COPD

Question 1

2 main ways COPD affects the lungs

Answer 1

Bronchitis and Emphysema

Question 2

what do we call the two main presentations of COPD? What do they correspond with?

Answer 2

Blue Bloaters vs Pink Puffers

Question 3

<1% of COPD cases are caused by _______

Answer 3

Alpha-1-antitrypsin deficiency

Question 4

Why are Blue Bloaters hypoxic and Pink Puffers not?

Answer 4

Blue bloaters have bronchitis, the mucus impedes O2 perfusion
Pink Puffers have emphysema, the don’t have as much mucus but the walls of their alveoli are being broken down. Part of their lungs start to collapse. The healthy areas can still perfuse

Question 5

Thin 65yo man, dyspnea, pursed-lip breathing with accessory muscle use, not cyanotic

Answer 5

Pink Puffer

Question 6

Large 65yo woman, dyspnea, constantly spitting up sputum, chronic cough, skin is slightly blue-tinged, smiling today upon exam

Answer 6

Blue Bloater

Question 7

Why is hemoptysis sometimes a symptom of COPD?

Answer 7

blebs can rupture or alveolar capillaries may leak.
Assume cancer until proven otherwise

Question 8

Do COPD pts have tachycardia or bradycardia?

Answer 8

Tachycardia in hopes to maintain CO for oxygenation

Question 9

Why would COPD cause osteoporosis?

Answer 9

smoking reduces blood supply to bones. Nicotine slows prod of osteoblasts. It also decreases the body’s absorption of Ca++

Question 10

PE findings?

Answer 10

Barrel chest, distant heart sounds, rhonchi, wheezes, cyanosis, accessory muscle use

Question 11

Would a barrel chest cause high or low voltage on ECG?

Answer 11

low bc there’s more space in b/w heart and leads

Question 12

Symp of both types of COPD?

Answer 12

Chronic cough, dyspnea (persistent, progressive), wheezing, cyanosis, tachypnea, tachycardia

Question 13

Poss complications of COPD

Answer 13

MI, arrhythmias, CHF, aortic aneurysm, pulm HTN, CVA, PE, DVT (due to hypercoagulability), lung cancer

Question 14

WU for COPD

Answer 14

#1 PFT Pulm Function Testing (spirometry)
CXR if trying to r/o others
O2 sat
ABG

Question 15

Which COPD pt’s get screened for alpha-1-antitrypsin deficiency?

Answer 15

ALL of them (only one time req)

Question 16

elevated eosinophils >300 indicates ___ in COPD pts

Answer 16

a good response to steroid treatment &
higher risk for exacerbations

Question 17

Image screening criteria for poss lung cancer due to smoking?

Answer 17

Must have all to get annual CT Scans:
55-80yo
Current or former smokers (within 15 yrs)
at least a 30pk/yr hx

Question 18

Once you stop smoking for ____ yrs, You hit the “reset button” for risk of lung cancer

Answer 18

15

Question 19

You have to be at least ____yo to do a PFT

Answer 19

5

Question 20

What does FEV1/FVC tell you? what should it be?

Answer 20

amnt of air you can exhale in 1 sec after a max inhale effort
norm adult ratio: FEV1/FVC >70%

Question 21

How to differentiate b/w COPD and Asthma?

Answer 21

Asthma has a weird bronchoconstriction response to methacholine/other stimuli. COPD doesn’t

COPD doesn’t respond as well to SABA (as seen by their FEV1 <200mL and <12% change)

Question 22

COPD CXR findings

Answer 22

hyperinflation, flattened diaphragm, incr retrosternal space
Decr vasculature and bullae in pts with emphysema bc alveoli are being destroyed)

Question 23

_____ is the ONLY trmnt that REDUCES MORTALITY

Answer 23

Supplemental O2 to keep sats >90%
give if O2 <55mHg or sats<88%

Question 24

Qs to ask pt to classify COPD symptoms

Answer 24

Productive cough?
Chest tightness?
shortness of breath?
affect your activity?
affect your sleep?
affect your energy?

Question 25

Trmnt for Group A COPD?

Answer 25

SABA +/- SAMA

Question 26

Trmnt for Group B COPD?

Answer 26

SABA + LABA or LAMA

Question 27

Trmnt for Group C COPD?

Answer 27

SABA + LAMA

Question 28

Trmnt for Group D COPD?

Answer 28

SABA + LAMA + LABA or SABA + LABA + ICS or worst case ss + eosinophils = SABA + LABA + LAMA + ICS

Question 29

Which ICS is once a day instead of BID? Fluticasone(Flovent, Arnuity), Mometasone(Asmanex), Budesonide(Pulmicort), Beclomethasone(Qvar), Ciclesonide(Alvesco)

Answer 29

Arnuity

Question 30

ICS + LAMA + LABA combos

Answer 30

Brextri (Budesonide/Glycopyrrolate/Formoterol) Trelegy (Fluticasone furoate/Umeclidinium/Vilanterol)

Question 31

When to consider Roflumilast (PDE-4 inhibitor)?

Answer 31

if in group D and eosinophils <100

Question 32

What are most common pathogens causing acute bronchitis in COPD pts?

Answer 32

H/ flu, Strep pneumoniae

Question 33

WU of COPD exacerbation

Answer 33

Labs: ABG, CBC, CRP, BNP, CMP, sputum culture O2 if spO2 <88% CXR EKG for dyspnea

Question 34

What steroid should you Rx to pt being discharged from ER for COPD exacerbation?

Answer 34

Oral prednisone

Question 35

Oral ABX for COPD related acute bronchitis infection

Answer 35

H. flu, S. pneumo. Still gotta treat like pneumonia: G +/-, atypicals coverage Best opts: Azithromycin (Macrolide/Zpak), Levofloxacin Others: Augmentin (amoxicillin-clavulanate), Bactrim (Trimethoprim-sulfamethoxazole), doxycycline

Question 36

Inpatient ABX for COPD related infection

Answer 36

1) Ampicillin, Ceftriaxone (Rocephin) 2) Azithromycin (macrolide/zpak) or Levaquin (fluoroquinolone)

Question 37

Indications for Assisted Ventilation (Noninvasive Positive Pressure Ventilation)

Answer 37

_**Respiratory Acidosis**_ Severe dyspnea acidosis (pH <7.35) Hypercapnia (pCO2 45-60mmHg) RR 25-35 bpm

Question 38

Contraindications to assisted ventilation for COPD

Answer 38

_Mask contraindications_ respiratory arrest unstable impaired mental status copious bronchial secretions extreme obesity

Question 39

When to intubate during COPD exacerbation

Answer 39

if contraindication to assisted ventilation (noninvasive positive pressure ventilation = NPPV) NPPV fails (worsening ABG)

Question 40

Inheritance pattern of Alpha-1-antitrypsin deficiency

Answer 40

Autosomal, codominant

Question 41

What does alpha-1-antitrypsin deficiency lead to?

Answer 41

**Panacinar emphysema** - enlarged air spaces in lower lobes due to destruction of alveolar septums (without fibrosis)

Question 42

Alpha-1-Antitrypsin deficiency presentation

Answer 42

<45 yo, non-smoker, COPD ss (dyspnea, cough, sputum) Liver: child w/liver failure, liver cancer, cirrhosis Panniculitis (bumps under skin, seen in obese)

Question 43

Alpha-1-Antitrypsin deficiency WU

Answer 43

CXR, PFT, Serum Alpha-1-antitrypsin level

Question 44

Alpha-1-Antitrypsin deficiency Trmnt

Answer 44

treat like COPD for ss and exacerbations Goal: serum > 50mg/dL Rx: Zemaira IV

Question 45

Alpha-1-Antitrypsin Deficiency CXR findings

Answer 45

green (air bronchograms from bronchiectasis) red (Pacainar Emphysema)