Pulm-COPD

Question 1

Describe how COPD is caused

Answer 1

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.

Question 2

What’s the best way to prevent COPD? Slow progress? improve survival?

Answer 2

smoking cessation is the most clinically efficacious and cost-effective way to prevent COPD, slow progression, and improve survival

Question 3

What is required for the diagnosis of COPD?

Answer 3

Spirometry

Question 4

What does the spirometry curve of COPD look like?

Answer 4

Look up

Question 5

If patients are asymptomatic (no cough, sputum), should you screen for COPD?

Answer 5

No. You should not screen for COPD with spirometry analysis

Question 6

How is COPD diagnosed

Answer 6

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.

Question 7

What do you do for patients with an FEV1 of less than 35%?

Answer 7

They should be assessed for adequacy of oxygenation with either ABG or oxyhemoglobin saturation with pulse ox

Question 8

Who should be considered for alpha-1 antitrypsin deficiency?

Answer 8

Ppl who develop COPD and have a reduced FEV1/FVC ratio at a young age (<40 years old)

Question 9

GOLD Criteria for COPD classification, what is:

GOLD1

Answer 9

Mild, FEV1 > or equal to 80% predicted

Question 10

GOLD Criteria for COPD classification, what is:

GOLD2

Answer 10

Moderate, FEV1 50-80%

Question 11

GOLD Criteria for COPD classification, what is:

GOLD3

Answer 11

Severe, FEV1 30-50%

Question 12

GOLD Criteria for COPD classification, what is:

GOLD4

Answer 12

Very severe FEV1<30% predicted

Question 13

How should you first approach someone who is not getting better on inhalers?

***HVC

Answer 13

Good inhaler technique should be insured before making changes to drug regimen

Question 14

When should someone be referred to a pulmonologist for their COPD?

Answer 14

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

Question 15

Pharmacological management of COPD A (low risk exacerbation, few symptoms)

Answer 15

A: low risk few symptoms, <1 exacerbation per year)

short acting anticholinergic (ipratropium) OR short acting B2 agonist (albuterol)

Question 16

Pharmacological management of COPD B (low risk exacerbation, few symptoms)

Answer 16

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)

Question 17

Pharmacological management of COPD C (high risk, fewer symptoms)

Answer 17

C: high risk for exacerbation, fewer symptoms (>2 exacerbations per year, no hospitalizations)

inhaled glucocorticoid+LABA (salmetrol, formoterol)

Question 18

Pharmacological management of COPD D (high risk, more symptoms)

Answer 18

D: high risk, more symptoms

inhaled glucocorticoid +LABA (salmeterol, formoterol) and/or long acting anticholinergic (tiotropium, umeclidinium)

Question 19

Examples of: SABA

Answer 19

ALbuterol, levalbuterol

Question 20

Examples of LABA

Answer 20

salmeterol, formoterol

Question 21

Examples of SA anticholinergic

Answer 21

ipratropium

Question 22

Examples of LA anticholinergic

Answer 22

tiotropium, umeclidinium

Question 23

Examples of inhaled GC

Answer 23

fluticasone, budesonide, mometasone, beclomethasone

Question 24

Which of the COPD treatments improve FEV1, health status and reduce the frequency of exacerbations?

***HVC

Answer 24

Long acting bronchodilators: LA beta2 agonists and LA anticholinergics (salmeterol, formoterol, tiotropium, umeclidinium)

Of note, these do NOT affect mortality

Question 25

Do you ever use inhaled GCs as primary or mono therapy for COPD?

Answer 25

No.

Question 26

What is the use of oral glucocorticoids for COPD?

Answer 26

These are reserved for limited periodic use in treating exacerbations of COPD and may provide some benefit in decreasing hospital readmission rates after exacerbation

Question 27

When do you use IV GC for COPD patients?

Answer 27

oral GCs are non-inferior to IV, but patients in the ICU or with nausea may have trouble taking oral.

Question 28

Are antibiotics indicated for chronic management of COPD

Answer 28

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

Question 29

What vaccines should ppl with COPD get?

Answer 29

Influenza
Pneumocococcal:
Age 19-64, should get 23
Age 65+: Should get 13, and 23 if >5 years since last 23 shot

Question 30

When should antibiotics be used in COPD?

Answer 30

For acute infectious exacerbations

Question 31

What is the most important goal in the management of COPD?

Answer 31

Smoking cessation

Question 32

Who gets Roflumilast?

Answer 32

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

Question 33

When is pulmonary rehabilitation recommended?

Answer 33

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

Question 34

When should the need for oxygen therapy be assessed for patients with COPD?

Answer 34

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

Question 35

When should lung volume reduction surgery be considered?

Answer 35

1. Severe COPD
2. Remain symptomatic despite maximal pharmacological therapy
3. Completed pulmonary rehabilitation
4. Evidence of bilateral predominant upper-lobe emphysema on CT scan
5. Postbronchodilator total lung capacity of >100% AND residual lung volume >150% predicted
6. Maximum FEV1 >20% and <45% of predicted and DLCO >20% predicted
7. Ambient air arterial PCO2 < 60mmHg AND arterial PO2 >45 mmHg

Question 36

When should a lung transplant be considered?

Answer 36

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

Question 37

What are the greatest predictors of acute exacerbation of COPD?

Answer 37

• History of a previous exacerbation

- baseline severity of airflow limitation

Question 38

When can a COPD exacerbation be treated at home?

Answer 38

less severe lung disease, mild-moderate symptoms

Question 39

What is the role of glucocorticoids for acute exacerbations of COPD?

Answer 39

reduce recovery time, improve lung function and arterial hypoxemia, decrease risk of early relapse, decrease treatment failure, and decrease length of hospital stay

Question 40

What is the role of antibiotics for acute exacerbations for COPD?

Answer 40

limited to patients with increased dyspnea and purulent sputum or those who require mechanical ventilation

Question 41

What is the best way to manage bronchiectasis?

Answer 41

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

Question 42

What are some conditions that could suggest a possible diagnosis of cystic fibrosis?

Answer 42

recurrent pancreatitis
male infertility
chronic sinusitis
severe nasal polyposis
non-TB mycobacterial infection
allergic bronchopulmonary aspergillosis
bronchiectasis
positive sputum culture for Burkholderia cepacia