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Nayla Foundations Exam 3 > COPD > Flashcards

COPD Flashcards

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1
Q

What does GOLD stand for

A

Global initiative for chronic Obstructive Lung Disease

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2
Q

COPD is the

A

4th leading cause of death in the world, and projected to be the 3rd by 2020 (d/t continued exposure to RF and aging of population)

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3
Q

What are the treatment objectives

A
  1. relieve and reduce impact of symptoms

2. reduce risk of adverse health events that can affect pt later

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4
Q

What are the GOLD levels of evidence

A

A: RCT, high quality evidence w/o significant limitation or bias
B: RCT with important limitations, limited body of evidence
C: non-random trials, observational studies
D: panel consensus judgement

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5
Q

What is COPD (definition)

A

common, preventable and treatable disease with PERSISTENT RESP SX and AIRFLOW LIMITATION due to airway or ALVEOLAR ABN, caused by SIGNIFICANT exposure to noxious particles/gas

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6
Q

What are the most common respiratory symptoms

A

Dyspnea (popcorn!)
Cough (first to shoe)
Sputum production
(these are underreported by patients)

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7
Q

What are the RF for COPD

A 
#1- Tobacco Smoking! 
also, biomass fuel exposure (stoves w/o chimney), fuel exposure, and air pollution
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8
Q

Patients with COPD due to fuel exposure have less __

A

Emphysema

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9
Q

What host factors predispose a pt to COPD

A

genetic abnormalities (asthma as kid, low birth weight)
abnormal lund development
accelerated aging

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10
Q

What happens during the course of COPD

A

exacerbations- acute worsening respiratory Sx needing additional therapy

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11
Q

COPD is associated with __ in most patients

A

significant concomitant chronic diseases- this increases M&M

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12
Q

COPD is more prevalent in what people

A

Those 40+ y/o, compared to those less than 40
M>W
Smokers>non-smokers

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13
Q

COPD exacerbations are responsible for the

A

greatest proportion of total COPD financial burden

Direct costs in U.S. are 32 billion $

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14
Q

What is “Disability adjusted life year” (DALY)

A

sum of years lost d/t premature mortality/years of live lived with disability, adjusted for severity of disability

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15
Q

What factors affect disease progression

A 
genetics, age, gender
lung growth/development
particle exposure
socioeconomic status
asthma
chronic bronchitis
infections
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16
Q

What is the pathology of COPD

A

chronic inflammation and structural changes

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17
Q

What is the pathophysiology of COPD

A

airflow limitation and gas trapping
gas exchange abnormalities
mucus/pulmonary HYPERsecretion

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18
Q

What processes allow COPD to have such detrimental effects

A

Oxidative stress
Protease inhibitors
inflammatory cells/mediators
peribronchiolar and interstitial fibrosis

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19
Q

When should COPD be considered

A

if the patient has dyspnea, cough, or sputum production (top 3 Sx), and/or Hx of exposure to RF

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20
Q

What test is required to make diagnosis

A

Spirometry! (shows SEVERITY of limitation and helps you make therapeutic decisions)
FEV1:FVC <70 confirms airflow limitation

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21
Q

What are the goals of COPD assessment

A

determine level of airflow limitation
impact of disease of pt health
risk for future events

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22
Q

What are concomitant diseases often present with COPD

A 
CVD
skeletal muscle dysfunction
metabolic syndrome 
osteoporosis
depression/anxiety
lung cancer
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23
Q

More detail on the top 3 COPD symptoms

A

Dyspnea: progressive, worse with exercise
Cough: intermittent, can be dry, recurring wheeze
Sputum: any pattern

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24
Q

What are OTHER symptoms of COPD

A

wheezing, chest tightness, fatigue, weight loss, syncope, rib fx, ankle swelling
depression/anxiety

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25
What medical history indicates COPD
Fix (esp. mom) comorbidities (cardiac, asthma, fibrosis) smoking, occupation, environment RF exposure
26
Are physical exams diagnostic
Not usually- but they help r/o other DDx
27
When should you NOT use spirometry
for screening an asymptomatic patient
28
What are obstructive spirometry results
FEV1: reduced FVC: normal FEV1:FVC: reduced
29
What are the GOLD classifications of severity of airflow limitation
1: Mild, FEV1 >80% 2: Moderate, FEV1 50%-80% 3: Severe, FEV1 30%-50% 4: Very severe, FEV1 <30%
30
How do you truly diagnose COPD
Symptoms + RF + Spirometry
31
What are the tests used to assess COPD
*COPD assessment tool (CAT) *Modifiec Medical Research Council questionnaire (mMRC) (SGRQ too complex for in office)
32
What is the biggest RF for a future exacerbation
History of an exacerbation
33
How do you treat the classes of COPD
Mild: SABD Moderate: SABD + abx/bronchodilators Severe: hospitalizations
34
What lab study can help predict exacerbations
Blood eosinophils (if treated with LABA and w/o ICS)
35
What is the ABCD assessment
A: mMRC 0-1/CAT <10-- 0-1 Exacerbations, no hospital B: mMRC 2+/CAT 10+-- 0-1 Exacerbations, no hospital C: mMRC 0-1/CAT <10-- 2+ exacerbations/1 hospital D: mMRC 2+/CAT 10+-- 2+ exacerbations/1 hospital
36
What does the new system (Grade 1-4 + ABCD) allow
PCP to better classify patients and understand when to increase or decrease meds
37
Who should be screened for AATD (alpha-1 antitrypsin deficiency)
all patients with COPD Dx (at least once) | <45 y/o with pan lobular basal emphysema
38
What are AATD levels
low concentration (<20% of norm) highly suggestive of homozygous deficiency
39
Some Ddx include
``` Asthma CHF Bronchiectasis TB diffuse panbronchiolitis obliterative bronchiolitis ```
40
hat is the KEY to maintenance therapy (greatest capacity to influence natural history of COPD)
Smoking cessation- esp. with pharm and nicotine replacement | But, efficiency of e-cigarettes is uncertain
41
How can pharm therapy help
it can reduce COPD Sx, frequency and severity of exacerbations, and improve health status
42
What management technique needs to be assessed regularly
inhaler technique!
43
What vaccine helps decrease incidence of lower respiratory tract infections
Influenza | pneumococcal (PCV 13, and PPSV 23 for all 65+)
44
What helps improve survival of patients with severe resting chronic hypoxemia
long term oxygen therapy
45
When should Oxygen NOT be routinely prescribed
If patient has stable COPD If patient has resting or exercise induced moderate desaturation (BUT, consider individual patient factors)
46
What patients benefit from long term ventilation (decrease mortality and prevent re-hospitalization)
Patients with severe chronic hypercapnia
47
What treatments are beneficial for advanced emphysema patients
Surgical or bronchoscope interventional treatments
48
What are brief strategies to help a patient willing to quit
``` Ask (EVERY patient EVERY time) Advise (urge them to quit) Assess (if willing) Assist (aid in quitting) Arrange (schedule follow up) ```
49
What meds are central to symptom management in COPD
Inhaled bronchodilators- commonly on a regular basis to prevent or reduce symptoms
50
What med helps improve FEV1 and symptoms
regular and as-needed use of SABA and SAMA- combo is superior to individual
51
What do LABA and LAMA do in COPD
improve lung function, dyspnea, and reduce exacerbation
52
What are mortality rates following hospitalization
23-80%, but they are declining
53
What meds can be used for palliative care
opiates, neuromuscular electrical stimulation, oxygen, and blowing a fan in their face helps with breathlessness nutrition supplement improves respiratory muscle strength in malnourished pull. rehab, nutrition support, and mind body interventions can help fatigue
54
What is the standard of care for decreasing M&M in patients hospitalized with exacerbations
Non-invasive ventilation as Non-invasive Positive Pressure Ventilation
55
What is lung volume reduction surgery (LVRS)
parts of lung are resected to reduce hyperinflation, which improves mechanical efficacy of respiratory muscles - esp in Emphysema patients
56
What is a downside to LVRS
increased M&M- so instead, some opt to do a less invasive bronchoscope approach to lung reduction
57
What should management strategies be
pharmacologic Tx complemented with non-pharmacologic Tx
58
What should effective management be based on once COPD has been diagnosed
individual assessment to reduce current symptoms and future risk of exacerbation
59
What are ways to reduce RF exposure
Smoking cessation Efficient ventilation Clinicians advise pt to avoid continues exposure/irritants
60
What three types of counseling were found effective in treating tobacco dependence
Practical, social support of family and friends, social support outside of Tx
61
What facilitates smoking cessation
First line pharm (varenicline, bupropion, nicotine gum/inhaler/nasal spray/patch) Financial incentive programs
62
How do Pharm Tx help treat stable COPD
reduce symptoms, risk and severity of exacerbations, and improve health status and exercise tolerance- but they are inhaled, to PROPER TECHNIQUE
63
When are LABA and LAMA preferred over short acting
patients with only occasional dyspnea | Inhaled>oral
64
When is Theophylline recommended
when other long term treatment bronchodilators are unavailable/unaffordable
65
Long term ICS is NOT recommended as
long-term monotherapy- must add LABA with it!
66
When can you consider adding a PDE4 inhibitor
If patient is not responding to LABA+ICS+LAMA and has very severe airflow obstruction
67
What meds are not recommended when managing COPD
Anti-tussive Statins Methylxanthines
68
What dosing therapy is recommended for managing COPD
initiation and subsequent escalation and deescalation pharm management BUT, not for groups C and D
69
What med can be added to a group D patient that is a former smoker and still having exacerbations
Macrolide (Azithromycin!)
70
What is "self management"
a major component of chronic care model that's aim is to motivate, engage and coach patients to positively adapt their behaviors and develop skills to better manage their disease
71
What are essential, recommended, and local dependent NON-pharm guidelines
Essential: smoking cessation Recommended: physical activity Dependent: flu/pneumo vaccine
72
When is long term oxygen therapy recommended
PaO2 <7.3 or SaO2 <88%- twice in three weeks | PaO2 7.3-8 or SaO2 <88% if evidence of P-HTN or peripheral edema (CHF), or polycythemia (H >55%)
73
When should surgical or bronchoscope modes of lung volume reduction be considered
In patients with emphysema and hyperinflation refractory to optimized medical care
74
What is recommended for patients with a large bulla
Bullectomy
75
When should a lung transplant be considered
Very severe COPD if w/o contraindications
76
What should "end of like care" conversations involve
discussion with patient and family about their views on resuscitation, advanced directives, and place of death preference
77
Is patient education important
Yes- but when used alone, no evidence that it will change patient behavior
78
When is rehab indicated
in all patients with relevant symptoms/at high risk for exacerbation
79
How should you monitor disease progression in your patient
Measurements: FEV1 decrease Symptoms: ask about cough, sputum, dyspnea, fatigue, activity limit, sleep disturbance Exacerbations: frequency, severity, type, and cause Imaging: indicated if clear or worsening symptoms Smoking status: ask at each visit
80
What should patient monitoring focus on
``` Dose of Rx meds adherence to regimen inhaler technique current regimen effectiveness side effects ```
81
What usually precedes an exacerbation
respiratory tract infection
82
What initial bronchodilators are recommended to treat an acute exacerbation
SABA (inhaled) +/- short acting anticholinergic
83
What chronic med should be started before leaving the hospital
long acting bronchodilators
84
How long and why use systemic corticosteroids
5-7 days | to improve FEV1, oxygenation, and shorten recovery time
85
Can antibiotics be used?
Sometimes, for 5-7 days | to reduce risk of early relapse, shorten recovery time and hospitalization duration
86
What should be the first mode of ventilation used in COPD with acute respiratory failure
Non-invasive mechanical ventilation
87
How are exacerbations classified
Mild (use SABD) Moderate (SABD + Abx +/- oral corticosteroids) Severe (hospitalization), can appear with acute respiratory failure
88
This is NOT respiratory failure
RR: 20-30 w/o accessory muscles No change in mental status Hypoxemia improved with O2 mask (28-35%) No PaCO2 increase
89
This is Acute Respiratory Failure, non-life threatening
RR >30 with accessory muscles No change in mental status Hypoxemia improved with O2 mask (25-30%) PaCO2 elevated 50-60 mmHg (hypercarbia)
90
This is Life threatening Acute Respiratory Failure
RR >30 with cessory muscles Acute change in mental status Hypoxemia not improved w/ O2 mask (or needs >40%) PaCO2 elevated >60 mmHg (hypercarbia)
91
What are potential indications for hospitalization
Severe Sx (worse dyspnea, high RR, low O2 sat, confusion, drowsy) Acute respiratory failure New onset cyanosis, peripheral edema, etc. Exacerbation fails to respond to initial medical management Presence of serious comorbidities (HF) Insufficient home support
92
How do you manage a NON life threatening exacerbation
``` ass severity, blood gases, chest imaging Give O2 therapy Bronchodilators +/- corticosteroid, abx, NIV *Monitor fluid balance, consider heparin, treat associated conditions ```
93
What are indications for ICU admission
``` Severe dyspnea not relieved with therapy changes in mental status persistent or worsening hypoxemia need INVASIVE mechanical ventilation hemodynamic instability ```
94
What are indications for NIV
Respiratory acidosis (PaCO2 >6) Severe dyspnea w/ signs of respiratory muscle fatigue Persistent hypoxemia despite O2 therapy
95
What meds reduce frequency of exacerbations
``` Bronchodilators (LABA/LAMA) Corticosteroid regimen (LABA+ICS) NSAID (Roflumilast) Anti-infective (vaccine, long term macrolide) Mucoregulators ```
96
What is a main cause of death in COPD patients
lung cancer
97
What comorbidity is associated with increased risk of exacerbations
GERD
98
What other comorbidities are frequent
Cardiovascular (CVD, HF, IHD, PVD, HTN, arrhythmia) Osteoporosis, depression/anxiety Bronchiectasis, obstructive sleep apnea
99
If a patient has COPD with a bunch of comorbidities, what should your attention be on
Ensuring simplicity of treatment to minimize polypharmacy

Nayla Foundations Exam 3 (5 decks)

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