COPD?
ABG Changes:
- Earlier in the course of the disease and often during the later stages both studies show normal oxygenation and ABGs show no evidence of chronic respiratory alkalosis
- Hypoxemia (paO2 ,55 mmHg) seen more frequently later in the course or during exacerbations
- Hypercarbia (chronic respiratory acidosis) is also seen more frequently later in the course or during exacerbations
- Acute hypoxemia and hypercarbia – worse than baseline during exacerbations – mental status changes may occur
Pulse Ox:
- Used frequently for home management, outpatient setting and inpatient monitoring to assess adequacy of oxygen transport both at rest and at exertion.
-
Adequate > 88% when hemoglobin is > 10 grams/dl
- Hemoglobin < 10 grams/dl may be suboptimal for oxygen transport.
- Hematocrit > 55 ml/dl indicates secondary polycythemia due to chronic hypoxemia
What CXR changes are seen in a patient with COPD?
- Air trapping
- Flattened diaphragm
- Hyperinflation = hyperlucency in the upper lung zones, widening of the intercostal spaces, ten or more ribs identified above the diaphragm
- Retrosternal air noted on lateral view
- Blebs and bullae – may be seen but are clearer on chest CT
What are 7 non-pharmacological interventions used in the management of patients with COPD?
-
Smoking cessation – difficult to achieve
- Behavioral modification techniques
- Nicotine replacement therapy including gum, lozenges and transdermal patches. All are available over the counter. Pharmacological smoking cessation aids include Bupropion (Zyban) 150 mg daily x 3 days then BID for 7-12 weeks. Varenicline (Chantix) is available in a starter pack then give 1 mg BID for 8-16 additional weeks.
- E-cigarettes – the effectiveness and safety as a smoking cessation is uncertain at present
- Heated or cooled aerosols of water in combination with chest physiotherapy may help thin secretions.
- Percussion and postural drainage are controversial in the management of COPD but same patients may benefit
- Social and family support available to the patient and impact of the disease on their life
- Pulmonary Rehab – improves dyspnea, health status and exercise tolerance. It decreases hospitalizations
- Self-management intervention with a provider decreases ER visits and hospitalizations. Education alone does not achieve the same result.
- Oxygen Therapy – long term administration of oxygen in patients with severe chronic resting hypoxemia increases survival
What is the goal of pharmacotherapy in patients with COPD?
The goal of pharmacologic therapy is to reduce symptoms, improve health and exercise tolerance and decrease episodes of exacerbations.
How is the GOLD (Global Initiative for Chronic Lung Disease) assessment tool used?
- It classifies the degree of severity of COPD by severity of airflow obstruction and guides medical management.
- The global strategy recommends the use of Interprofessional care management throughout all levels of care with EBP and best practices and provides new evidence for pulmonary rehab and palliative care.
- GOLD system includes four categories
- Measurements are post bronchodilator
- Two or more exacerbations/year indicates a worsening of GOLD score. Other conditions (co-morbidities) should be assessed.
What are the 4 categories of the GOLD assessment tool?
- GOLD 1: Mild-FEV, 80% or greater of predicted
- GOLD II: Moderate-50% or less FEV1, less than 80% predicted
- GOLD III: Severe-30% or less FEV1, less than 50% predicted
- GOLD IV: Very severe-FEV1 less than 30% predicted
What are some common comorbidities occurring in patients with COPD with stable disease?
- CVD
- HF
- CAD
- Arrhythmias
- PVD
- HTN
- osteoporosis
- depression/anxiety
- lung cancer
- DM
- metabolic syndrome
- GERD
- bronchiectasis
- OSA Drug management – stable COPD
What is the MOA of anticholinergics and how are they used in patients with COPD?
- Anticholinergic agents – decrease airway secretions and airway smooth muscle tone. These agents are the mainstay of COPD management.
- Watch for side effects that may include dry mouth, dry hacking cough, oral candidiasis (teach good oral hygiene) and urinary retention (particularly in older men).
What are the side effects to look out for with anti-cholinergics?
Watch for side effects that may include dry mouth, dry hacking cough, oral candidiasis (teach good oral hygiene) and urinary retention (particularly in older men).
What are the preferred anti-cholinergics for COPD management?
- Ipratropium bromide (Atrovent), 2 puffs QID; also premixed in saline for use in handheld nebulizer. or
- Tiotropium bromide (Spiriva) 18 mcg once daily by HandiHaler
- Aclidinium (Tudorza) 400 mcg inhaled BID
- Umeclidinium (Incruse Ellipta) 62.5 mcg inhaled daily
What is the MOA of bronchodilators?
Beta2 -adrenergic receptor agonists - relax smooth muscle tone, improve airflow, stimulate ciliary motion to promote secretion mobilization
When are short acting inhaled B2 agonists used in patients with COPD and what are two preferred short acting inhaled B2 agonists?
Short acting B2 agonists are used for episodic symptom exacerbation:
- Albuterol (Proventil, Ventolin), also premixed in NS for handheld nebulizer use
- Levalbuterol (Xopenex) metered dose inhaler and nebulizer solutions. Possibly less tachycardia and tremor effect than albuterol. Much more expensive than albuterol.
Short acting beta agonist bronchodilators can induce tremor and tachycardia
For what and when are long acting B2 agonists indicated for patients with COPD?
Long acting B2 agonists are indicated for maintenance only; they are not recommended without concomitant use of inhaled corticosteroid
What are 2 long acting B2 agonists used in treatment of COPD?
- Salmeterol (Servent Diskus) – has a prolonged receptor binding – patients need thorough education to avoid overuse to prevent arrhythmias. Advair contained Salmeterol 50 mc and fluticasone 100, 250 or 500 mcg. Dosage: 1 puff BID.
- Formoterol (Foradil inhaler) - Similar prolonged receptor binding. Symbicort contains Formoterol 4.5 mcg and budesonide 80 or 160 mc – 2 puffs BID. Dulcera contains Formoterol 5 mcg and mometasone 100 mc. Dose 2 puffs BID.
How should long acting B2 agonists be combined with corticosteroids?
Combination of corticosteroid and LABA inhalation is recommended and should be administered at standard dose of LABA with titration of corticosteroid. This combination is primarily for asthma, is used for COPD with bronchitis
What is the GOLD 1 (mild) treatment plan?
- FEV 1 80%; the patient may be asymptomatic or may have chronic cough and sputum
- Start a short-acting beta agonist when needed
What is the GOLD 3 (severe) treatment plan?
- FEV1 30-50%, some symptoms daily
- Add inhaled corticosteroid if repeated exacerbations
What is the GOLD 4 (very severe) treatment plan?
- GOLD IV: very severe. FEV1 less than 30% or less than 50% with severe respiratory failure. Multiple symptoms
- Long term oxygen for severe hypoxia
- Consider surgical options
What are the physical exam findings seen in asthma?
- Reduced air entry sounds – normal auscultatory exam does not preclude asthma
- Prolonged expiration with expiratory wheezing
- Associated symptoms of hay fever or allergic rhinitis
- Signs of atopy such as eczema, rhinitis or nasal polyps often co-exist with asthma
- Hyper resonance on thoracic percussion can be noted during an acute asthma attack
What are some differential diagnoses for Asthma in older adults?
- COPD
- Congestive heart failure
- PE
- Endobronchial obstruction (tumor)
- Cough related to side effect of medications
- Vocal cord dysfunction
Describe the symptoms associated with step 1 of the 6 stepwise management of Asthma
Is defined as symptoms :
- occurring less than or equal to 2 days/week
- less than or equal to 2 nighttime awakenings (
nocturnal asthma. Dyspnea, wheezing, chest tightness that awakens the patient from sleep) a month
- less than or equal to 2 day/week use of SABA for symptom relief
- no interference with normal activity
- normal FEV1 between exacerbations
- FEV1 greater than 80% predicted
- normal FEV1/FVC
What medications are used in Step 1 of the 6 stepwise approach for asthma?
Patients are given SABA’s PRN:
- Albuterol HFA Inhaler 2 inhalations every 4 hr PRN,
- Albuterol 2.5 mg via nebulizer every 4 hr PRN
- Levalbuterol inhaler 2 inhalations every 4-6 hr PRN
- Levalbuterol 0.63-1.25 mg every 4-6 hr PRN
- Pirbuterol inhaler 2 inhalations every 4-6 hr PRN
Assess patient understanding of use of inhalers and/or nebulizers, assess environment for possible triggers, and follow up in 2-6 weeks for level of asthma control
Describe the symptoms associated with step 2 of the 6 stepwise management of Asthma
Mild Persistent:
- Symptoms greater than 2 days/week but not daily
- 3-4 nighttime awakenings/month
- greater than 2 days/week but not daily and not more than one time per day use of a SABA for symptom relief
- minor limitation with normal activity
- FEV1 greater than 80% predicted and normal FEV1/FVC.
What medications are used in Step 2 of the 6 stepwise approach for asthma?
Preferred-low dose inhaled corticosteroid (ICS)
- Budnesonide (Pulmicort Flexhaler) 180-360 mcg BID
- Ciclesonide (Avlesco) 80 mcg BID
- Fluticasone (Flovent HFA) 88 mcg BID
- Mometasone (Asmanex) 220 mcg daily or BID
Management: Alternative – leukotriene modifier (less effective)
- Montelukast (Singulair) 10 mg orally daily
- Zafirlukast (Accolate) 20 mg orally BID
Describe the symptoms associated with step 3 of the 6 stepwise management of Asthma
Moderate persistent:
- Daily symptoms
- more than 1 time/week that the patient experiences nighttime awakening but not nightly awakening
- daily use of a SABA for symptom relief
- some limitation with normal activity
- FEV1 greater than 60% but less than 80% predicted, FEV1/FVC reduced 5%
What medications are used in Step 3 of the 6 stepwise approach for asthma?
Preferred –low dose ICS plus LABA or medium dose ICS
- Advair 100 mcg one inhalation BID
- Symbicort 80 mcg two inhalations BID
- Dulcera 2 inhalations BID
Consider a short course or oral systemic corticosteroids; consider consulting asthma specialist, SQ allergen immunotherapy if indicated. Continue ongoing assessment of compliance and education. Reevaluate clinical status in 2-6 weeks.
Describe the symptoms associated with step 4-6 of the 6 stepwise management of Asthma
Severe persistent
- Symptoms throughout the day
- often up to seven nighttime awakenings per week
- several times a day use of a SABA for symptom relief
- extremely limited normal activity
- Fev1 less than 60% predicted
- FEV1/FVC reduced by more than 5%
- Assess for hypoxemia in these categories.
What medications are used in Step 4-6 of the 6 stepwise approach for asthma?
Step 4
- Preferred – medium dose ICS plus LABA
- Advair 250 mcg 1 inhalation BID
- Symbicort 160 mcg 2 inhalations BID
Consider short course of oral corticosteroids, continue ongoing compliance, education needs, need for allergen immunotherapy and clinical status reevaluation in 2-6 weeks.
Step 5
- Preferred – high dose ICS plus LABA (Advair 500).
- Consider omalizumab (Xolair). Strongly consider a short course of oral corticosteroids. Continue ongoing assessments of compliance, education and clinical status in 2-6 weeks. Consult to asthma specialist is warranted.*
Step 6
- Preferred-high dose ICS plus LABA (Advair 500) plus higher dose oral corticosteroid.
- Consideration for omalizumab for patients with allergies and frequent exacerbations. Does* patient need to be hospitalized? Assess compliance, education needs. Consult asthma specialist. Step down therapy if possible if asthma has been well controlled for at least 3 months
What is bronchiectasis?
- Clinical disorder characterized by periodic cough with production of copious sputum (one or more cups per day, occasionally bloody).
- It is often post inflammatory meaning you might see it after a severe pneumonia, obstruction of a bronchus by a foreign body or with healing of tuberculosis.
