COPD

Question 1

Difference between chronic bronchitis and emphysema

Answer 1

bronchitis = central areas
emphysema = terminal airway of bronchioles and alveoli

Question 2

Explain how tobacco leads to COPD-Emphysema

Answer 2

fill in

Question 3

pathophys of COPD-chronic bronchitis

Answer 3

inflammation stops airway d/t smooth muscle hypertrophy

Question 4

How many etiologies of COPD are there?

Answer 4

MANY, treat differently

Question 5

chronic bronchitis vs emphysema clinical presentation

Answer 5

Blue bloater
Male patient
Overweight
Cyanosis

Emphysema: thin patients, barral chest chest, muscle wasting, sickly

Question 6

What are the three historical symptoms ESSENTIAL for dx COPD?

Answer 6

Coughing (often accompanied by increased effort to breathe, air hunger, gasping, and wheezing)

Dyspnea (air trapping and airflow limitation result in progressive exertional shortness of breath - ask if this limited activity)

Sputum production: excess mucus

Question 7

Why can you have weight gain or loss in COPD?

Answer 7

Muscle wasting from COPD
Weight gain = more sedentary, activity limitation

Question 8

What are the associated symptoms of COPD that are sometimes seen in COPD (but not required for dx)

Answer 8

Activity limitation (including intercourse)
Wheezing +/- chest tightness
Syncope
Anxiety / depressive symptoms (QOL is lower

Question 9

What are the risk factors of COPD?

Answer 9

Family history

Smoking history
Consider age at initiation, average amount smoked per day since initiation, cessation date if applicable

Environmental history
Secondhand smoke exposure, air pollution, occupational exposure
History of childhood pulmonary infections, HIV, or TB

Asthma

Question 10

How does the PE of COPD differ from mild compared to mod/severe?

Answer 10

Mild Disease
PE is often normal; may pick up on prolonged expiration, faint end-expiratory wheeze with forced expiration

Moderate / Severe Disease
Lung hyperinflation → ↑ resonance with percussion
Decreased breath sounds, wheezes
Crackles at lung bases
Distant heart sounds
Increased AP diameter

Question 11

What lung sounds do you hear in barrel chest COPD?

Answer 11

Bilateral wheezing and fine crackles/rales

Question 12

How does end-stage COPD present in PE?

Answer 12

End-stage Disease / Chronic Respiratory Failure
Tripod posturing
May have calloused forearms, swollen bursae on extensor surface of forearms
Use of accessory muscles for breathing
Expiring through pursed lips
Hoover’s sign → lower intercostal interspace retraction during inspiration
Cyanosis (typically lips or nails)
Rarely nail clubbing¹

Question 13

What do you typically see on fingers with smoking history?

Answer 13

Signs of heavy smoking
Yellowing of fingers / nails

Question 14

How long do you need cough for chronic bronchitis?

Answer 14

Productive cough >3 months for 2 consecutive years

Question 15

Why do you see pneumothorax from emphysema?

Answer 15

Alveoli ruptures

Question 16

What test do you do for COPD?

Answer 16

PFTs
Spirometry

Question 17

What do you do to screen COPD?

Answer 17

Capture screening

Only screen adults who present with at least 1 of the 3 cardinal symptoms OR if they have a gradual decline in activity with risk factors for COPD
Consider CAPTURE Questionnaire

Question 18

What labs do you order for COPD?

Answer 18

Labs - CBC, BMP, TSH (decreased respiratory drive), BNP/NT-proBNP (excess fluid), serum alpha-1 antitrypsin (if family history), CMP possibly, because the antitrypsin may be low
CXR

polycythemia

Question 19

Is COPD reversible with an inhaler?

Answer 19

No, because there is dmg to the alveoli that cannot be fixed merely with a bronchodilator like albuterol

Question 20

What is the FVC and FEV1/FVC of COPD?

Answer 20

FVC > 80% with FEV₁/FVC < 0.7

Question 21

When might you concern Dlco in COPD?

Answer 21

In presence of moderate / severe airflow limitations (FEV₁ ≤50% predicted)
Resting O2 ≤92%
Exertional hypoxemia (<90%)
Severe dyspnea (mMRC ≥2)

Question 22

When would you order an aterial blood gas (ABG)?

Answer 22

Low FEV₁ (< 40% predicted)
Low O₂ saturation on pulse ox (< 92%)
Depressed LOC
Assessment of hypercapnia in “CO₂ retainers” who are given supplemental oxygen (risk of hypercapnic respiratory failure)
Signs of right heart failure

done inpatient

Question 23

What do you see in mild vs moderate/severe COPD in ABG?

Answer 23

Mild COPD: low pO₂ and normal pCO₂
Moderate to severe COPD: worsening pO₂ and elevated pCO₂

Question 24

What is base excess if it’s negative?

Answer 24

More negative it is an acidosis
More positive it is an alkalosis

Question 25

When do you order a CXR for COPD?

Answer 25

Imaging is not needed for making the diagnosis of COPD Consider CXR and CT chest (w/o contrast) CT has greater sensitivity to detecting disease than CXR Indications Dyspnea/cough etiology is unclear Rule out complicating process during acute exacerbations Pneumonia, pneumothorax, heart failure Evaluate for comorbidities Lung CA, bronchiectasis, pleural disease, ILD, heart failure

Question 26

What do you typically see in CXR of emphysema

Answer 26

Restrosternal air space Long narrow heart shadow

Question 27

What do you use to stage COPD? And what three things is this based on?

Answer 27

Global Initiative for COPD GOLD Airflow limitation symptom severity exacerbation

Question 28

After gold category is determined, what is assessed?

Answer 28

severity of symptoms, based on mMRC and CAT test

Question 29

What does mMRC assess?

Answer 29

severity of breathlessness

Question 30

What does the CAT assess?

Answer 30

multitude of symptoms present

Question 31

For staging, what do we base the category off of?

Answer 31

The higher number of mMRC or CAT

Question 32

What is therapy management for COPD based on?

Answer 32

The patient! Even if the algorithm says something else.

Question 33

What non-pharm is good for COPD?

Answer 33

Smoking cessation gradually increase exercise behavioral counseling bupropion

Question 34

What vaccines should COPD patients have up to date?

Answer 34

Influenza COVID-19 PCV-20 OR PCV-13 followed by PCV-23 Tdap Zoster in patients >50

Question 35

What is often seen in COPD patients?

Answer 35

Vitamin D, so you should supplement in that case

Question 36

If a patient has a low O2 sat, what might you need?

Answer 36

O2, but this may get stuck and make it to where they cannot get rid of CO2

Question 37

When is pulm rehab indicative

Answer 37

Referral Indicated for class B and E often do elliptical, counseling on smoking cessation, coping skills because it is a chronic disease process

Question 38

If you use an inhaler, what should you do?

Answer 38

Wash out mouth, because steroids suppress the immune system

Question 39

How often do you follow up COPD?

Answer 39

3-6 months if doing well 1-3 months if initation of therapy yearly spirometry (need to order)

Question 40

What are the risk factors of COPD exacerbation?

Answer 40

Advanced age Chronic productive cough Duration of COPD History of prior antibiotic therapy COPD-related hospitalization within past year Comorbid conditions (CAD, CHF, DM) Respiratory infections (trigger ~70% of exacerbations)

Question 41

What is an acute COPD exacberation?

Answer 41

Same s/s, just worsens over hours-days hemoptosis respiratory complications mental status change (likely acidotic) Can ask for CAT score during this time

Question 42

How often are acute COPD patients managed outpatient? When do you consider inpatient?

Answer 42

80% When to consider inpatient management Severe symptoms → sudden worsening of resting dyspnea, high respiratory rate, decreased O2 sat, confusion, drowsiness Acute respiratory failure Onset of new PE findings (cyanosis, peripheral edema) Failure to respond to initial medical management Presence of serious comorbidities (CHF, arrhythmias) Insufficient home support*

Question 43

Outpatient management of acute COPD exacerbation

Answer 43

Outpatient Management Adjust bronchodilator therapy Increase dose/frequency of SABA Consider adding SAMA if not already utilized Consider spacers / nebulizer therapy Consider oral glucocorticoid therapy Example: prednisone 40 mg/day x 5 days vs. prednisone 30 mg taper Antibiotics for increased cough, sputum production, and purulence Macrolide (azithromycin, clarithromycin) 2nd or 3rd gen cephalosporin (cefuroxime, cefdinir) Amoxicillin-clavulanate (Augmentin) Respiratory fluoroquinolone (levofloxacin, moxifloxacin)

Question 44

How long can a patient be on a steroid?

Answer 44

No longer than 5 days, because there will be a risk of infection

Question 45

What antibiotics are used for Acute COPD exacerbation?

Answer 45

Empiric and then culture for sensitivity to get a specific med

Question 46

Why do you not want to have O2 supplement greater than 92% for COPD exacerbation?

Answer 46

Because you are worried about trapping too much O2 in the lungs

Question 47

When do you follow up patients with acute exacerbation of COPD?

Answer 47

4 weeks and then 12-16 weeks

Question 48

What genetic issue can cause COPD?

Answer 48

Alpha-1 Antitrypsin Deficiency

Question 49

What does Alpha-1 Antitrypsin Deficiency lead to? What should you order?

Answer 49

Alpha-1 Antitrypsin (ATT) is an enzyme naturally produced by the liver and migrates to the lungs via the blood ATT protects the lungs from neutrophil (elastase) damage ATT deficiency occurs when there is a genetic defect of ATT preventing its release from the liver Two pathophysiologic processes ATT deficiency in the lungs leads to loss of elastin in the alveolar wall and early onset emphysema An accumulation of ATT in the liver leads to destruction of hepatocytes and liver disease Order LFTs or CMP

Question 50

What is Alpha-1 Antitrypsin Deficiency symptoms?

Answer 50

Symptoms of chronic hepatitis, cirrhosis, or hepatocellular carcinoma Symptoms of panniculitis → inflammation of subcutaneous tissue Hot, painful, red nodules or plaques characteristically on the thigh or buttocks

Question 51

How do you treat Alpha-1 Antitrypsin Deficiency symptoms?

Answer 51

Same as COPD

Question 51

Difference between bronchiectasis and bronchitis?

Answer 51

An irreversible focal or diffuse dilation and destruction of the bronchial walls

Question 52

Bronchietasis sputum

Answer 52

Copious, foul-smelling, thick, purulent sputum is characteristic

Question 53

What do you see in CXR of Bronchietasis?

Answer 53

tram tracks take CXR to r/o pneumonia

Question 54

How do you diagnose Bronchietasis?

Answer 54

CT shows bronchial wall thickening and dilated airways Ballooned or “honeycomb” appearance

Question 55

What is the treatment for Bronchietasis?

Answer 55

Non-pharmacologic management as in COPD Empiric antibiotics for acute exacerbations Amoxicillin, Amoxicillin-clavulanate, Doxycycline, TMP-SMX Consider long-term antibiotics for pts with ≥ 3 exacerbations/year¹ Bronchial hygiene Mucolytic therapy, bronchodilators, chest physiotherapy Surgical resection → indicated in poorly controlled focal disease Lung transplant → indicated when FEV₁ <30% predicted

Question 56

OSA

Answer 56

dx w/ sleep studies males, obese

Question 57

OSA dx criteria

Answer 57

≥5 obstructive respiratory events (apneas, hypopneas, or respiratory-related arousals) per hour of sleep plus one or more of the following: Sleepiness, non-restorative sleep, fatigue, insomnia Waking with breath-holding, gasping, or choking Habitual snoring or breathing interruptions HTN, mood disorder, cognitive dysfunction, CAD, CVA ≥15 or more predominantly obstructive respiratory events per hour of sleep, regardless of associated symptoms or comorbidities