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COPD - Exam 1 Flashcards

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1
Q

What are the 3 classic respiratory symptoms associated with COPD? What are the 2 pathophys categories?

A

dyspnea, cough and sputum

Chronic bronchitis
Emphysema

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2
Q

_____ and extensive _______ are key physiologic makers of COPD. Name 4 factors that can cause narrowing of the small airways

A

Airflow obstruction

airway destruction

Immune cells, molecules, mucus, fibrotic tissue

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3
Q

smoking increasing ________ causes alveolar tissue damage. What is the happening in chronic bronchitis?

A

neutrophil elastase

inflammation of the bronchus leading to narrowing

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4
Q

overweight
cyanotic
elevated hemoglobin
peripheral edema
rhonchi
wheezing

What am I?

A

chronic bronchitis

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5
Q

older and thin
severe dyspnea
quiet chest
hyperinflation on xray

What am I?

A

emphysema

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6
Q

Weight gain
Weight loss
Activity limitation (including intercourse)
Wheezing +/- chest tightness
Syncope
Anxiety / depressive symptoms

What am I?
Is weight gain or loss associated with worse prognosis?

A

COPD

weight loss is worse because the body is working very hard to breathe, resulting in weight loss

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7
Q

What are COPD risk factors?

A

Family hx
smoking hx
environment
hx of childhood pulm infections
HIV
TB
asthma

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8
Q

What will mild COPD present like? moderate/severe?

A

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

Lung hyperinflation
Decreased breath sounds, wheezes
Crackles at lung bases
Distant heart sounds
Increased AP diameter

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9
Q

Describe wheezing. What phase is it heard in?

A

a continuous musical sound heard in the expiratory phase

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10
Q

Describe fine crackles (Rales). What phase are they heard in?

A

brief and discontinuous, high pitched and popping noise.

both inspiration and expiration

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11
Q

What do early inspiration fine crackles indicate? late inspiration?

A

chronic bronchitis

pneumonia, CHF or atelectasis

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12
Q

Tripod posturing
Use of accessory muscles for breathing
Expiring through pursed lips
Hoover’s sign
cyanosis
nail clubbing is possible but rare

A

End-stage Disease / Chronic Respiratory Failure

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13
Q

What is Hoover’s sign?

A

lower intercostal interspace retraction during inspiration

**pt must take shirt off to see

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14
Q

What is the timeframe and criteria to be considered chronic bronchitis? What is a common complication?

A

Productive cough >3 months for 2 consecutive years

cor pulmonale (right sided heart failure)

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15
Q

**Who is screened for COPD? what is the questionnaire called? What score do you need to have to indicate COPD?

A

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

CAPTURE Questionnaire

CAPTURE scores 2-4 are indicative of clinically significant COPD

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16
Q

What is COPD defined as? What are some additional labs you would want to order?

A

COPD is defined by irreversible or partially reversible airflow limitation after bronchodilator administration as tested using spirometry

Pulse oximetry every visit
Labs - CBC, BMP, TSH, BNP/NT-proBNP, serum alpha-1 antitrypsin
CXR

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17
Q

**When you give a pt who has asthma a bronchodilator, what happens?

A

asthma conditions significantly improve! vs COPD have only slight to no improvement

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18
Q

What is FEV and FVC?

A

FEV₁ - Forced Expiratory Volume in 1 second
aka how much you can push out of your lungs in 1 second

FVC - Forced Vital Capacity - amount of air moved in 1 breath

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19
Q

**What is the spirometry results criteria that indicate an obstructive lung condition?

A
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20
Q

_____ is not necessary for routine assessment of COPD but is great for assessing the severity of emphysema

A

DLCO

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21
Q

DLCO ______ in proportion to severity of disease

A

decreases as the disease gets worse

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22
Q

Draw the Dr. Sheppard? graph how how to tell if something is met/resp acid/alk based on ABG values

A
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23
Q

What ABG values would you expect to find in mild COPD? moderate/severe COPD?

A

mild: Low pO₂ and normal pCO₂

moderate/severe: worsening pO₂ and elevated pCO₂

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24
Q

What is base excess in arterial blood gas? Base excess _____ in metabolic alkalosis and ______ in metabolic acidosis

A

the amount of acid or base required to restore a liter of blood to its normal pH at a PaCO2 of 40 mmHg

increases

decreases (or becomes more negative)

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25
T/F: imaging is needed for making the diagnosis of COPD
FALSE!! imaging is not required but you can consider CXR and chest CT w/o
26
When would imaging be indicated when working a pt up for COPD?
Dyspnea/cough etiology is unclear Rule out complicating process during acute exacerbations Evaluate for comorbidities
27
What will a CXR on a pt with emphysema look like? chronic bronchitis?
Hyperinflation Flattened diaphragm Increased retrosternal air space Long, narrow heart shadow like to be normal unless comorbities/complications
28
**What is COPD staging based on? What is the organization that sets the guidelines?
Airflow limitations Symptom severity Exacerbations Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria
29
**What are the airflow limitations in COPD staging?
30
After the pt's GOLD category is determined, what do you do next?
calculate mMRC and CAT score mMRC - assesses severity of breathlessness CAT - assesses multitude of symptoms present
31
What does mMRC stand for? What does it assess?
Modified Medical Research Council Dyspnea Scale (mMRC mMRC - assesses severity of breathlessness
32
What does CAT stand for? What does it assess?
COPD Assessment Test (CAT) CAT - assesses multitude of symptoms present
33
What is the scale range for mMRC?
0-4 -> 0=very mild and 4= severe
34
What does the CAT stand for? What does it assess? What is the scoring range?
COPD Assessment Test (CAT) CAT - assesses multitude of symptoms present 0-40-> 0 is mild and 40 is severe
35
**draw the entire graph for GOLD assessment COPD staging
36
What are the 3 goals for COPD management?
Improve symptoms Decreased number of exacerbations Improve patient functioning and quality of life
37
What are some non-pharm COPD management?
SMOKING CESSATION!! +/- behavioral counseling vaccinate!!! healthy BMI/lose weight Vit D supplementation regular, progressive exercise oxygen therapy pulm rehab
38
What vaccines are recommended for all COPD pts?
1. Influenza 2. COVID-19 3. PCV-20 OR PCV-13 followed by PCV-23 4. Tdap 5. Zoster in patients >50 6. New RSV vaccine
39
______ deficiency is associated with ______ and hospitalization for COPD exacerbations
vit D reduced lung function
40
When is oxygen therapy helpful in COPD?
Proven to increase survival in patients with severe chronic resting arterial hypoxemia pO2 ≤ 55 mmHg on ABG O2 sat ≤ 88% pO2 >55 <60 + RHF or erythrocytosis Severe hypoxemia with exertion
41
What GOLD stages of COPD is pulm rehab indicated for? What are the components of pulm rehab?
Indicated for COPD class B and E components: exercise training promotion of healthy behavior psychological support
42
What are the 2 categories of short-acting bronchodilators? Long-acting?
Short-acting Beta Agonists (SABA) Short-acting Muscarinic Antagonists (SAMA) Long-acting Beta Agonists (LABA) Long-acting Muscarinic Antagonists (LAMA)
43
Tachycardia Tremor Cardiac arrhythmia jittery Are SE of _____ medication. What must you do before you prescribe one? What are the medications in this category?
SABA education your pt on the possible SE!! Albuterol (Proventil, Ventolin, Proair) Levalbuterol (Xopenex)
44
Dry mouth dry eyes metallic taste prostatic symptoms Are SE of _____ medication. What are the medications in this category?
SAMA Ipratropium Bromide (Atrovent)
45
Tachycardia Tremor Headache Are all SE of ____ medication What are the meds in this class?
LABA Arformeterol Salmeterol Formeterol
46
Which LABA only comes in NEB form?
Arformeterol
47
Dry mouth constipation urinary retention Are all SE of ____ medication What drugs are in this class?
LAMA QD: Tiotropium Umeclidinium Revefenacin BID: Aclidinium Glycopyrrolate
48
Olodaterol /Tiotropium Vilanterol/Umeclidinium Formoterol/Glycopyrrolate Formoterol/Aclidinium What drug class?
LABA + LAMA
49
Salmeterol/Fluticasone propionate Vilanterol/Fluticasone furoate Formoterol/Budesonide What drug class?
LABA + ICS
50
Fluticasone furoate/Umeclidinium/ Vilanterol Beclometasone/Formoterol/ Glycopyrronium Budesonide/Formoterol/ Glycopyrrolate What drug class?
LABA + LAMA + ICS
51
**Draw the chart for initial pharm management for COPD based on GOLD category
52
What is the textbook answer for follow-up pharm management for COPD?
if one med is working, do NOT stop. if s/s are not well controlled need to add another medication to regime
53
What factors strongly favor adding on ICS to med regime? What factors favor use? What factor go AGAINST use?
look at eosinophil count!!
54
What is the proper technique for how to use an inhaler?
uncap shake the inhaler 10-15 times take a deep breath and breathe out all the way hold the inhaler upright hold the inhaler in your mouth above your tongue and between your teeth seal lips around the inhaler press down on the inhaler and breath in as much as you can hold your breath for 5-10 seconds slowly breathe out
55
When is it indicated to remove ICS therapy?
pneumonia inappropriate indication for ICS when it was first prescribed lack of response well controlled s/s can try deescalation with close f/u
56
What drug class is Roflumilast (Daliresp)? What is the indication? What are the SE?
phosphodiesterase-4 (PDE-4) inhibitor reduce exacerbations in severe COPD psych reaction: anxiety, depression, insomnia avoid if possible in pts with mental health history
57
What drug class is theophylline (Theobid)? What is the indication? Need to be cautious when prescribing to ______ because of ______
non-specific phosphodiesterase inhibitor refractory COPD liver impaired pts toxicity can occur
58
_____ MOA suppresses cytokine release and inhibits pulmonary neutrophil infiltration → reduces inflammation, pulmonary remodeling and mucociliary malfunction
Roflumilast (Daliresp)
59
_______ MOA relaxes smooth muscle → suppresses airway response to noxious stimuli → increased diaphragm contraction force
Theophylline (Theobid)
60
What is the follow-up recommendation for COPD pts? How often should spirometry be performed?
1-3 months following initial diagnosis and initiation of therapy Patients can be followed every 3-6 months once stabilized at least annually
61
What are risk factors for acute COPD exacerbations?
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)
62
What does decreased mental status tell us on a pt who presents with an acute COPD exacerbation?
hypercapnia or hypoxemia
63
What are some acute COPD exacerbation management options?
Adjust bronchodilator therapy Consider spacers / nebulizer therapy Consider oral glucocorticoid therapy Antibiotics for increased cough, sputum production, and purulence CPAP machine
64
When should abx be considered in a COPD exacerbation? Which ones?
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)
65
What is the target oxygen range for supplemental oxygen in COPD? Why would it be bad for the number to be above target range?
88-92% too much oxygen can decrease the body's natural respiratory drive which can led to a build up of CO2
66
What is the inpatient therapy for COPD exacerbation?
supplemental O2 reverse obstruction IV abx: Levaquin, ceftriaxone, pip/taz order pulm rehab
67
______ an enzyme naturally produced by the liver and migrates to the lungs via the blood. What is it's job?
Alpha-1 Antitrypsin (AAT) ATT protects the lungs from neutrophil (elastase) damage
68
What are the 2 pathophysiologic processes related AAT deficiency?
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
69
Same as emphysema in COPD at much younger age Symptoms of chronic hepatitis, cirrhosis, or hepatocellular carcinoma Symptoms of panniculitis → inflammation of subcutaneous tissue What am I?
AAT deficiency: Alpha-1 Antitrypsin Deficiency
70
What is panniculitis?
Hot, painful, red nodules or plaques characteristically on the thigh or buttocks
71
What factors would make you think to order AAT diagnostic testing? What will the test show?
In patients <45 Non-smokers or minimal smoking (<10-15 years) FH of emphysema and/or liver disease Adult onset asthma that does not respond to bronchodilators Panniculitis or unexplained liver disease low serum AAT levels
72
What is the tx for Alpha-1 Antitrypsin Deficiency?
Refer to provider specializing in disease Possible infusion of donor AAT Aggressive lifestyle modifications Pharmacotherapy, O2 therapy, vaccinations as indicated in COPD Prompt management of acute respiratory infections Pulmonary rehab
73
What is bronchiectasis? What causes it? What is the result?
An irreversible focal or diffuse dilation and destruction of the bronchial walls infection plus impaired draining/obstruction with impaired host defense Often results from recurrent inflammation or infection of the airways
74
What does bronchiectasis lead to? **What is the PE finding that leads you to this dx? What will their lungs sound like?
Leads to inflammation, mucosal edema, cratering, ulceration, and neovascularization of airway **Copious, foul-smelling, thick, purulent sputum is characteristic Rales/rhonchi/wheezing on exam
75
Why do you need to order an CXR if you suspect bronchiectasis? **What is the CXR finding clinical pearl related to bronchiectasis? What do they reflect?
to rule out pneumonia **“tram tracks” are characteristic and reflect dilated airways dilated airways
76
What will Bronchiectasis look like on imaging?
CT shows bronchial wall thickening and dilated airways Ballooned or “honeycomb” appearance
77
What 2 additional tests do you need to order for bronchiectasis?
sputum culture and bronchoscopy
78
Why do you need to order a bronchoscopy in bronchiectasis?
assess for underlying mass or foreign body in focal disease
79
What is the tx for bronchiectasis?
SMOKING CESSATION!! +/- behavioral counseling vaccinate!!! healthy BMI/lose weight Vit D supplementation regular, progressive exercise oxygen therapy pulm rehab abx for acute exacerbations: Amoxicillin, Amoxicillin-clavulanate, Doxycycline, TMP-SMX mucolytic therapy, bronchodilators, chest physiotherapy (vest that vibrates to break up mucous in chest so they can cough it out) surgical resection lung transplant
80
When is long-term abx indicated for bronchiectasis? When is a lung transplant indicated?
Consider long-term antibiotics for pts with ≥ 3 exacerbations/year indicated when FEV₁ <30% predicted
81
What are the risk factors for obstructive sleep apnea?
Increasing age, male, obesity, smoking, craniofacial or upper airway abnormalities Comorbid conditions such as pregnancy, ESRD, CHF, COPD, hx of stroke (CVA)
82
What is the pathophys behind obstructive sleep apnea?
Recurrent, functional collapse of pharyngeal airway during sleep → reduced airflow → intermittent disturbances in gas exchange and fragmented sleep
83
What are the 2 OSA questionnaires? What test is first line to dx OSA?
Berlin Questionnaire STOP-BANG In-laboratory polysomnography (sleep study
84
What is the dx criteria for OSA?
≥5 obstructive respiratory events (apneas, hypopneas, or respiratory-related arousals) per hour of sleep plus one or more of the following: (long list) OR ≥15 or more predominantly obstructive respiratory events per hour of sleep, regardless of associated symptoms or comorbidities
85
What is the management of OSA?
Weight loss is paramount!!! Continuous positive airway pressure (CPAP) oral appliances (mouth piece that hold the jaw forward) upper airway surgery to create a bigger hole in the back of the throat hypoglossal nerve stimulation
86

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