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LMCC Part II > COPD > Flashcards

COPD Flashcards

1
Q

ddx for COPD

A 
COPD
chronic bronchitis
emphysema
asthma
bronchiectasis
central airway obstruction 
--bronchogenic or metastatic cancer or LAD
TB
obliterative bronchiolitis
diffuse panbronchiolitis 
heart failure
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2
Q

what history suggests COPD

A

10+ year smoking history or significant second hand smoke

exertional dyspnea

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3
Q

what are the diagnostic criteria for COPD

A

on spirometry–>
FEV1/FVC less than 0.70

INcomplete reversal post bronchodilator

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4
Q

how does emphysema present

A

“pink puffer”
muscle wasting
weight loss
hyperventilation

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5
Q

how does spirometry distinguish between COPD and asthma

A

both have FEV1/FVC less than 0.70 but asthma has improvement with bronchodilator

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6
Q

what do you see on CT for bronchiectasis

A

bronchial wall thickening and bronchial dilation

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7
Q

what might you see on CXR in TB

A

upper lung zone scarring and/or calcified granulomata

*this is in a patient with persistent cough and constitutional symptoms

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8
Q

how does chronic bronchitis present

A

“blue bloaters”

CO2 retention, increased AP diameter

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9
Q

what common meds worsen COPD

A

ASA/NSAIDs

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10
Q

what are some red flags in asthma

A

rescue inhaler more than 3x per week

nocturnal symptoms

symptoms of cor pulmonale

indicators of severe/worsening COPD

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11
Q

what are 5 indicators of severe or worsening COPD

A

home O2

steroids

mobility assistance

obesity

4 or more episodes per year

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12
Q

what are signs of respiratory distress

A 
fragmented speech
pursed lip breathing 
nasal flaring
tracheal tug
accessory muscle use 
intercostal indrawing
paradoxical abdominal movements
tripoding
reduced breath sounds
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13
Q

what signs would you look for specifically on peripheral exam for COPD/obstructive lung disease

A

peripheral or central cyanosis

clubbing

smokers fingers

eczema

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14
Q

what qualifies as “barrel chest”

A

AP/lateral diameter ratio above 0.9

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15
Q

what is hoovers sign

A

inward movement of the lower ribcage during inspiration instead of outward like normal

implies a flat, but functioning, diaphragm which is associated with COPD

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16
Q

what should you examine on palpation in the exam for COPD/obstructive lung disease

A 
chest expansion
hoovers sign
tracheal deviation
tactile fremitus 
subxiphoid cardiac impulse
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17
Q

what should you examine on percussion in the exam for COPD/obstructive lung disease

A

expect hyperresonance or loss of cardiac dullness

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18
Q

what qualifies as increased forced expiratory time

A

FET longer than 9 seconds

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19
Q

what would you expect on auscultation for COPD/obstructive lung disease

A

soft breath sounds

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20
Q

what would you expect to see on CBC-D in COPD/obstructive lung disease

A

increased hematocrit to compensate for deceased PaO2

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21
Q

in addition to CBC-D, what other blood test should be done in COPD and why

A

ABG

PaO2 for treatment assessment

PaCO2 to assess for CO2 retention and need for NIPPV during acute exacerbation

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22
Q

what blood work might you order in COPD/obstructive lung disease

A

CBC-D

ABG

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23
Q

what radiology might you order in COPD/obstructive lung disease

A

CXR
Echo–if s/s of RV dysfunction and PHTN
ECG

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24
Q

what special tests might you order in COPD/obstructive lung disease

A

spirometry/PFTs

allergy testing
BMD
sputum induction
methacholine challenge (asthma) if normal spirometry and asthma suspected

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25
Q

what is the appropriate O2 target in CO2 retainers/COPD/obstructive lung disease

A

88-92%

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26
Q

how to manage an emergent COPDE

A

ABCs

supplement O2 if below 88%

consider BiPAP in COPD if no need for intubation and have moderate hypercapnia/acidosis

intubate if–> respiratory failure, fatigue, unable to maintain adequate oxygenation

inhaled medications, systemic corticosteroids, antibiotics in infectious cases

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27
Q

which COPD patients should be referred to pulmonary rehab

A

those with moderate to severe disease

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28
Q

what type of approach is best with pharmacological management for COPD

A

stepwise and use lowest step that achieves optimal control based on the patients severity of COPD

develop an exacerbation plan with the patient for pharmacologic therapies including short acting bronchodilators, oral corticosteroids and antibiotics

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29
Q

describe COPD

A

persistent airflow limitation that is typically progressive, not fully reversible, and associated with an abnormal inflammatory response of the lungs to noxious particles or gasses i.e to cigarette smoke

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30
Q

what are the two most common conditions that contribute to COPD

A

emphysema (destruction of alveoli)

chronic bronchitis (inflammation of bronchioles)

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31
Q

what is an AECOPD

A

increase in dysnpea, cough and/or sputum that is beyond normal day to day variation

may be acute in onset but can also have more indolent course and result in change in regular mediation

mortality risk increases as the number of exacerbations increases

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32
Q

what confirms the diagnosis of COPD

A

spirometry showing airflow limitation

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33
Q

in which patients should you consider a COPD diagnosis

A

a patient 40 or older who has

  1. respiratory symptoms including dyspnea (progressive, persistent, worse with exercise), chronic cough, and increased sputum production

AND

  1. one of the following:
    - history of exposure to cigarette smoke
    - history of environmental/occupational exposure to smoke, dust or gas/fumes
    - frequent respiratory infections or
    - family history COPD
34
Q

what other two diagnoses should you consider in COPD

A

asthma (stared in childhood) or asthma-COPD overlap syndrome (ACOS)

35
Q

what is the natural course of COPD

A

slowly progressive over years even with treatment

36
Q

how does CXR vary between asthma and COPD

A

usually normal in asthma

in COPD shows hyperinflation and other COPD changes

37
Q

is a CXR helpful in diagnosing COPD

A

no. .. may suggest but still need spirometry

* may be useful and should be documented if there are concerns about other significant comorbidities

38
Q

define mild COPD

A

FEV1 80 or above

breathlessness on moderate exertion, recurrent chest infections, little or no effect on daily activities

39
Q

define moderate COPD

A

FEV1 50-79

increased dyspnea

breathlessness walking 100m on level ground

increasing limitation of daily activities

cough and sputum production

exacerbations requiring corticosteroids and/or antibiotics

40
Q

define severe COPD

A

FEV1 30-49

dyspnea on minimal exertion

daily activities severely curtailed

expiring regular sputum production

chronic cough

41
Q

define very severe COPD

A

FEV1 less than 30

42
Q

what are the therapeutic goals for COPD management

A
  1. alleviate breathlessness and other respiratory symptoms that affect daily activities
  2. prevent and reduce the frequency and severity of acute exacerbations
  3. minimize disease progression and reduce the risk of morbidity/mortality
  4. optimally manage comorbidities to reduce exacerbations and COPD symptoms related to them
43
Q

lifestyle treatments for COPD

A
  1. smoking cessation (even in long term smokers) –> this is the main cause of COPD and the main contributing factor for disease progression
  2. physical activity –> remaining active despite SOB must remain a priority for all patients with COPD
  3. pulmonary rehab
  4. diet considerations–> make sure BMI stays in normal range as this limits disease progression and reduces morbidity/mortality **reduced BMI is one of the most important risk factors for COPD progression
  5. air quality
  6. oxygen therapy to maintain PaO2 above 60mmHG or SpO2 above 90% at rest, on exertion and during sleep
  7. immunization
44
Q

what are the benefits of smoking cessation in COPD even in long term smokers

A

this is the main cause of COPD and the main contributing factor for disease progression

immediate benefits: improves symptom control, slows progression of disease, improves CV outcomes, reduces long term risk of lung cancer

45
Q

what vaccines to offer

A

influenza and pneumococcal polysaccharide vaccine –are covered

46
Q

what should you also address for long term planning for patients with COPD

A

advance care planning –initiate for all patients with diagnosis of COPD

47
Q

what should you do for a patient who is on inhaled meds for COPD

A

evaluate patients inhaler technique and adherence regularly –up to 90% of patients use their device incorrectly

48
Q

what is the goal of step 1 of COPD pharma therapy

A

symptom relief

49
Q

what is the goal of step 2 of COPD pharma therapy

A

symptom relief and prevent exacerbations

50
Q

what is the goal of step 3 of COPD pharma therapy

A

prevent exacerbations

51
Q

what meds are used in step 1 of COPD pharma therapy

A

SABA or SAMA monotherapy

then

SAMA + SABA combination

52
Q

what COPD meds should NOT be used concurrently

A

LAMA and SAMA

53
Q

what meds are used in step 2 of COPD pharma therapy

A

LABA or LAMA monotherapy

then

LAMA + LABA combination

54
Q

what meds are used in step 3 of COPD pharma therapy

A

triple therapy

LAMA + LABA + inhaled corticosteroid

55
Q

what is a way to remember that SABA/SAMA are used in step 1

A

step 1 is Symptom relief–S=SAMA/SABA

56
Q

what should you prescribe for all symptomatic patients

A

short acting inhaled bronchodilator (SABA–short acting beta2 agonist) or short acting muscarinic antagonist (SAMA) for acute, short term relief or SOB

for those with mild COPD, SAMA/SABA monotherapy is recommended

SAMA may be better at preventing exacerbations and may also be better tolerated (limited evidence)

57
Q

what is a LAMA and a LABA

A

long acting muscarinic antagonist

long acting beta 2 agonist

58
Q

in which patients would you move to triple therapy

A

FEV1 less than 50% predicted and 2 or more exacerbations in the last 12 months

59
Q

is ICS monotherapy recommended in COPD

A

no

60
Q

what is the most common cause of AECOPD

A

bacterial or viral infection

can also be caused by PE, pneumothorax, heart failure, pleural effusion

61
Q

how should a patient manage a severe AECOPD complicated by acute respiratory failure

A

MEDICAL EMERGENCY

patient should seek medical treatment

62
Q

how should most AECOPD be managed

A

more than 80% can be managed as outpatient

63
Q

how long should an AECOPD persist before starting oral corticosteroid or antibiotics

A

no hard rule… some guidelines suggest 48 hours

64
Q

what pharmacotherapy should be used in AECOPD

A
  1. short acting bronchodilator–> salbutamol
  2. oral corticosteroids–> prednisone
  3. antibiotics
65
Q

what dose of salbutamol in AECOPD

A

salbutamol 400-800 mcg (4-8 puffs) delivered via metered dose inhaler with a spacer

OR

salbutamol 2.5 mg by nebulizer

administer frequently (every couple of hours) and titrate to response

66
Q

what dose of prednisone in AECOPD

A

prednisone 40 mg PO for 5 days (but prednisone 50mg is usually used in canada)

*oral corticosteroids shorten recovery time, improve lunch function, etc.

67
Q

what would suggest alpha 1 antitrypsin deficiency

A

early onset emphysema or COPD

unexplained liver disease

family history

68
Q

how should you plan for AECOPD with your patient

A

made a COPD flare up plan (theres a print out online)

69
Q

name a SABA

A

salbutamol (ventolin)

use for acute relief, 1-2 puffs PRN

70
Q

name a SAMA

A

ipratropium (atrovent)

2 actuations TID to QID

71
Q

brand name for SAMA+SABA

A

combivent

72
Q

name 2 LABAs

A

salmeterol

formoterol

73
Q

name one LAMA

A

tiotropium

74
Q

brand name one ICS + LABA

A

symbicort

75
Q

name 2 ICS

A

budesonide (pulmicort)

fluticasone (flovent)

76
Q

what antibiotic is sometimes prescribed as maintenance therapy to reduce risk of AECOPD

A

azithromycin 250 mg PO daily or 250 mg PO 3x/week

77
Q

what is a NAC

A

mucolytic that can be adjunctive therapy for COPD

78
Q

what causes 50% of AECOPD

A

viral chronchitis

79
Q

when should you empirically start antibiotics in AECOPD

A

if have 2 of:
increased SOB
increased sputum volume
increased sputum purulence

–if have only 1 of those, wait for sputum gram stain, C&S

80
Q

what antibiotic to use for simple AECOPD

A

amoxicillin 500mg PO TID 7-10 days

81
Q

what antibiotic to use for complicated AECOPD

A

amox-clav 500 mg PO TID x7-10 days

or cefuroxime

82
Q

what is a complex AECOPD

A

4 or more exacerbations per year, failure of first line agents, antibiotics in previous three months, CAD, home O2, chronic steroid use

LMCC Part II (52 decks)

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