Pulm-COPD Flashcards
Describe how COPD is caused
it is structural change caused by chronic inflammation from inhaling noxious particles or gases. You lose the protein elastin which causes a decrease in the elastic recoil of the lung.
What’s the best way to prevent COPD? Slow progress? improve survival?
smoking cessation is the most clinically efficacious and cost-effective way to prevent COPD, slow progression, and improve survival
What is required for the diagnosis of COPD?
Spirometry
What does the spirometry curve of COPD look like?
Look up
If patients are asymptomatic (no cough, sputum), should you screen for COPD?
No. You should not screen for COPD with spirometry analysis
How is COPD diagnosed
You perform spirometry both before and after administration of an inhaled bronchodilator. A POST-bronchodilator fixed FEV1/FVC ratio less than 70% is diagnostic for COPD. This is different from asthma in that asthma is reversible after bronchodilator.
What do you do for patients with an FEV1 of less than 35%?
They should be assessed for adequacy of oxygenation with either ABG or oxyhemoglobin saturation with pulse ox
Who should be considered for alpha-1 antitrypsin deficiency?
Ppl who develop COPD and have a reduced FEV1/FVC ratio at a young age (<40 years old)
GOLD Criteria for COPD classification, what is:
GOLD1
Mild, FEV1 > or equal to 80% predicted
GOLD Criteria for COPD classification, what is:
GOLD2
Moderate, FEV1 50-80%
GOLD Criteria for COPD classification, what is:
GOLD3
Severe, FEV1 30-50%
GOLD Criteria for COPD classification, what is:
GOLD4
Very severe FEV1<30% predicted
How should you first approach someone who is not getting better on inhalers?
***HVC
Good inhaler technique should be insured before making changes to drug regimen
When should someone be referred to a pulmonologist for their COPD?
Diagnosis of COPD at <40 years of age
- Frequent exacerbations (>2 per year) despite frequent exacerbations
- Rapid disease course
- Severe COPD, FEV1<50%
- Need for O2 therapy
- Onset of a comorbid condition (especially CV)
- Diagnostic uncertainty
- Symptoms disproportionate to severity of airflow obstruction
- Confirmed or suspected antitrypsin deficiency
- Pt request for a second opinion
- Candidate for lung transplant or lung reduction surgery
Pharmacological management of COPD A (low risk exacerbation, few symptoms)
A: low risk few symptoms, <1 exacerbation per year)
short acting anticholinergic (ipratropium) OR short acting B2 agonist (albuterol)
Pharmacological management of COPD B (low risk exacerbation, few symptoms)
B: low risk, more symptoms, less than or equal to one exacerbation per year
long acting anticholinergic (tiotropium, umeclidinium, glycopyrronium) OR long acting B2 agonist (salmeterol, formoterol)
Pharmacological management of COPD C (high risk, fewer symptoms)
C: high risk for exacerbation, fewer symptoms (>2 exacerbations per year, no hospitalizations)
inhaled glucocorticoid+LABA (salmetrol, formoterol)
Pharmacological management of COPD D (high risk, more symptoms)
D: high risk, more symptoms
inhaled glucocorticoid +LABA (salmeterol, formoterol) and/or long acting anticholinergic (tiotropium, umeclidinium)
Examples of: SABA
ALbuterol, levalbuterol
Examples of LABA
salmeterol, formoterol
Examples of SA anticholinergic
ipratropium
Examples of LA anticholinergic
tiotropium, umeclidinium
Examples of inhaled GC
fluticasone, budesonide, mometasone, beclomethasone
Which of the COPD treatments improve FEV1, health status and reduce the frequency of exacerbations?
***HVC
Long acting bronchodilators: LA beta2 agonists and LA anticholinergics (salmeterol, formoterol, tiotropium, umeclidinium)
Of note, these do NOT affect mortality
Do you ever use inhaled GCs as primary or mono therapy for COPD?
No.
What is the use of oral glucocorticoids for COPD?
These are reserved for limited periodic use in treating exacerbations of COPD and may provide some benefit in decreasing hospital readmission rates after exacerbation
When do you use IV GC for COPD patients?
oral GCs are non-inferior to IV, but patients in the ICU or with nausea may have trouble taking oral.
Are antibiotics indicated for chronic management of COPD
No, there is some evidence to support that macrolides (like azithromycin) used chronically in patients with moderate to severe COPD may help decrease exacerbations but more evidence is needed
What vaccines should ppl with COPD get?
Influenza
Pneumocococcal:
Age 19-64, should get 23
Age 65+: Should get 13, and 23 if >5 years since last 23 shot
When should antibiotics be used in COPD?
For acute infectious exacerbations
What is the most important goal in the management of COPD?
Smoking cessation
Who gets Roflumilast?
It is an oral selective PDE-4 inhibitor and its use should be limited to add-on therapy in severe COPD associated with chronic bronchitis and a history of recurrent exacerbations
**It is not a bronchodilator, it is expensive and has not been shown to be effective in other groups with COPD
When is pulmonary rehabilitation recommended?
Pulmonary rehab is recommended for all symptomatic patients with an FEV1 of less than 50% predicted and specifically for those hospitalized with an acute exacerbation of COPD
When should the need for oxygen therapy be assessed for patients with COPD?
all stable patients with an FEV1 less than 35% predicted or in patients with clinical symptoms or signs suggestive of respiratory failure or right sided heart failure
When should lung volume reduction surgery be considered?
- Severe COPD
- Remain symptomatic despite maximal pharmacological therapy
- Completed pulmonary rehabilitation
- Evidence of bilateral predominant upper-lobe emphysema on CT scan
- Postbronchodilator total lung capacity of >100% AND residual lung volume >150% predicted
- Maximum FEV1 >20% and <45% of predicted and DLCO >20% predicted
- Ambient air arterial PCO2 < 60mmHg AND arterial PO2 >45 mmHg
When should a lung transplant be considered?
History of exacerbation associated with acute hypercapnia (arterial PCO2 greater than 50 mmHg)
Pulmonary hypertension
Cor pulmonale
FEV1 <20% predicted with DLCO <20% of predicted OR homogeneous distribution of emphysema
What are the greatest predictors of acute exacerbation of COPD?
- History of a previous exacerbation
- baseline severity of airflow limitation
When can a COPD exacerbation be treated at home?
less severe lung disease, mild-moderate symptoms
What is the role of glucocorticoids for acute exacerbations of COPD?
reduce recovery time, improve lung function and arterial hypoxemia, decrease risk of early relapse, decrease treatment failure, and decrease length of hospital stay
What is the role of antibiotics for acute exacerbations for COPD?
limited to patients with increased dyspnea and purulent sputum or those who require mechanical ventilation
What is the best way to manage bronchiectasis?
Treat any modifiable causes
No data for routine use of short- or long- acting bronchodilators or the long term use of systemic GCs in patients with bronchiectasis
Pulmonary rehab programs are effective in patients with bronchiectasis and are associated with significant improvements in exercise capacity and fewer outpatient and ED visits
What are some conditions that could suggest a possible diagnosis of cystic fibrosis?
recurrent pancreatitis male infertility chronic sinusitis severe nasal polyposis non-TB mycobacterial infection allergic bronchopulmonary aspergillosis bronchiectasis positive sputum culture for Burkholderia cepacia
