COPD

Question 1

COPD is characterized by…

What are the two classic types (although there is much overlap)

Answer 1

progressive airflow limitation and enhanced chronic inflammatory response

• small airway dz (blue bloaters-chron. bronchitis)
• parenchymal destruction (pink puffers-emphysema)

Question 2

What happens in small airway disease? What is its nickname and what is predominant?

Answer 2

airway inflammation and airway remodeling

“BLUE BLOATER” chronic bronchitis predominant

Question 3

What happens in parenchymal destruction? What is its nickname and what is predominant?

Answer 3

loss of alveolar attachments and decreased elastic recoil

“PINK PUFFER”, emphysema predominant

Question 4

pink puffer description

Answer 4

Emphysema-predominant, adequate oxygenation for a longer time period
“Pink Puffer” b/c of pursed-lip breathing, pink skin and thin body habitus (air comes in easily but need to recruit accessory muscles to get it out)

Question 5

blue bloater description

Answer 5

Chronic Bronchitis-predominant
hypoxemia and respiratory acidosis more common; cor pulmonale from pulm HTN
“Blue Bloaters” due to cyanosis and overweight body habitus

Question 6

Chronic Bronchitis definition

Answer 6

chronic productive cough for 3 months during 2 consecutive years with no other casue

Question 7

Structural changes in chronic bronchitis

Answer 7

• mucous gland hyperplasia->excess mucus and narrowing of bronchioles
• bronchial squamous metaplasia
• loss of ciliary tranport

Question 8

What happens to the bronchial wall and what does that (primary mediator)?

Answer 8

inflammation of bronchial wall-infiltration of submucosal layer by NEUTROPHILS

Question 9

What else is thought to play an important role in chronic bronchitis?

Answer 9

Chronic bacterial infection and hyper-reactivity are thought to play an important role

Question 10

What kind of obstruction occurs in chronic bronchitis?

Answer 10

inspiratory and expiratory

Question 11

What occurs due to impeded ventilation of chronic bronchitis?
How does parenchymal damage of chronic bronchitis compare to that of emphysema?

Answer 11

hypoxemia and hypercarbia

less parenchymal damage than emphysema

Question 12

How is EMPHYSEMA characterized?

Answer 12

pathologic enlargement of the air spaces distal to the terminal bronchioles du to destruction of alveolar walls

Question 13

What is the destructive process of emphysema?

Answer 13

not clearly understood (possibly too much elastase or too little antitrypsin activity)

Question 14

3 structural changes in emphysema

Answer 14

1. dramatic decline in alveolar surface area available for gas exchange
2. decreased elastic recoil, which limits airflow
3. loss of alveolar supporting structure

Question 15

Emphysema: effect on capillary bed and the effect of this

Answer 15

emphysema destroys the capillary bed, resulting in reduced Co2 diffusing capacity
->hypercarbia (hypercapnia)
BUT NOT AS SIGNIFICANT HYPOXEMIA

Question 16

When does airflow obstruction occur in emphysema?

Answer 16

airflow obstruction mostly during exhalation

Question 17

What is asthma and what mediates it?

Answer 17

Asthma is a chronic inflammatory disorder of the airways-primarily EOSINOPHIL mediated

Question 18

3 steps in asthma

Answer 18

airway hyper-reactivity->increased secretions, mucosal edema, constriction of bronchial smooth muscle->airway obstruction
[reversible]

Question 19

Emphysema describe: age at sx onset, character of dyspnea, cough, sputum prod., sputum appear

Answer 19

Emphysema onset: usually after age 50
dyspnea: progressive, constant, severe
cough: absent to mild
sputum prod: absent to mild
sputum appearance: clear, mucoid

Question 20

Chronic bronchitis describe: age at sx onset, character of dyspnea, cough, sputum prod, sputum appearance

Answer 20

Chronic Bronchitis onset: usually late 30s-40s
dyspnea: intermittent, mild to moderate
cough: persistent, severe
sputum production: persistent, severe
sputum appearance: mucopurulent

Question 21

When does COPD present?

Answer 21

5th or 6th decade

Question 22

Cardinal sxs of COPD:

Answer 22

CARD SXS: dyspnea, chronic cough and sputum production

• cough usually occurs in the morning
• in early COPD dysp on sig exertion, but progresses to miminal exertion or rest

Question 23

Exposure to what puts you at risk for COPD?

Answer 23

• tobacco smoke

- other inhaled irritants (occupational dusts, pollution)

Question 24

DDx for COPD

Answer 24

Asthma, Bronchiectasis, CHF, Obliterative bronchiolitis, central airway stenosis, lung cancer, TB, coccidioidomycosis, cystic fibrosis (younger pts), acute bronchitis (80-90% viral)

Question 25

Risk factors for COPD

Answer 25

1. CIGARETTE SMOKING (#1 cause, 80% of COPD pts, most have at least 20 pack year hist) 2. air pollution (indoor and outdoor) 3. second hand smoke 4. airway hyper-responsiveness 5. Generic RF: alpha-1 antitrypsin deficiency (<1% of all cases, causes premature emphysema)

Question 26

How does cigarette smoking contribute to COPD?

Answer 26

- cig smoke stimulates elastase enzymatic activity, causing degenerative changes in elastin and alveolar structures - causes release of cytotoxic oxygen radicals from WBCs in lung tissue (amt. and duration of cig smoking contribute to dz severity)

Question 27

What kind of environmental/occupational exposure will place the proletariat at risk for COPD?

Answer 27

coal miners, grain handlers, metal molders, workers exposed to dust, cooking with biomass fuels (1/3 of the world)

Question 28

Name a hereditary syndrome that results in early onset of emphysema. What is the average age of appearance?

Answer 28

Alpha 1-antitripsin deficiency (<1% of US cases of emphysema) onset: 53 y/o nonsmokers, 40 y/o smokers (process is accelerated in smokers w/AAT def)

Question 29

What is Alpha 1-antitrypsin? What happens if it disappears?

Answer 29

AAT is a protease inhibitor which inhibits elastase and several other proteolytic enzymes -if AAT is not present in adequate amt, elastase & other proteolytic enzymes destroy lung tissue

Question 30

COPD physical exam HEENT

Answer 30

check oral cavity closely, look for tobacco staining

Question 31

COPD physical exam neck

Answer 31

masses, JVD

Question 32

COPD physical exam chest

Answer 32

"body habitus"-look for increased AP diameter (barrel chest), use of accessory muscles, rate, effort of breathing, central cyanosis

Question 33

COPD physical exam lungs

Answer 33

decreased breath sounds, rhonchi, wheezes, crackles, prolonged exhalation (tends to be bilateral)

Question 34

COPD physical exam percussion

Answer 34

hyper-resonant

Question 35

COPD physical exam heart

Answer 35

possible gallop, RV life, PMI

Question 36

COPD physical exam abdomen

Answer 36

possible hepatomegaly, tenderness

Question 37

COPD physical exam exterior

Answer 37

cyanosis, clubbing, muscle wasting, tobacco stains on fingers, peripheral edema

Question 38

Emphysema exam findings

Answer 38

``` increased AP diameter "distant" breath sounds hyper-resonant to percussion possible pursed-lip breathing using accessory muscles ```

Question 39

COPD CBC results

Answer 39

usually normal, may show polycythemia (increased H/H) later in chron. bronchitis, due to hypoxemia

Question 40

COPD ABG results

Answer 40

hypoxemia (not as significant in emphysema as chron bronch), hypercarbia (CO2 retention)

Question 41

COPD EKG results

Answer 41

sinus tachycardia, peaked P waves, and right axis deviation, RVH

Question 42

Should you do a sputum examination in COPD?

Answer 42

NOT usually recommended/helpful (can be colonized w/bacteria anyway) -recommended if you've been treating a patient and they're not getting better

Question 43

3 CXR findings suggestive of emphysema

Answer 43

- hyperinflation (possibly with bullae) - flattening of diaphragms - enlargement of retrosternal air space

Question 44

CXR findings suggestive of chronic bronchitis

Answer 44

- cardiac enlargement - pulmonary congestion - increased lung markings

Question 45

CT for COPD? sens, spec?

Answer 45

CT, esp high resolution CT has much greater sensitivity and specificity than standard chest radiography for dx of COPD, but NOT necc. for ROUTINE work-up

Question 46

name 3 pulmonary function tests (PFTs)

Answer 46

forced vital capacity (FVC) forced expiratory volume in 1 second (FEV1) FEV1/FVC

Question 47

Define forced vital capacity (FVC). What would you see in COPD?

Answer 47

FVC: amount of air forcefully exhaled after a maximal inspiration (varies w/height & age) -usually normal or slightly decreased in COPD vs. low in restrictive dz

Question 48

Define FEV1? What is normal, what do you see in obstructive airway dz?

Answer 48

FEV1=forced expiratory volume in 1 sec normal>80% of predicted FEV1 DECREASES in obstructive airway dz (reversible in asthma; increases w/bronchidilator)

Question 49

FEV1/FVC: normal value, abnormal meanings

Answer 49

normal FEV1/FVC: 70-80% decreased FEV1 w/normal FVC suggests obstructive airways dz <70% post bronchodilator

Question 50

GOLD guidelines severity of airflow limitation-1st step

Answer 50

patients must have FEV1/FVC<70% to be staged

Question 51

GOLD Stage I COPD PVTs, sxs, and tx

Answer 51

mild COPD FEV1/FVCor= 80% predicted with or without sxs Tx: short-acting bronchodilator

Question 52

GOLD Stage 2 COPD PVTs, sxs and tx

Answer 52

moderate COPD FEV1/FVC<80 DOE, w/ or w/out cough and sputum production tx: -short acting bronchodilator when needed -regular tx w/one or more long-acting bronchodilators -rehabilitation