PULMO-COPD Flashcards
MC smoking 80-90% cases, 10x likely Heredity (α-1 anti-trypsin deficiency) Second-hand smoke air pollution (work/environment) childhood respiratory infections
Risk factors COPD
S/S COPD
Chronic cough and sputum production,
DOR and DOE
H/o inhalation exposure
Persistent, progressive and exacerbated U/LRI
Irreversible inflammatory damage- airways, alveoli
PE
Cor pulmonale – alteration of RV fx or structure d/t pulmonary HTN , RHF, JVD, PEdema, Hepatomegaly
Breath sounds diminished d/t hyperinflation
Heart sound distant
Inc. (AP) thoracic diameter and low diaphragms
Impairment of expiratory airflow – “air trapping”
Destruction of lung parenchyma
Inc. accessory muscles,
Pulmonary Function Tests
Measurement of lung volumes
Quantitation of diffusing capacity of CO (DLCO)
Pulse oximetry
DLCO – diffusing capacity of the lungs for carbon monoxide; measures ability of lungs to transfer gas. low DLCO d/t dec. gas exchange from destruction of alveoli –
Narrow ddx of lung disease
air gets trapped in the lungs but gas exchange is not happening in ideal
Lung volumes N, but with hyperinflation
Decreased peak flow rate
Pulsus paradoxus- abnormally large decrease in stroke volume, >10mmhg drop inspiration. HR- dec inhale, exhal inc. (severe COPD attacks)
Obstructive pattern
Required for DX and evaluation
Reduced FEV1
Dec FEV1/FVC ratio
FVC may be normal with mild- becomes reduced with progressive disease secondary to air trapping
Increased RV lung volume to total lung capacity; hyperinflation
Spirometry in COPD
Dec vasculature markings Squeezed cardiac siloquette Darker Lungs (air trap) Flatten diaphragm Bulle Hyperinflation
What determinants are on a CXR for emphesema?
Emphysema
Compliance work is increased ,elastic recoil is dec.(alveoli destroyed elastic)
P-V curve is shifted up and left. causing air trapping
CW-Less in asthma (constricted) slight in chronic bronchitis.
enlargement of the distal air spaces
Hypercapnia-Loss of alveolar capillary surface area
s/s-dyspnea, hyperinflation, irreversible airflow abnormalities
Chronic Bronchitis
Chronic, productive cough >3mo mo over 2y consecutive
ETI-Smooth muscle hypertrophy, inflammation, and plugging small airways with mucus
Obstruction somewhat reversible with β-agonists
S/S-may significant hemoptysis
Must r/o neoplasm
Diagnosing COPD
Chronic cough- intermittently, throughout the day
Rare nocturnal
Chronic Sputum Production
Dyspnea-worsening over time,“increased effort to breath,” “heaviness,” “air hunger,” or “gasping”
Worsens with exercetion, URI/LRI
History of exposure to:
Tobacco smoke
Occupational dusts/chemicals
Smoke from heating or cooking fuels
Polycythemia in Pts with chronic hypoxia; ABG: respiratory acidosis w/ hypoxemia
FEV1 and FVC - detects degree of obstruction
Staging system- classification of severity of airflow limitation; guide to management; assessing for significant hypoxia
Labs
GOLD Staging for COPD Severity Stage 0
Stage 0 At risk Normal spirometry Chronic symptoms Cough Sputum production
GOLD Staging 3
Severe COPD FEV1/FVC < 70% of predicted FEV1 < 30% of predicted Sx of right heart failure severe hypoxemia Increased mortality Obtain consultation
GOLD Staging 4
Very severe COPD FEV1/FVC < 70% of predicted FEV1 < 30% of predicted or FEV1 < 50% of predicted and symptoms of chronic respiratory failure PaO2 < 60mmHg (+/-) PaCO2 > 50mmHg
Bring it up every visit
Discuss strategies to quit
Ask if patient ready
What has worked, what hasn’t, identify obstacles
Counseling, family/network support
1-800-NO-BUTTS
Nicotine replacement products
Chantix- effective $$$$, but ADE- Mental dz
Wellbutrin for cravings- helpful long term
Stop early better
never too late to stop- can see lung improvement
Smoking Cessation Management
stable COPD
#1 Inhaled β-adrenergic (SNS) agonists, short and long term
Anticholinergic bronchodilators may be used in combo
Bronchodilators
Corticosteroids
may have adverse side effects and have not been shown to benefit most COPD
Proven beneficial up to 2 weeks in acute exacerbations of chronic bronchitis
Antibiotics
acute exacerbation- inc. volume and purulence of sputum
1st- doxycycline, cefuroxime or amoxicillin-clavulanate; 2nd line azithromycin
Antibiotics accelerate improvement in peak ERV, lessen the rate of relapse
Repeat infections contribute to inflammatory airway narrowing and damage to surrounding alveoli by the release of proteases or free radicals from PMN’s
Superinfection is common with H influenza, S pneumoniae, M catarrhalis, Mycoplasma pneumoniae
Acute hypoxemia=acute exacerbations of COP
Supplemental O2 acute therapy
Pulse oximetry <88% for continuous (qualify)
Goal-Target PaO2 of 60-65, O2 saturation > 90%
Prolongs life
Oxygen Therapy
Rehab-Increase exercise capacity, improve QOL
Multi-disciplinary, “group therapy”,
Exercise studies show no change in VO2max but higher workload (better efficiency)
Nutrition-protein deficiencies, emphysema low, d/t inc. work
LVRS or lung transplant, lung volume reduction surgery (removal of portion of diseased lung)
Prevention- Pneumovax, Influenza vaccine
Patient education
Therapy
Polycythemia –
Hct >52% in men, 48% in women;
Hgb >18.5 in men, 16.5 in women; most often due to hypoxia
ABG Normal values — normal pH is 7.36 to 7.44,
PCO2 is 36 to 44 mmHg,
HCO3 21 to 27 mEq/L
Labs Blood norms
reduced the number of patients who require arterial blood gases (ABGs).
does not provide information about alveolar ventilation or hypercapnia (PaCO2 >45 mmHg),
inaccurate in the setting of an acute exacerbation of COPD.
Pulse oximetry
The indications for measuring ABGs
arterial oxygen tension [PaO2],
carbon dioxide tension [PaCO2]
acidity [pH])
Low (FEV1) <50 percent predicted
Low pulse oximetry <92 percent
Depressed level of consciousness
Assessment for hypercapnia in at risk patients 30 to 60 minutes after initiation of supplemental oxygen
disease progresses_hypoxemia becomes severe_ hypercapnia may develop.
Hypercapnia likely when the forced FEV1 falls below one liter.
ABG worsen during acute exacerbations and may also worsen during exercise and sleep.
Acute exacerbation of COPD
LAMA (anticholinergic) – Spiriva SAMA (anticholinergic) – Atrovent LABA (beta-agonist) – Serevent, Flovent Combo anticholinergic/beta-agonist – DuoNeb, Combivent Combo LABA/ICS – Advair
NIH Drugs
COPD umbrella term
ICD 10
Many other cause
4th Leading cause of death
All have ICD10
Emphsema
asthma
Chronic broncitis
Pink Puffers- Emphesema
No bronciitic component Barrel chest Dyspena early Hunched over Hyperventilatin Adquate O2 Weigh loss-Acid Base, wasting energy to get air in, malnourished Quiet breath sounds Older
Blue Bloater-Chronic Bronchitis
Bronchitis component cough mucus No barrel chest Dyspnea late No air hunger Ventilation ok- Inc HgB Cyanosis -toes fingers Cor pulmonate- RHF Obese Wet Wheezing
Stage 1
Mild COPD FEV1/FVC < 70% of predicted FEV1 ≥ 80% of predicted Mild airflow limitation Minimal symptoms Not at increased risk for mortality
Stage 2
Moderate COPD FEV1/FVC < 70% of predicted FEV1 < 50% of predicted Moderate symptoms of chronic cough, sputum production Mild hypoxia Obtain pulmonary consultation
BODE index for survival predictions
Dyspna scale
Higher the points= lower risk for survival
