Week 7 Resp: Asthma & COPD Flashcards
An adolescent who has exercise-induced asthma (EIA) is on the high school track team and has recently begun to practice daily during the school week. The adolescent uses two puffs of albuterol via a metered-dose inhaler 20 minutes before exercise but reports decreased effectiveness since beginning daily practice. What will the primary care pediatric nurse practitioner do?
A Counsel the adolescent to decrease the number of practices each week
B Increase the albuterol to four puffs, 20 minutes prior to exercise
C Order a daily, inhaled corticosteroid medication
D Prescribe cromolyn sodium in addition to the albuterol
C Order a daily, inhaled corticosteroid medication
Children with EIA should use 2 puffs of a B2-agonist and/or cromolyn MDI 15 to 30 minutes prior to exercise, but, since tolerance may develop if a B2-agonist is used more than a few times a week, it should not be used as a controller monotherapy. Those who exercise regularly should use an ICS as a controller medication. Patients with asthma should be encouraged to exercise to improve overall health. Increasing the albuterol dose will not overcome the tolerance. And ICS is a preferred controller medication.
The primary care pediatric nurse practitioner is examining a school-age child who has had several hospitalizations for bronchitis and wheezing. The parent reports that the child has several coughing episodes associated with chest tightness each week and gets relief with an albuterol metered-dose inhaler. What will the nurse practitioner order?
A Allergy testing
B Chest radiography
C Spirometry testing
D Sweat chloride test
C Spirometry testing
Spirometry testing is the gold standard for diagnosing asthma and is then used on a regular basis to monitor, evaluate, and manage asthma. Allergy testing should be considered but is not diagnostic of asthma. Chest radiography should not be routine. A sweat chloride test is used based on history.
A school-age child who uses a short-acting beta2-agonist (SABA) and an inhaled corticosteroid medication is seen in the clinic for an acute asthma exacerbation. After four puffs of an inhaled, short-acting B2-agonist (SABA) every 20 minutes for three treatments, spirometry testing shows an FEV1 of 60% of the child’s personal best. What will the primary care pediatric nurse practitioner do next?
A Administer an oral corticosteroid and repeat the three treatments of the inhaled SABA
B Admit the child to the hospital for every two hour inhaled SABA and intravenous steroids
C Give the child 2 mg/kg of an oral corticosteroid and have the child taken to the emergency department
D Order an oral corticosteroid, continue the SABA every three to four hours, and follow closely
D Order an oral corticosteroid, continue the SABA every three to four hours, and follow closely
Children with an incomplete response (FEV1 between 40% and 69% of personal best) should be given oral steroids and instructed to continue the SABA every 3 to 4 hours with close follow-up. Hospitalization is not necessary unless severe distress occurs. An FEV1 less than 40% after treatment indicates a need to be seen in the ED.
A child who has been diagnosed with asthma for several years has been using a short-acting B2-agonist (SABA) to control symptoms. The primary care pediatric nurse practitioner learns that the child has recently begun using the SABA two or three times each week to treat wheezing and shortness of breath. The child currently has clear breath sounds and an FEV1 of 75% of personal best. What will the nurse practitioner do next?
A Add a daily inhaled corticosteroid
B Administer three SABA treatments
C Continue the current treatment
D Order an oral corticosteroid
A Add a daily inhaled corticosteroid
The child is showing a need to step up treatment based on the frequency of symptoms, greater than twice each week. The PNP should order an inhaled corticosteroid maintenance medication to control symptoms and reduce the need for a SABA. The child is not having an acute exacerbation, so does not need 3 SABA treatments. Oral corticosteroids are given for moderate obstruction
An adolescent who has asthma and severe perennial allergies has poor asthma control in spite of appropriate use of a short-acting beta2-agonist (SABA) and a daily high-dose inhaled corticosteroid. What will the primary care pediatric nurse practitioner do next to manage this child’s asthma?
A Consider daily oral corticosteroid administration
B Order an anticholinergic medication in conjunction with the current regimen
C Prescribe a LABA/inhaled corticosteroid combination medication
D Refer to a pulmonologist for omalizumab therapy
D Refer to a pulmonologist for omalizumab therapy
Children older than 12 years who have moderate to severe allergy-related asthma and who react to perennial allergens may benefit from omalizumab as a second-line treatment when symptoms are not controlled by ICSs. The PNP should refer children to a pulmonologist for such treatment. Daily oral corticosteroid medications are not recommended because of the adverse effects caused by prolonged use of this route. Anticholinergic medications are generally used for acute exacerbations during in-patient stays or in the ED. A LABA/ICS combination will not produce different results.
Which of the following exam findings can be seen in a patient with COPD?
A Increased tactile fremitus and a high-positioned diaphragm
B Decreased tactile fremitus and generalized hyperresonance to percussion
C Positive egophany and dullness to percussion
D Decreased AP to lateral diameter and adventitious sounds
B Decreased tactile fremitus and generalized hyperresonance to percussion
Patients with COPD may have low, flat diaphragm, decreased tactile fremitus and hyperresonance, increased AP to lateral diameter and adventitious sounds. Positive egophany and dullness are suggestive of consolidation or mass.
The nurse practitioner seeing a patient with dyspnea and cough considers asthma and COPD as differential diagnosis since symptoms often overlap. A diagnosis of COPD is favored if:
A Symptoms present earlier in life
B Airflow limitation is not reversible
C The patient has a productive cough
D The chest x-ray shows hyperinflation
B Airflow limitation is not reversible
Airflow limitation is largely reversible with asthma, and irreversible in COPD. COPD most often presents midlife with slowly progressive symptoms. Chest x-ray is not needed to diagnose asthma or COPD but may show hyperinflation with both conditions. Cough can occur with both asthma and COPD.
Which test is the most diagnostic for chronic obstructive pulmonary disease (COPD)?
A COPD Assessment Test
B Forced expiratory time maneuver
C Lung radiograph
D Spirometry for FVC and FEV1
D Spirometry for FVC and FEV1
Spirometry testing is the gold standard for diagnosis and assessment of COPD because it is reproducible and objective. The forced expiratory time maneuver is easy to perform in a clinic setting and is a good screening to indicate a need for confirmatory spirometry. Lung radiographs are non-specific but may indicate hyperexpansion of lungs. The COPD assessment test helps measure health status impairment in persons already diagnosed with COPD.
A patient diagnosed with chronic obstructive pulmonary disease reports daily symptoms of dyspnea and cough. Which of the following is an effective first line therapy?
A Anticholinergic or LAMA
B Inhaled corticosteroid
C Antibiotics
D Theophylline
A Anticholinergic or LAMA
Anticholinergic medication such as ipratropium is used as first-line therapy in patients with daily symptoms. Inhaled corticosteroids are used with LABA therapy in a step wise approach, especially in patients with stage 3 or 4 COPD. Antibiotics are used in an exacerbation. Theophylline is a third-line agent.
A patient with COPD has an FEV1 of 45%, a CAT score of 8, and 3 exacerbations in the past year. The patient’s COPD should be classified as:
A Stage 1, Group B
B Stage 2, Group B
C Stage 4, Group D
D Stage 3, Group C
D Stage 3, Group C
Stage 3 (severe COPD) the FEV1 is between 30-50% predicted with repeated exacerbations. Group C patient group are usually GOLD 3 or 4, more than 2 exacerbations in 1 yr or more than one with hospitalization and CAT score less than 10.
Grade: FEV1 % predicted GOLD 1: >/= 80 GOLD 2: 50-79 GOLD 3: 30-49 GOLD 4: < 30
Moderate/severe exacerbation hx/ Symptoms
Group A: 0 or 1 no hospitalization/ mMRC 0-1 or CAT < 10
Group B: 0 or 1 no hospitalization/mMRC >/=2 CAT >/=10
Group C:>2 or >1 w/ hospitalization/ mMRC 0-1 CAT < 10
Group D: >2 or >1 w/ hospitalization/ mMRC >/2 or CAT >/=10
Which is characteristic of obstructive bronchitis and not emphysema?
A Damage to the alveolar wall
B Destruction of alveolar architecture
C Mild alteration in lung tissue compliance
D Mismatch of ventilation and perfusion
C Mild alteration in lung tissue compliance
Obstructive bronchitis causes much less parenchymal damage than emphysema does, so there is milder alteration in lung tissue compliance. The other symptoms are characteristic of emphysema.
A 35-year-old woman with a long history of well-controlled asthma presents with worsening of her symptoms over the last month. She has been using fluticasone MDI 110 mcg twice per day faithfully for the last 2 years. Over the last month, she has had to use her rescue inhaler in the mornings 2 to 3 times per week. She does not smoke. Her medications include an oral contraceptive pill (OCP), a multivitamin, ibuprofen as needed, and propranolol (recently added for migraine prophylaxis).
What would you advise?
Recognize that medications for arthritis (NSAIDS), hypertension (beta-blockers), or glaucoma may exacerbate asthma. It may be helpful to stop her propranolol. If that is ineffective, reevaluate for environmental factors such as new exposures at work or a smoking roommate. Consider comorbid conditions or other diagnoses, such as allergic rhinitis, obesity, GERD, or OSA. Pulmonary embolus may also be a consideration as she is taking an OCP.
potential side effects of long-term ICS as controller medication in adults
decreased bone density
sub-scapular cataracts
skin bruising
glaucoma
adrenal suppression used as a marker for systemic absoprtion - occurs at doses of 1.5 mg/day for aLL ICS except fluticasone, which occurs at 0.75 mg/day
bone mineral density should be followed in older adults on high dose ICS, esp w/ other RF for osteoporosis
Ca and Vit D supp recc for pts taking ICS w/ RF for osteoporosis
potential side effects of long-term use of LABAs
small but statistically significatn increase in ashtma-related and pulmonary death in pts using salmeterol vs placebo , focused in young African americans , unclear patho
unclear if ICS protect agaisnt this risk
black box warning: LABAs should not be used w/o ICS and should probably be given trial of ICS alone first
differences in classification of children vs adults with asthma
Classification of asthma severity is more difficult in younger children. Therefore, criteria for diagnosis and initiation of controller medications have been developed using the number of times steroids have been prescribed and factors which would predispose the child to asthma.
differences in comorbidities of children vs adults with asthma
Both the differential and the most common comorbidities seen with these patient populations require different thought processes. For example, cystic fibrosis and BPD usually come to mind at some point while working up a young child with asthma. GERD should probably be higher on our list when treating both children and adults. Allergic symptoms probably have an even greater role in children than in adults (hence the more frequent use of LTRAs)
differences in tx of children vs adults in asthma
Step 3 for children under 5 years is medium-dose ICS. However, there is an option to introduce a LABA for step 3 with a low-dose ICS for all patients 5 years and older. Concerns regarding the safety and efficacy of LABAs, particularly in the youngest children, have limited the use of LABAs in this population.
differences in referral of children vs adults in asthma
In children under 5 years old, the 2007 guidelines recommend specialist referral for treatment steps 3 and up (treatment above medium-dose ICS). Referral is recommended for treatment steps 4 and up (medium-dose ICS + LABA) for those over 5 years old.
A 10-month-old girl is brought to primary care clinic for hospital follow-up. She was admitted one week ago for three days with the diagnosis of WARI (wheezing-associated with respiratory infection). She has no additional medical history and was born at term. In addition to her well-child checks, she has been seen on two other occasions for wheezing associated with colds. She received oral steroids at one of those visits. She now appears well and is in no distress. Mom reports that she has not needed to use her albuterol for the last two days. She took her last dose of oral prednisone today.
What is her diagnosis?
persistent asthma
At what point would you consider using a controller medication in managing 10-month old with asthma?
Young children may have little to no impairment on a daily basis but still be at high risk for severe exacerbations. Inhaled corticosteroids are recommended for long-term control therapy if:
• 4 wheezing episodes in a year affecting sleep and lasting more than 1 day and who have a positive asthma risk profile**
• 2 or more exacerbations requiring oral corticosteroids in the last 6 months
• the child requires more than 2 doses of short-acting bronchodilator per week for more than 4 weeks
**Positive asthma profile:
• One or more of the following: atopic dermatitis, sensitization to aeroallergen, parental history of asthma;
or
• Two or more of the following: wheezing apart from colds, more than 4% blood eosinophilia, food sensitization.
You decide to prescribe a controller medication in the 10 month old girl with asthma. Her mother is concerned about giving long-term medications to a child this young.
What would you prescribe?
What are the risks and benefits of controller medications in young children?
Budesonide is the only inhaled glucocorticoid that is FDA approved for children under 4 years old, but others such as fluticasone and beclomethasone are also frequently used. Although budesonide is approved for children over 1 year old, efficacy has been proven even in infancy in preventing recurrent wheezing. Budesonide tends to be the most expensive; beclomethasone is the least expensive.
Both asthma itself and repeated doses of oral corticosteroids are associated with growth suppression and delayed puberty. In general, ICSs are safe in adults and children of all ages. Primary concerns include linear growth and bone density. Dose related, short-term decreases in growth velocity have been observed with ICSs in the first 2 years of therapy.
Would you use a nebulizer or a metered dose inhaler (MDI) in the 10 month old with asthma?
Certainly, it is difficult for most children under the age of 5 to coordinate their breathing with a metered-dose inhaler (MDI). Traditionally, nebulizers have been used for young children, but recent data have shown a spacer (one-way valve) with a mask to be equally effective in delivering SABAs in mild to moderate asthma exacerbations. The most important point to make is proper technique with any delivery system. Masks should fit tightly. If a spacer is used, 3 to 4 breaths with each MDI activation should be attempted. If a nebulizer is used, a mouthpiece is preferred. If using a mouthpiece is not possible (as in young children), the mask should fit snugly over the mouth and nose. Holding it 1 cm away reduces the dose by 50%, 2 cm reduces it by 80%.
What can be done to minimize medication side effects in the 10 month old girl with asthma?
If the child does not have a measurable response in 4 to 5 weeks, discontinue the medication and consider other diagnoses.
If a child does have a measurable response sustained for 3 months, consider stepping down treatment to a lower dose.
Children have a high rate of remission. More efficient delivery of medication to the lungs (as opposed to the mouth or the room) minimizes the dose needed. Therefore, the use of spacers and masks and instructions to keep nebulizer masks on the patient’s face are helpful.
Instruct patients who are old enough to coordinate their breathing with the MDI.
Have patients rinse their mouths out after use to minimize the risk of thrush and systemic absorption.
Wash the face off after nebulizer treatments to minimize effects on skin.
Dry-powder inhalers may minimize cough, throat irritation, and dysphonia if these are present.
An 8-year-old boy presents to primary care clinic with nighttime cough. On further questioning, his mother did notice this at times when he was younger, but it seemed to go away within a day or two. It now wakes him from sleep at least once a week. He sometimes has difficulty breathing when he runs, but this has been attributed to his being a little overweight in the past. On physical exam, his lungs are clear, and he is in no distress. His BMI is 21 kg/m2. Nasal mucosa is hyperemic and bluish. Chest x-ray reveals slightly hyperinflated lungs.
Does this patient have asthma?
To confirm the diagnosis of asthma, you ideally need information from spirometry. The hallmark of asthma is episodic symptoms of airway obstruction with or without hyper-responsiveness (cough, wheezing, chest tightness). This obstruction is as least partially reversible on spirometry (10%-12%). Often, these symptoms are worse at night. In fact, they may be present only at night or with exercise, particularly in children. In general, triggers can be identified such as respiratory infections, dust, smoke, air pollution, stress, menstrual cycles, changes in weather, or exercise.
What other diagnoses would you consider in the 8 year old boy w/ nighttime cough?
Ddx
allergic rhinitis, sinusitis, vocal cord dysfunction, cystic fibrosis, vascular slings, laryngotracheomalacia, foreign body, heart failure, gastroesophageal reflux, obstructive sleep apnea (OSA), and bronchopulmonary dysplasia (BPD).
In adults, the differential may also include chronic obstructive pulmonary disease (COPD), bronchiolitis obliterans (BOOP), medication-related cough (such as with an angiotensin-converting enzyme inhibitor), malignancy, or chronic pulmonary embolism.
Although history and physical exam are critically important, they may not be able to completely separate a diagnosis of asthma from other possible diagnoses. Chest x-ray can be helpful. Spirometry (showing obstruction and reversibility) is required for the diagnosis in patients older than 5 years old. It should be repeated every 1 to 2 years.
The 8 year old boy with nighttime symptoms twice a week has a Spirometry that shows FEV1 of 85% and FEV/FVC of 85%, which improves with short-acting bronchodilator treatment.
How severe is the asthma?
The first step in treating asthma is determining its severity at baseline, or intrinsic disease activity (NAEPP Guidelines, 40). Since he has nighttime symptoms more than once a week, he has moderate persistent asthma, although his lung function falls into the mild category.
The guidelines emphasize both impairment (the frequency and severity of symptoms) and risk (of future exacerbations, lung growth or damage, medication risks).1 So, if a child has more than 2 exacerbations in 6 months (if younger than 5 years old) or in 12 months (if older than 5 years old) but does not have daytime or nighttime impairment, he is still characterized as having persistent asthma. Lung function is included in the 5- to 11-year-old criteria but not in younger children.
The primary differences in classifying the younger and older ages are inclusion of lung function, classification of exacerbation frequency, and nighttime awakenings.
How should the 8 year old boy with moderate persistent asthma be treated? In addition to medication, what else should treatment include?
The treatment of asthma should be approached in a stepwise approach (NAEPP Guidelines, 42) from step 1 (occasional use of SABAs) to step 6 (high-dose ICS + LABA + oral steroids). He should be treated with medium-dose ICSs. A low-dose ICS with LABA is an equally acceptable option if the patient has failed ICS treatment alone previously. Alternative therapy includes low-dose ICS with either LTRA or theophylline. In addition to initiation of medication, there are three additional factors that should be addressed: environmental control, comorbid conditions, and patient education
environmental control tx for asthma
Planning with family to minimize known triggers such as: inhalant allergens or irritants, tobacco exposure, dust mites, animal dander, cockroaches, and mold. Other triggers may include medications (aspirin or NSAIDS), cold air, physical activity, and sulfites in foods (wine or beer, dried fruit, potato flakes).1 Food allergens other than sulfites are rarely associated with asthma exacerbations. However, patients with known food allergy and asthma are at increased risk for fatal anaphylaxis when exposed to the food allergen.
comorbid conditions with asthma that need to be addressed
sinusitis, rhinitis, gastroesophageal reflux disease (GERD), obstructive sleep apnea (OSA), obesity, stress, and depression.
education on asthma
should be tailored to the patient’s age as well as health literacy of caregivers to promote a partnership in care, including them in creating an action plan. This should include self-monitoring of symptoms (symptom or peak flow monitoring), avoidance of triggers, administration of medications, and a written asthma action plan. Peak flow monitoring may be more helpful in patients who have difficulty perceiving symptoms (ie, moderate to severe disease or history of severe exacerbations).
The 8 year old boy with moderate persistent asthma is prescribed a medium-dose ICS and have him return in 6 weeks. He continues to have a night-time cough, though it has decreased in frequency to twice per month. He is using his albuterol prior to football practice but feels some chest tightness about halfway through practices. He has not noticed any side effects of his inhalers.
Is his asthma well controlled?
His asthma is not well controlled (NAEPP Guidelines, 53). He is still waking more than once a month at night and has some limitations in activity. Treatment with SABAs immediately before exertion usually prevents exercise-induced bronchospasm (EIB). However, if significant limitations still exist, a step-up in therapy may be needed.
The goal of asthma therapy is asthma control. This means reducing impairment (prevent chronic symptoms, require infrequent use of SABAs, maintain nearly normal lung function and normal activity levels) and reducing risk (prevent exacerbations, minimize need for emergency care or hospitalization, have minimal or no adverse effects of therapy, prevent loss of lung function; or for children, prevent reduced lung growth).
How will you adjust the 8 year old boys therapy who is not well controlled on a medium-dose ICS and albuterol?
Before stepping up his medication regimen, evaluate his compliance with medications, inhaler technique, and environmental control. Screen for other comorbid conditions. Does he have symptoms of sleep apnea? GERD is common in patients with nighttime symptoms, even if they do not have common symptoms of heartburn. You may want to consider behavioral approaches (avoiding fatty or spicy foods, elevating head of bed, not eating within three hours of going to bed) or medical treatment for GERD.
After addressing the above, consider a step-up in therapy. In this case, consider switching to a medium-dose ICS plus LABA. An alternative therapy would be a medium-dose ICS plus either LTRA or theophylline.
When would you consider specialist referral in pt with asthma?
The NAEPP Guidelines recommend consideration of referral for any of the following reasons:
• recent hospitalization or life-threatening exacerbation
• additional testing is indicated (skin testing, bronchoscopy)
• complex medication regimen
• consideration of immunotherapy
• complicating comorbidities (such as OSA)
• more than two exacerbations in a year requiring oral corticosteroids
• difficult-to-control asthma
What is the duration of action for a short-acting beta-agonist (SABA) such as albuterol for the treatment of an acute asthma exacerbation?
A, 5 to 15 minutes
B. 30 to 60 minutes
C. 1 to 2 hours
D. 3 to 4 hours
D. 3 to 4 hours
The onset of action for a short-acting beta-agonist (SABA) such as albuterol is 15 minutes. The duration of action for a SABA is 3 to 4 hours.
Which of the following medications has been shown to reduce asthma symptoms, improve lung function, decrease airway inflammation, and reduce the frequency and severity of asthma exacerbations?
A. Inhaled corticosteroids
B. Short-acting beta-agonist (SABA)
C. Long-acting beta-agonist (LABA)
D. Leukotriene receptor antagonist
A. Inhaled corticosteroids
What is the onset of action for a SABA such as albuterol for the treatment of an acute asthma exacerbation?
A. 5 to 15 minutes
B. 30 to 60 minutes
C. 1.5 to 2 hours
D. 3 to 4 hours
A. 5 to 15 minutes
The onset of action for a SABA such as albuterol is 15 minutes. The duration of action for a SABA is 3 to 4 hours.
A 56-year-old female presents to primary care clinic to establish care. She has no past medical history and takes no medications. She has a 40 pack-year history of ongoing tobacco use but denies any current symptoms of COPD (specifically cough, chronic sputum production, and dyspnea). She wishes to be screened for COPD as her father was diagnosed with COPD in his 60s and died of COPD in his late 80s.
What other risk factors for COPD should you inquire about?
Advanced Age
Genetic Predisposition ( alpha-1-antitrypsin deficiency)
Smoking and exposure to environmental tobacco (primary)
Influenza and pneumonia
Malnutrition/obesity
Insufficient physical activity
Presence of comorbidities
Occupational hazards
Should the 56 year old women asking to be screened for COPD be screened for COPD? If so, using what modality?
Yes, she should be screened for COPD, Spirometry
CXR for initial screening/diagnosis (used to confirm hyperinflation or can see bullae)
Chest CT - can be used to rule out malignancy
Lab - screening for genetic disorder alpha-1-antitrypsin deficiency
Six minute walk test
What should you do for the 56 year old women patient today regarding her COPD risk?
Classify her COPD based on spirometry and symptoms
Encourage smoking cessation
Encourage increased exercise
The 56 year old female smoker returns 4 years later at age 60 after being lost to follow-up. She has continued to smoke 1 ppd. Now, she has dyspnea on exertion that has been slowly progressive over the last 6 months and a cough with scant sputum production in the morning.
What evaluation is warranted at this time and what are you specifically looking for (including physical exam, labs, and diagnostic testing)?
On physical exam, one should look for evidence of hyperresonance, hyperinflation, hypoxia (with pulse oximetry and evaluation for cyanosis), and evaluation for evidence of cor pulmonale.
. A complete blood count (CBC) should be obtained to evaluate for anemia or polycythemia, and an arterial blood gas (ABG) can be considered as well. An evaluation for alpha-1 antitrypsin should be undertaken in Caucasian patients less than 45 years old with COPD, especially those with little or no toxin exposure, or in patients with COPD who do not respond to therapy. In addition, chest x-ray should be obtained
Ddx for COPD
- Asthma
- Congestive heart failure (CHF)
- Bronchiectasis
- Interstitial lung disease
- Pulmonary fibrosis
- Tuberculosis
What are the diagnostic criteria for COPD severity based on spirometry?
Classifying Severity by Spirometry:
Stage I: Mild
FEV1 ≥ 80% of predicted
Usually, not always, chronic cough and sputum production. At this stage the individual may not be aware that their lung function is abnormal.
Stage II: Moderate
FEV1 50–79% of predicted
Worsening airflow limitation and usually a progression of symptoms, with SOB w/exertion.
Stage III: Severe
FEV1 30–49% of predicted
Further worsening airflow limitation, increase SOB with repeated exacerbations that have an impact on QoL.
Stage IV: Very Severe
FEV1 < 30% of predicted, or
FEV1 < 50% of predicted plus chronic respiratory failure present
Severe airflow limitation plus chronic respiratory failure. QoL is very impaired and exacerbations can be life threatening.
What are the goals of management for COPD?
Reduce symptoms- Control cough and secretions and improve quality of life. Decrease exacerbations
Reverse or reduce airflow obstruction
Prevent and eliminate infections
Maximize exercise tolerance/ maximize lung function
Promote smoking cessation
Control complications- Polycythemia, hypoxemia, R sided heart failure
The now 60 year old female has a pulse oximetry of 96% at rest and 92% with exertion. CBC is normal, and chest x-ray shows evidence of hyperinflation. Her spirometry results include an FEV1/FVC ratio of 0.6 and FEV1 55% of predicted
What therapy should be offered at this time?
smoking cessation should be emphasized
Influenza and pneumococcal vaccines should be given
Pulmonary rehabilitation should be considered for symptom control and quality of life
For this patient, pharmacotherapy should include long-acting bronchodilators and short-acting agents for rescue.
Inhaled steroids confer no mortality benefit but may improve symptoms and decrease exacerbations. These medications should be considered in patients with frequent or repeated exacerbations but are not currently indicated in this patient.
The now 60 year old female patient is started on salmeterol to be used twice daily and albuterol as a rescue inhaler. Two months later, she calls the office with 2 days of increased sputum volume and purulence along with increased dyspnea. She has had no fever, chills but has upper respiratory infection symptoms and a sick granddaughter at home. In the office, she is tachypneic and dyspneic but no in acute respiratory distress. She has bilateral end-expiratory wheezing and moderate air movement.
What do you do?
A chest x-ray, CBC, and basic metabolic panel (BMP) are indicated to evaluate for other etiologies of her dyspnea and for a possible pneumonia. Pulse oximetry should be measured and oxygen provided with a goal saturation of 90% to 92%
She is started on salmeterol to be used twice daily and albuterol as a rescue inhaler. Two months later, she calls the office with 2 days of increased sputum volume and purulence along with increased dyspnea. She has had no fever, chills but has upper respiratory infection symptoms and a sick granddaughter at home. In the office, she is tachypneic and dyspneic but no in acute respiratory distress. She has bilateral end-expiratory wheezing and moderate air movement.
Does she meet criteria for an acute COPD exacerbation and why?
Yes, the 3 cardinal symptoms of an exacerbation include increased dyspnea, increased sputum volume, and increased sputum purulence. She meets all 3 and has at least a moderate COPD exacerbation.
How should the 60 year old females COPD exacerbation be managed?
Treatment for COPD exacerbations should include oral steroids (40 mg daily for 5 days), increased frequency of bronchodilators (beta-agonists and/or anticholinergics—neither class has proven superior) and a short course of oral antibiotics.
Antibiotic Guidlines:
Group A: Mild exacerbation and no risk for poor outcome
B-lactam
Tetracycline
Bactrim
Group B: Moderate exacerbation and risk for poor outcome
B-lactam/B-lactamase inhibitor (augmentin)
Group C: Severe exacerbation and risk for P. Aeruginosa infection
Fluoroquinolones
Which of the following tests is used to assess the severity of chronic obstructive pulmonary disease (COPD)?
A. Chest x-ray
B. Chest CT
C. Spirometry
D. Arterial blood gas
C. Spirometry
Spirometry is used to quantify the severity of COPD, and should be used when making the initial diagnosis. Chest x-ray or chest CT may be helpful during the initial diagnosis of COPD, if diagnosis is uncertain, or during acute exacerbations but are not used to quantify the severity of COPD. Arterial blood gas may be helpful in assessing the degree of hypoxemia or hypercapnia associated with chronic COPD, but is not used to assess the severity of COPD.
Which of the following interventions has shown an increase in survival in patients with severe COPD?
A. Inhaled corticosteroids
B. Long-acting beta2 adrenergic agonists
C. Long-acting anticholinergic agents
D. Oxygen
D. Oxygen
Oxygen use in patients with severe COPD and persistent hypoxemia improves survival. Long-acting bronchodilators including long-acting beta2 adrenergic agonists (eg, salmeterol, formoterol) and long-acting anticholinergics (tiotropium) have been shown to decrease the risk of COPD exacerbation by 15% to 20% but have not been shown to increase survival in patients with severe COPD. Inhaled corticosteroids (eg, fluticasone, beclomethasone) have also been shown to decrease the risk of COPD exacerbation, but have not been shown to improve survival.
A 60-year-old man has spirometry testing that shows FEV1:FVC (forced expiratory volume in the first second of expiration / forced vital capacity) less than 0.7 as well as FEV1 45% of predicted value. What stage of COPD does he have?
A. Stage 1 (mild) COPD
B. Stage 2 (moderate) COPD
C. Stage 3 (severe) COPD
D. This patient does not have COPD
C. Stage 3 (severe) COPD
Patients with COPD have airflow obstruction which is defined as the FEV1 to FVC ratio of less than 0.7 after bronchodilator administration. Patients with FEV1 greater than or equal to 80% of predicted value have stage 1 (mild) COPD. Patients with FEV1 50% to 79% of predicted value have stage 2 (moderate) COPD. Patients with FEV1 30% to 49% of predicted value have stage 3 (severe) COPD. Patients with FEV1 less than 30% of predicted value or FEV1 less than 50% of predicted value plus chronic respiratory failure have stage 4 (very severe) COPD.
A 72-year-old man with chronic obstructive pulmonary disease (COPD) presents to the emergency department with progressively worsening shortness of breath. Using 2 L/min of oxygen at home, he is usually able to walk around the house without limitation. Over the past 4 days, however, he has had increasing dyspnea on exertion and increased cough productive of thick green sputum. He has not had chest pain or worsening of his chronic mild ankle edema. He has smoked two packs of cigarettes daily for the past 50 years. Previous pulmonary function tests (PFTs) demonstrated a decreased forced expiratory volume in 1 second (FEV1) of 35% and FEV1/FVC (forced vital capacity) ratio of less than 0.70. Physical examination shows tachycardia, tachypnea, and decreased breath sounds with diffuse wheezing bilaterally. Arterial blood gas (ABG) analysis shows acidemia from a partially compensated respiratory acidosis. He is placed on noninvasive positive-pressure ventilation with marked improvement of his acidemia. This is the patient’s second hospitalization this year for COPD.
What are the important features in the patient’s history that suggest an exacerbation?
Increased productive cough
dyspnea on exertion
thick green sputum
respiratory distress
A 72-year-old man with chronic obstructive pulmonary disease (COPD) presents to the emergency department with progressively worsening shortness of breath. Using 2 L/min of oxygen at home, he is usually able to walk around the house without limitation. Over the past 4 days, however, he has had increasing dyspnea on exertion and increased cough productive of thick green sputum. He has not had chest pain or worsening of his chronic mild ankle edema. He has smoked two packs of cigarettes daily for the past 50 years. Previous pulmonary function tests (PFTs) demonstrated a decreased forced expiratory volume in 1 second (FEV1) of 35% and FEV1/FVC (forced vital capacity) ratio of less than 0.70. Physical examination shows tachycardia, tachypnea, and decreased breath sounds with diffuse wheezing bilaterally. Arterial blood gas (ABG) analysis shows acidemia from a partially compensated respiratory acidosis. He is placed on noninvasive positive-pressure ventilation with marked improvement of his acidemia. This is the patient’s second hospitalization this year for COPD.
You are seeing this patient for follow up in primary care after his discharge from the ED and he has recovered to baseline.
What interventions will you discuss with the patient that will decrease his risk of future exacerbations?
Based on the information provided above, how would you classify his COPD and what should be included in his pharmacologic management?
STOP SMOKING
Classified as Severe COPD
Pharmacologics: SABA PRN, supplemental O2 to SpO2 of 90%, Symbicort 160/4.5 BID
During your physical exam on the 72 year old man with COPD, you note that the patient has chronic mild ankle edema and elevated JVD.
What complication do you suspect?
CHF
Cor Pulmonale
When diagnosing a patient with COPD, what are some expected findings in the patient’s history, exam and diagnostic testing?
Expected findings with COPD: shortness of breath, wheezing, chest tightness, chronic cough with sputum that may be green/white/or clear, fatigue, swelling in ankles. The patient is likely a smoker or has a history of severe asthma.
Diagnostic testing: Pulmonary function testing, chest x ray, CT scan to detect possible emphysema, arterial blood gas
emphysema vs chronic bronchitis
Emphysema: decreased mental alertness, minimal cyanosis, thin frame due to inc work of breathing, pursed lip breathing, barrel chest
Vs.
Chronic bronchitis: excessive mucus production, cough, fever, symptoms may come and go, edematous or overweight (“blue bloaters”), dusky or cyanotic in appearance
ddx of COPD
TB bronchitis pulmonary HTN pneumonia bronchiectasis asthma CHF covid PE
What are the laboratory and imaging findings in chronic obstructive pulmonary disease in the various stages and during an exacerbation?
PFTs, CXR (bullae, decreased parenchymal markings, hyperlucency), ABG during exacerbations,
Pulse OX, CMP (sodium retention), CBC (mild polycythemia), BNP, EKG
COPD tx
Offer smoking cessation meds/tools
SABAs, Anticholinergics, LABAs (alone or in combo with anticholinergic), ICS, Methylxanthines
Exacerbations (outpatient): Bronchodilators (7-days), oral steroids (5 or 7-day burst), PRN O2
- Antibiotics if increased purulence of sputum or if requiring mechanical ventilation
- B-lactam, Tetracycline, Bactrim, Augmentin, Fluoroquinolones–depending on severity of exacerbation
What is included in the criteria for supplemental oxygen use?
A. An oxygen saturation of less than 88% on room air
B. The presence of hypoxia and hypercapnia
C. The patient has a persistent cough and sputum production
D. An oxygen desaturation to less than 90% during exercise
A. An oxygen saturation of less than 88% on room air
Which of the following abnormalities on a CBC are a result of severe COPD?
A. Elevated hematocrit
B. Low platelet count
C. Low white blood cell count
D. Elevated CO2
A. Elevated hematocrit
It is important to note O2 therapy can reduce polycythemia
A child with asthma has wheezing throughout expiration, a prolonged expiratory phase, decreased breath sounds at the base and intercostal retractions on physical assessment. Based on the exam, the child’s asthma severity is
A. Mild
B. Moderate
C. Severe
D. Impending respiratory arrest
B. Moderate
Which of the following slows the progression of COPD in smokers, outside of smoking cessation?
a. Making sure the environment is free of all pollutants
b. Eliminating all pets from the environment
c. Engaging in moderate to high levels of physical activity
d. Remaining indoors with air conditioning as much as possible
c. Engaging in moderate to high levels of physical activity
Which statement about COPD is true?
a. The prevalence of COPD is directly related to increasing age
b. The incidence of COPD is about equal in men and in women.
c. Cigar or pipe smoking does not increase risk of COPD
d. Environmental factors such as smoke do not affect the potential for COPD
a. The prevalence of COPD is directly related to increasing age
