COPD - Clinical Approach Flashcards
Define COPD
Group of diseases characterized by an obstructive ventilatory defect
Two groups of COPD
- Chronic bronchitis
- Emphysema
3rd leading cause of death in the USA
COPD
(10 year mortality 50%)
3 Obstructive airway disease
- asthma (reversible)
- COPD (partially reversible)
- emphysema
Risk factors for COPD (6)
(LO!!!)
- smoking (80-90%)
- pollution, dust, chemicals
- infections
- allergy/asthma
- white elderly male
- alpha-1 antitrypsin deficiency (<1%)
COPD is a progressive airflow limiting disease with an abnormal _______ response to noxious gases.
inflammatory (i.e. CD8, MF, neutrophils, IL-8, TNF-a)
Define chronic bronchitis
cough w/sputum (3 tbsp) for 3 months out of 2 consecutive years WITHOUT any discernible cause
COPD symptoms (3)
- dyspnea on exertion
- productive cough
- acute chest illness
(usually begins in the 5th decade of life)
COPD physical signs on auscultation (2)
- diminished breath sounds
- rhonchi/wheeze
COPD: physical findings (visual inspection)
- barrel shaped chest
- horizontal ribs
- peripheral cyanosis w/elevated JVP
- Hoover sign (indrawing of lower intercostal spaces during inspiration)
- low, flat diaphragm
COPD: physical findings in the physical examination (2)
- hyperresonance to percussion
- prolonged expiratory phase
- pursed lip breathing
Pathophysiology of COPD (6)
(LO!!!)
- mucus production
- reduced mucociliary clearance (cough & sputum)
- loss of elastic recoil
- increased smooth muscle
- pulmonary hyperinflation
- hypoxemia and/or hypercapnia
Structures damaged by COPD (3)
(LO!!!)
- peripheral airways
- lung parenchyma
- pulmonary vasculature
Describe the early inflammatory changes of COPD (3)
(LO!!!)
- Increased number of goblet cells
- Mucous gland hyperplasia
- Fibrosis, narrowing of peripheral airways
In COPD, the repeated cycles of injury and repair of the peripheral airways leads to _______.
scarring, narrowing and fixed obstruction/collapse of airways
(inflammation→ edema, mucus hypersecretion adds to obstruction)
Define lung parenchyma
Respiratory bronchioles and alveoli
(aka acinus)
Smoking is more likely to cause damage to the ____ lobes, whereas alpha 1 antitrypsin causes damage to the _____ lobes.
- upper
- lower
In COPD, all lung parenchyma damage is due to an overproduction of ______ is in response to ______.
- endogenous proteinases
- repeated and prolonged inflammation
What is the cause for peripheral airway collapse in COPD?
Destruction of alveolar attachments to the outer wall
(damage to alveoli→loss of elastic recoil)
How does cigarette smoke cause damage to the pulmonary vasculature (3)?
- Causes endothelial dysfunction
- thickening of the intima
- increase smooth muscle cells and tone
(chronic hypoxemia→ further vasoconstriction)
How can COPD lead to pulmonary hypertension (2)?
- Increase afterload of the right ventricle
- Increase viscosity (erythrocytosis) in the right ventricle
(Cor pulmonale (RV Failure) is the end result)
In COPD, gas exchange problems occur when the FEV1 is less than _____
1 L
Proximal acinar (centrilobular/centriacinar) emphysema is an inflammation of proximal acinus due to tobacco abuse (or coal workers pneumoconiosis). Smoke gets trapped early in the bronchioles and proximal acinus, leading to _____.
Elastase production increases proximally, destroying elastin
Panacinar emphysema involves the ______.
Entire acinar complex affected due to alpha-1-antitrypsin deficiency.
(Elastase increase (normally inhibited by alpha-1) destroys elastin throughout the acinus)
Distal acinar emphysema (aka paraseptal) occurs ______
distally near the septum or pleura (blebs).
(Mostly upper lobes; a/w spontaneous pneumothorax)
Irregular emphysema is unclassified, mixed or scarring due to ______.
chronic infections in an irregular pattern.
(Rarely significant airflow obstruction)
COPD
(note the horizontal ribs, increased intercostal space, narrow cardiac shadow/vertical heart, increased translucency)
emphysema due to tobacco
Which is COPD? Which is normal?
Spirometry findings of COPD
- decreased FEV1
- FEV1/FVC < 60%
What is indicated by this graph?
severe irreversible airway obstruction
(compare to normal below)
What is the utility of an arterial blood gas in COPD?
Provides clues to acuteness and severity of disease exacerbation
Patients with COPD have mild to moderate hypoxemia without ______.
hypercapnia (they have a higher tolerance for CO2)
pH of ____ usually indicates acute respiratory compromise
7.3
(near normal, thanks Kidneys!)
Chronic hypoxia leads to increasing pulmonary artery pressure w/resultant _________.
cor pulmonale and pulmonary hypertension
COPD therapy to prolong life (6)
- smoking cessation
- vaccinate
- oxygen
- pulmonary rehab
- Lung Volume Resection Surgery (LVRS)
- lung transplant (chronic bronchitis)
COPD tx (symptomatic) (2)
- MDI (SABA, LABA, anticholinergics SAMA/LAMA)
- Corticosteroids
Treatment recommendations
SABA/SAMA
Fill in the blank and give treatment recommendations (3)
- LABA/LAMA
- pulmonary rehab
- SABA/SAMA
Fill in the blank and give treatment recommendations (4)
- LABA/LAMA
- SABA/SAMA
- Pulmonary Rehab
- inhaled glucocorticoids if repeated exacerbations
Fill in the blank and give treatment recommendations (6)
- one short-acting bronchodilator
- inhaled glucocorticosteroids (repeated exacerbations)
- treat complications
- pulmonary rehab
- long-term O2 therapy
- surgical consult
Sx of acute COPD exacerbation (4)
- worsening hypoxia
- dyspnea
- cough & sputum
- infection
(⅓ have no obvious cause)
Acute COPD exacerbation treatment
- SABA/SAMA
- IV steroids
- IV broad spectrum ABX (if infection suspected)
- OMM/RT
- mechanical ventilation
(diuresis if chronic bronchitis or cor pulmonale)
What is the difference between COPD & bronchiectasis
bronchiectasis produces copious amounts of sputum
(similar disease)
