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PULMONARY BOARDS > COPD > Flashcards

COPD Flashcards

(85 cards)

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1
Q

What do epithelial cells produce to create small airway fibrosis

A

TGF-B

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2
Q

What do macrophages produce to increase inflammation

A

LTB4 and IL-8 (neutrophil and T-cell chemottractant)

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3
Q

Primary lymphocytes involved in pathogenesis of COPD

A

CD8+ cytotoxic T cells

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4
Q

Male and female death in copd, who is more effected

A

female > male

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4
Q

Worse prognostic gene in AAT

A

ZZ worst
Then SZ
then MZ, then SS and MM with highest AAT serum level

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4
Q

emphysema in non-smoking person aged <45yo

A

AAT deficiency

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5
Q

Imaging associated with AAT

A

bullous disease at lung bases, panacinar

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6
Q

When is IV a1-antitrypsin therapy indicated and effect

A
  1. high-risk homogenous phenotype patient (ZZ)
  2. FEV1 35-65% (GOLD); ATS recs <80%
  3. plasma AAT level <11 or 57 mg/dL; other therapy optimized
  • Modest effect in slowing lung function decline but NO effect in preventing exacerbations
  • Not recommended for other emphysema
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7
Q

Is digital clubbing not typical in COPD?

A

no

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8
Q

Rate of FEV1 decline each year in non-smokers vs smokers

A

30 ml/year vs. 60 ml/year

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9
Q

Inspiratory capacity of ___ is an independent predictor of mortality in COPD

A

<25%

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10
Q

Bronchial thermoplasty indication and contraindications in asthma

A

<18
Steroids 2 in the past year

Contraindicaions
FEV1 <60
More than 3 exacerbations

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11
Q

CAT score components and cut offs

A

Cough
Phlegm
Chest tightness
Breathlessness
Activities
Confidence
Sleep
Energy
Max 40, min 0
Cut off of 10 = quality of life impact
Minimal important difference is 2

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12
Q

COPD GOLD score number cut offs

A

> 80
50
30

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13
Q

Predictor of survival in COPD

A

BODE
BMI (lower BMI is a poor prognostic marker)
Obstruction (FEV1% predicted) >65 = 0 (then 50, 36)
Dyspnea (mMRC) (same numebers as mmRC)
Exercise (6MWT) >350m = 0 (then 250, 150 cut offs)

Each component is 3 (except BMI (<21 = 1, >21 = 0) Refer for LT if BODE = 7-10 (80% mortality at 52 mo)

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14
Q

56F with COPD describes dyspnea when hurrying on level ground, post bronch FEV1 is 45% predicted, no h/o exacerbations w/in the past year. GOLD combined assessment?

A

GOLD Stage 3A; mMRC 1

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15
Q

TORCH trial findings

A
  • Salmeterol reduced exacerbations
  • Salmeterol-fluticasone combination reduced exacerbations
  • Pneumonia more likely in patients taking fluticasone
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16
Q

UPLIFT trial revealed that tiotropium was associated with the following outcomes:

A
  • Reduction in exacerbations
  • Reduction in hospitalizations related to exacerbations
  • Improved quality of life
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17
Q

Things that reduce COPD exacerbations

A

LABA, LAMA and LABA/ICS

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18
Q

Which therapy has been shown to slow the rate of FEV1 decline in COPD

A

smoking cessation
(not inhalers)

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19
Q

Pulm rehab improves:

A

Dyspnea
quality of life
6MWD

Not FEV1

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20
Q

Benefit of pulmonary rehabilitation BREATH(e) EASY

A

Breathless reduction
Recovery after exacerbation
Exercise capacity (6MW shuttle walk)
Anxiety and depression reduction
Training of respiratory muscles
Hospitalization frequency and days in hospital decreased
Enhanced efficacy
Arm function improvement and endurance training of upper limbs
Survival
Your quality of life improvement

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21
Q

LVRS Benefits (3)

A

survival
Exercise
QOL

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22
Q

LVRS patient selection for greatest mortality benefit

A
  1. Upper lobe-predominant emphysema, poor exercise capacity <40W in men, <25W in women after pulm rehab
  2. Upper lobe-predominant emphysema and high exercise capacity has no survival benefit BUT improves QOL and exercise capacity

NETT trial 2003

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23
LVRS physiological benefit (3)
1. improves elastic recoil 2. expiratory airflow 3. mechanical function of diaphragm
24
LVRS Contraindications (5)
1. FEV1 <20 2. DLCO <20 3. diffuse/homogenous emphysema on CT 4. Combination of diffuse emphysema and high exercise capacity (increased mortality) 5. prior mediasternotomy
25
Oxygen benefits and how many hours it's needed
>15 hours/day 1. survival 2. exercise tolerance Only in NOTT trial (avg 18h/d), not validated in LOTT trial - no survival or QOL benefit
26
Who benefits from O2 therapy
PaO2 <55mmHg or SaO2 <88% PaO2 56-59 mmHg or Sao2 <89% AND - EKG Evidence of cor pulmonale - Hematocrit >55 - RHF/pulmonary HTN
27
Why is using FEV1/FVC <0.7 a better tool for COPD than using LLN
helps discriminate COPD-related hospitalization and mortality vs. LLN
28
GETomics
Gene, environment interaction over the lifetime
29
Prevalence men to female in COPD, which is more
female
30
COPD risk in smokers (percentages per pack)
15-20% of 1 ppd smokers and 25% of 2 ppd smokers will develop COPD
31
Cadmium fume exposure is associated with
COPD
32
pesticide exposure, organic and inorganic dust is associated with ___
COPD
33
50% of COPD deaths in developing countries are from
biomass smoke, 75% are women
34
Cells found in airways in non-smoker COPD
eosinophils
35
Definition of chronic bronchitis
chronic cough and sputum for 3mo/year for 2 consecutive years
36
Mucin in chronic bronchitis that cause more exacerbations
MUC5AC MUC5AB cause more exacerbations
37
Lung function peaks at what age ____
20-25 yo 50% of COPD could be due to people never achieving peak FEV1
38
Dysanapsis
mismatch of airway tree caliber to lung size in early life
39
SABA and SAMA benefit (separately) (2)
FEV1 Symptoms
40
LABA and LAMA benefit (separately) (4)
lung function dyspnea health status exacerbations
41
LAMA benefit (3)
exacerbation hospitalizations effectiveness of pulmonary rehab
42
Combination LAMA+LABA benefit (3)
improves FEV1 Symptoms Exacerbations MORE than monotherapy
43
ICS+LABA combination
more effective than single therapy FEV1 Health status exacerbations
44
Triple therapy benefits over dual therapy (4)
better than dual therapy in 4 components 1. REDUCES MORTALITY in symptomatic COPD with h/o frequent exacerbations 2. lung function 3. QOL 4. Exacerbations
45
Regular treatment with ICS in COPD increases ___
risk of pneumonia in those with severe disease
46
Who might benefit from ICS in COPD
- frequent exacerbations 1-2 or more - AEC 300 - concomitant asthma
47
Who may not benefit from ICS in COPD
blood eos <2% or <100 Repeated pneumonia events History of NTM/MTB Independent of ICS, blood eos <2% associated with increased risk of pneumonia
48
FLAME Study compacompared LABA/LAMA vs ICS/LABA and found ____
Study population: FEV1 25-60% + mMRC 2+ and at least 1 exacerbation in the past 1 year (high dose salmeterol-fluticasone) - longer time to first exacerbation in LABA/LAMA group - Higher incidence of pneumonia in ICS group
49
IMPACT and ETHOS trials showed: ___
ETHOS: Triple therapy vs ICS/LABA or LABA/LAMA - 2 doses of steroids vs ICS/LABA and LAMA/LABA - rate of mod-severe exacerbation was lowest in triple therapy - in patients with mod-severe COPD, 2+ exacerbation, FEV1 <50% pred - Eos did not modify effect - Decreased mortality shown in higher dose of ICS IMPACT: Triple therapy vs LAMA/LABA and ICS/LABA - decreased all cause mortality compared to LABA/LAMA but NOT to ICS/LABA
50
Macrolide benefit in COPD
erythromycin and azithromycin prolongs time to first exacerbation, decreases exacerbation
51
What population does macrolides not work as well in (for those with COPD)
current smokers
52
Indications for Roflumilast and what is the trial
REACT 2015 - 13% reduction in exacerbations Indications: - FEV1 <50% & chronic bronchitis - use of steroids +2x, 1 hospitalization
53
MOA of Roflumilast
PDE4 inhibitor
54
Prevalence of A1AT deficiency in COPD
1-3%
55
Benefit of Dupilumab in COPD
AEC >300: 30% reduction in exacerbations when added to triple inhaled therapy AND in smokers
56
COPD treatment based on groups
A: a LAMA (one bronchodilator) B: LABA+LAMA E: LABA+LAMA consider ICS in eos >300
57
Mode of inheritance A1AT
autosomal co-dominant pattern - SERPINA1 gene chromosome 14
58
Normal and abnormal allele in A1AT
M is normal S or Z is associated with deficiency
59
A1AT is associated with (3)
1. liver disease/ cirrhosis 2. Necrotizing panniculitis 3. c-ANCA positive vasculitis
60
61
Major Contraindication to AAT augment therapy
IgA deficiency --> anaphylaxis (pooled human AAT) - plasma serum lvl >11 micromol/L or 57 mg/dL
62
Lung Health Study smoking cessation study shows ___
1. Slower FEV1 decline 2. Mortality benefit in sustained quitters some in intermittent quitters
63
Vaccinations needed for COPD
1. Influenza 2. RSV 3. COVID 4. TdaP 5. PCV20
64
Benefits of pulmonary rehab (4)
1. Improvement in dyspnea, exercise capacity, QOL/anxiety/depression 2. Reduces frequency of exacerbations 3. Reduces the number of readmissions in the YEAR following initiation 4. Initiation within 90d of discharge = reduction in all-cause mortality at 1 year
65
Optimum duration of pulm rehab
6-8 weeks
66
When is O2 therapy indicated during exercise
Desaturation or PaO2 <55 during exercise only
67
Indication for NIV in COPD
pCO2 >52 and pH >7.35
68
Target of NIV in COPD
decrease paCO2 by 20% from baseline OR <48 mmHg
69
NIV in COPD benefit
mortality at 1 year (high PIP of 25 PEEP 5 in this study) Kohnlein, Lancet 2014
70
BLVR indication/patient selection (4)
1. hyperinflation due to severe emphysema (ok if it is homogenous) 2. nonsmoking >4 mo 3. BMI <35 4. Has been stable on <20 mg prednisone
71
BLVR risk
PTX 20-30% (most in the first 3 days)
71
BLVR benefit (5)
improved FEV1 Dyspnea 6MWD QOL RV NOT mortality
72
COPD is related to (7 comorbidities)
1. HF (20-70%) 2. CAD and MI 30 days after AECOPD 3. Osteoporosis (emphysema and severity of airflow F>M, low BMI) 4. GERD 5. Metabolic syndrome >30% 6. OSA overlap --> WORSE prognosis 7. PVD
73
Factors associated with increased risk of exacerbation
1. SINGLE BEST PREDICTOR regardless of severity: prior exacerbations 2. Blood AEC >300 Others: advanced age, PH, cobormid conditions, h/o antibiotic use, severity of airflow limitation
74
Most common cause of COPD exacerbation
infections viral = longer recovery
75
What increases mortality in COPD
1. frequent exacerbations (1y after hospitalization, 28% mortality) 2. PaCO2 >50 mmHg (33% mortality in 6 mo, 43% mortality at 1 year)
76
Benefit of antibiotics in AECOPD
1. shorten recovery time 2. reduce risk of treatment failure 3. reduce hosp duration
77
Contraindication to BLVR (12)
Noncomplete fissure (collateral ventilation) (CT Chest and AI) >95% completion is good --> then use another method to check this by obstructing airflow (CV-, flow should cease after a while) DLCO <20 FEV < 15 or >45% RV/TLC >150-175% TLC >100 RVSP >45 LVEF <45 Hypoxemia paO2 <44 mHg Hypercapnia >60 Large bullae >30% occupation Nodule that is high risk to be malignant Smoking LIBERATE trial
78
Evaluation of when to give O2 in high altitude/flight in COPD
COPD with resting SpO2 <92% or <95% and dyspnea, do a 6MWT COPD with SpO2 <84% with 6MWT, HAST is advised If >84% while walking 6MWT, no in-flight O2 is advised
79
Benefit in NIV with high-intensity vent during sleep and what type of vent
mortality benefit decreased rehospitalization ASV
80
Definition of bronchopulmonary dysplasia
need for O2 at least for 28 days after birth
81
How long do you have to do pulm rehab to see the evidence-based benefits, and what are the benefits
24 mo Prolongs walking distance and COPD assessment scores (BODE)
82
Criteria for List for lung transplant in COPD
One or more of the following: BODE 7-10 FEV <20% Mod-severe PH History of severe exacerbations Chronic hypercapnea Has to be age <70 and BMI 16-35

PULMONARY BOARDS (9 decks)

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