Pulmonology - Obstructive lung disease - DONE Flashcards
What is COPD?
Chronic airflow limitation secondary to chronic bronchitis or emphysema that is usually progressive, may be accompanied by airway hyperreactivity, and is sometimes partially reversible.
What is the global impact of COPD?
COPD is the 12th leading cause of disease burden worldwide and is predicted to rise to the 4th leading cause by 2020.
What PFT results suggest COPD?
- The gold criteria use a FEV1/FVC < 70% that persists after the maximal therapy (irreversible airflow obstruction).
- The American Thoracic Society has recently changed the diagnosis to be a value of FEV1/FVC that is below the lower limit of normal prediction for the patient based on age, ethnicity, gender, and height.
What PFT results suggest asthma?
FEV1/FVC < 70% that typically normalizes after treatment, significant improvement with bronchodilator (increase in FEV1 or FVC of ≥ 12% and at least a 200-mL change in either), with a normal DLCO
What is emphysema?
- Defined anatomically as abnormal, permanent enlargement of air spaces distal to the terminal bronchioles, accompanied by destruction of their walls.
- Traditionally, this definition includes the absence of fibrosis, though there is controversy.
What is chronic bronchitis?
Chronic sputum production every day for at least 3 months per year for 2 consecutive years
What is a “pink puffer”?
- A thin patient with predominant emphysema, complaining of severe dyspnea and often using accessory muscles of respiration, especially with exertion.
- Cough is rare.
- Edema and polycythemia are absent.
What are the physical examination features of “pink puffers”?
Breath sounds are diminished; adventitial sounds are absent.
What are the laboratory features of “pink puffers”?
PFTs demonstrate normal to slightly diminished PaO2 and PaCO2, an increased TLC, and diminished DLCO.
What is noted on the chest radiographs in these patients?
Hyperinflation, flattened diaphragms, and diminished vascular markings, particularly at the apices
What is a “blue bloater”?
A patient with predominantly chronic bronchitis, a chronic productive cough, and frequent exacerbations caused by chest infections
What are the physical examination features of “blue bloaters”?
- Cyanosis, polycythemia, and edema are often present.
- Chest exam is very noisy, with rhonchi and wheezing.
What are the laboratory features of “blue bloaters”?
ABG with PFTs reveals hypoxemia, an elevated PaCO2, and normal TLC and DLCO.
What is seen on the chest radiograph in these patients?
Reveals increased interstitial markings, particularly at the bases and thickening of the bronchial walls; diaphragms are not flattened.
Which category do most patients with COPD fall into?
The majority of patients with COPD have both chronic bronchitis and emphysema
List 5 risk factors for COPD:
Smoking, genetic predisposition, occupational exposure to dusts and chemicals, smoke from home cooking and heating fuels, and air pollution
What is cor pulmonale?
Right-sided heart failure secondary to a pulmonary process, that is, not from a left heart problem
What are the physical examination features of cor pulmonale?
May include increased P2, right-sided S4 and S3, tricuspid regurgitation murmur, jugular venous distention with a large V wave, hepatomegaly, hepatic tenderness, ascites, and edema
What may the chest radiograph demonstrate in COPD?
Hyperinflation, increased size of the retrosternal airspace, decreased vascular markings and hypolucency of the apices, bullae, interstitial markings, predominantly at the bases (“dirty lungs” secondary to peribronchiolar fibrosis/inflammation), low, flat diaphragms, and enlarged pulmonary arteries
What pathologic changes occur with cigarette smoking?
Upper lobe centrilobular emphysema
What is the first laboratory test to check when looking for a genetic cause of COPD?
α1-Antitrypsin levels
What is the pathologic change that occurs with α1-antitrypsin disease?
Panacinar emphysema that favors the lower lobes
What other organ systems are affected in α1-antitrypsin disease?
The liver (chronic active hepatitis, cirrhosis), and rarely the skin (necrotizing panniculitis)
What is a bulla?
A sharply demarcated area of emphysema, measuring 1 cm or more in diameter and possessing a wall <1 mm in thickness
What is a bleb?
Gas-containing space within the visceral pleura
What are the treatment options for stable COPD?
Smoking cessation, long- and short-acting anticholinergic agents (ipratropium bromide [Atrovent], tiotropium [Spiriva]) and β-adrenergic agonists (albuterol, salmeterol [Serevent], formoterol [Foradil]), inhaled and oral steroids, theophylline, oxygen, including transtracheal, pulmonary rehabilitation, NIPPV, and anabolic steroids
What treatments for COPD have been shown to improve mortality?
Smoking cessation
What treatments for COPD have been shown to decrease exacerbations?
Pulmonary rehabilitation and inhaled steroids
What are the treatment options for acute COPD exacerbations?
- Give oxygen if the O2 saturation is <90%; monitor for hypercarbia with an ABG.
- Give nebulized albuterol and ipratropium bromide. IV or oral steroids (0.5–1 mg/kg/d up to 125 mg every 6 hours, followed by a taper over 2 weeks). Consider giving antibiotics if the patient has 2 of the following 3 criteria: dyspnea, increased volume of sputum, and purulent sputum.
- Consider NIPPV before endotracheal intubation.
- Consider inhaled corticosteroids at discharge.
Are oral or IV steroids better for COPD exacerbations not requiring ICU admission?
There is no difference in outcomes for oral versus IV steroids in COPD patients not requiring ICU admission.
List the side effects of theophylline.
Nausea, vomiting, tremors, headache, seizures, tachyarrhythmias, hyperglycemia, hypokalemia, difficulty urinating in elderly males with prostatism, aggravation of peptic ulcer disease and gastroesophageal reflux, and sleep disturbance such as insomnia
What organisms are referred to as “smoker’s bugs”?
Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pneumoniae
What antibiotics can be used for outpatient exacerbation of COPD?
- Trimethoprim-sulfamethoxazole, amoxicillin, tetracycline (cost-effective), amoxicillin-clavulanate, cefuroxime, advanced-generation macrolides/azalides, and quinolones.
- Erythromycin is not a good choice because it does not get two-thirds of the most important microorganisms, H. influenzae and M. catarrhalis.
- It does get S. pneumoniae.
- Beware of the interaction of theophylline with erythromycin and clarithromycin.
What are the most common precipitants of acute respiratory failure in patients with COPD?
- Infection, CHF, medical noncompliance, sedative medications, pulmonary embolism, and rib fracture.
- Infection is the most common precipitant.
When is oxygen therapy indicated?
When the room air PaO2 is ≤55 mm Hg (SaO2 ≤88%) or the PaO2 is <60 mm Hg (SaO2 <89%) in a patient with polycythemia (hematocrit >55 mg/dL) or cor pulmonale. Oxygen may cause worsening hypercarbia.
Which is more rapidly lethal, hypoxemia or hypercarbia?
Hypoxemia kills.
What vaccinations should be given to patients with COPD?
Pneumovax (if given before age 65 then repeat once after age 65) and influenza vaccine (yearly in the fall)
What is the long-term prognosis for COPD patients hospitalized on mechanical ventilation who are discharged to home?
50% 1-year mortality rate
What are the indications for lung transplantation for COPD?
- FEV1 <25% of predicted
- Room air, resting PaO2 <55–60 mm Hg
- Hypercapnia (PaCO2 ≥55 mm Hg)
- Secondary pulmonary HTN
- Clinical course: Rapid rate of decline in FEV1 or life threatening exacerbations
- Age criterion for single lung transplantation is generally 65 years.
What is the survival rate after lung transplantation?
- 75% at 1 year
- 60% at 2 years
What is lung volume reduction surgery?
Lung volume reduction surgery removes a portion of emphysematous lung tissue to improve the function of remaining lung
