GOLD guidelines 2023 Flashcards
(154 cards)
1
Q
The main environmental exposures leading to COPD are ____
A
- Tobacco smoking
- Inhalation of toxic particles and gases from household and outdoor air pollution
2
Q
The most relevant (albeit rare) genetic risk factor for COPD
A
Mutation in SERPINA-1 gene —> alpha 1-antritypsin deficiency
3
Q
Confirms the diagnosis of COPD
A
The presence of non-fully reversible airflow limitation (FEV1/FVC < 0.7 post-bronchodilation) measured by spirometry
4
Q
-Individuals with (+) Structural Lung lesions, and/or physiologic abnormalities, WITHOUT airflow obstruction
-May or may not develop airflow obstruction
A
Pre-COPD
5
Q
-Normal ratio (FEV1/FVC ≥ 0.7 after bronchodilation) but abnormal spirometry (FEV1 < 80% of reference, after bronchodilation)
-Associated with increased all-cause mortality
-Not always a stable phenotype
-Can transition to both normal and obstructed spirometry overtime
A
Preserved Ratio Impaired Spirometry (PRISm)
6
Q
High prevalence of COPD seen in
A
-Smokers
-Ex-smokers
-≥40 years old
7
Q
According to PLATINO, the highest prevalence of COPD is seen in
A
Age >60 years old
8
Q
According to BOLD, global prevalence of COPD is ________
A
10.3%
9
Q
Key environmental risk factor for COPD
A
Cigarette Smoking
10
Q
Non-smoking COPD is more common in: ___
A
- Females
- Younger age groups
11
Q
Characteristic of Non-smoking COPD
A
- Exhibits similar (or milder) respiratory symptoms and quality of life
- Lesser rate of decline in lung function over time
- Lower neutrophils and a trend towards higher eosinophil numbers in the airway sputum
- Similar spirometric indices
- Greater small airways obstruction (respiratory oscillometry and radiology)
- Less emphysema
- Similar defect in macrophage phagocytosis of pathogenic bacteria
12
Q
In COPD, in smokers (vs non-smokers)
A
-Higher prevalence of respiratory symptom and lung function abnormality
-Greater annual rate of decline of FEV1
-Greater COPD mortality
13
Q
Principal symptoms of impaired mucous clearance
A
Cough and dyspnea
14
Q
Occupational exposures account for ____of either symptoms or functional impairment consistent with COPD.
A
10-20%
15
Q
___ is responsible for ~50% of the attributable risk for COPD in low and middle income countries
A
Air pollution
16
Q
In never smokers, _____ is the leading known risk factor for COPD
A
Air pollution
17
Q
Chronic exposure to ___________, significantly impairs lung growth, accelerates lung function decline in adults, and increases the risk for COPD
A
PM 2.5 and Nitrogen Oxide
18
Q
Accelerated telomere shortening
A
Marker of accelerated aging
19
Q
Anthropometric mismatch of airway tree calibre relative to lung volume
A
Dysanapsis
20
Q
-Related to initial mechanisms that eventually leads to COPD
-“biological”
A
Early COPD
21
Q
-Can occur at any age
-May or may not progress at any time
-Used to describe the severity of airflow obstruction measured spirometerically
A
Mild COPD
22
Q
-Directly relates to the chronological age of the patient
-Seen patients around 20-25 years old
-Associated with significant structural and functional lung abnormality
A
Young COPD
23
Q
Adults diagnosed of asthma were found to have a _____ of acquiring COPD over time compared to those without asthma
A
12-fold higher risk
24
Q
____ of asthmatic patients developed irreversible airflow limitation and reduced diffusing lung capacity
A
20%
25
Independent predictor of COPD and respiratory mortality in population studies
Airway Hyperresponsivess
(can exist without asthma diagnosis)
26
An indicator of risk of excess decline in lung function in patients with mild COPD
Airway hyperresponsiveness
27
Chronic cough and sputum production for **at least 3 months per year** for **two consecutive years**, in the absence of other conditions that can explain these symptoms
Chronic Bronchitis
28
Factors associated with increased prevalence of Chronic Bronchitis in COPD
1. Male Sex
2. Younger Age
3. Greater pack-years of smoking
4. More severe airflow obstruction
5. Rural location and increased occupational exposure
29
Mucin (large glycoproteins) polymers lining the human airways
1. MUC5AC (proximal airway **surface goblet cells**)
2. MUC5B (surface secretory cells throughout the **airways and submucosal gland**)
30
Mucin polymer thats is associated more specifically with **increased exacerbation frequency, increased symptoms and greater lung function decline**
Sputum MUC5AC
31
In COPD, this mucin is markedly increased due to **submucosal gland hyperplasia** leading to airway occlusion
Sputum MUC5B
32
In adults <50 years old, _______ represents as an **early marker for susceptibility** to the long term risk of COPD and all-cause mortality
Chronic Bronchitis **WITHOUT** airflow limitation
33
Associated with **accelerated FEV1 decline**
Chronic bronchial infection
(particularly with **Pseudomonas aeruginosa**)
34
_________ is both a differential diagnosis or possible comorbidity for COPD
Tuberculosis
35
Due to **Methylation disruptions in airway epithelium**, these type of patients has increased risk of COPD
HIV patients
36
Inflammatory changes in COPD
1. Increased numbers of **macrophages** in peripheral airways, lung parenchyma and pulmonary vessels
2. Increased **activated neutrophils**
3. Increased **lymphocytes**
37
Protease-mediated destruction of this major connective tissue component is an important feature of emphysema in COPD
Elastin
38
__________ related to the loss of elastic recoil, reduces inspiratory capacity, and is commonly associated with dynamic hyperinflation during exercise related to airflow limitation —> causing _______ and _______
Static Lung Hyperinflation
Exertional dyspnea
Limiting exercise capacity
39
Main mechanism of abnormal pulmonary gas exchange resulting to **different degrees of arterial hypoxemia** with or without hypercapnia
Ventilation/Perfusion mismatch
40
Pulmonary hypertension in COPD is caused by: _____ (2)
Intimal hyperplasia
Smooth muscle hypertrophy/hyperplasia
41
COPD Taxonomy: **Childhood asthma**
COPD-A (asthma)
42
COPD Taxonomy: **Tobacco smoke, Maternal smoking, Vape, Cannabis**
COPD-C (cigarette)
43
COPD Taxonomy: **Early life events, Low birthweight, Premature birth**
COPD-D (development)
44
COPD Taxonomy: **Alpha-1 anti-trypsin deficiency**
COPD-G (genetics)
45
COPD Taxonomy: **Childhood infections, Tuberculosis-associated, HIV-associated**
COPD-I (infections)
46
COPD Taxonomy: **Household pollution, Ambient air pollution, Wildfire smoke, Occupational Hazards**
COPD-P (pollution)
47
COPD Taxonomy: **unknown cause**
COPD-U (unknown)
48
Most **characteristic symptom** of COPD
Chronic Dyspnea
49
**Cardinal symptom** of COPD
Major cause of the disability and anxiety associated with COPD
Dyspnea
50
Often the **first symptom** of COPD
Chronic Cough
51
Large volume of sputum
Possible underlying **Bronchiectasis**
52
Purulent sputum
Increase in inflammatory mediators
Possible onset of bacterial infection
53
Ankle swelling in COPD may indicate ___
Presence of **Cor pulmonale**
54
Bronchodilation in Spirometry
Short-acting beta agonist
DOSE: 400 mcg
FEV1 measure after 10-15 min after
Short-acting anti-cholinergic
DOSE: 160 mcg
FEV1 measure after 30-45 minutes after
55
Initial Assessment in patients with COPD
1. Severity of Airflow Limitation
2. Nature and Magnitude of current symptoms
3. Previous history of moderate and severe exacerbation
4. Presence and type of other diseases (multimorbidity)
56
GOLD GRADING OF SEVERITY
**Gold 1: Mild**
FEV1 ≥ 80% predicted
57
GOLD GRADING OF SEVERITY
**Gold 2: Moderate**
50% ≤ FEV1 <80% predicted
58
GOLD GRADING OF SEVERITY
**Gold 3: Severe**
30% ≤ FEV1 <50% predicted
59
GOLD GRADING OF SEVERITY
**Gold 4: Very Severe**
FEV1 <30%
60
Episodes of acute respiratory symptom worsening often associated with increased local and systemic inflammation
Acute Exacerbation
61
The best predictor of having frequent exacerbations (defined as two or more exacerbations per year)
Previous history of exacerbations
62
A modifiable source of exercise intolerance by rehabilitation
Skeletal Muscle Dysfunction
63
Lung volume study in COPD
increase in TLC, particularly during exercise
(Increase in both Static and Dynamic Hyperinflation)
64
In COPD patients, DLCO values are predictive of increased symptoms, decreased exercise capacity, worse health status, increased risk of death (independent of severity of airflow obstruction)
DLCO <60%
65
In smokers without airflow obstruction, DLCO value that is marker of emphysema, or sign of risk for developing COPD overtime
DLCO <80%
66
Should be measured in any patient with dyspnea disproportionate to the severity of airflow obstruction
Single breath Carbon monoxide diffusing capacity of the lungs (DLco)
67
Indications for **Chest CT Scan**
1. COPD patients with **persistent exacerbations**
2. Symptoms **out of proportion to disease severity** on lung function testing
3. **FEV1 less than 45%** predicted with significant **hyperinflation and gas trapping**
4. Those who meet criteria for **lung cancer screening**
68
Indications for **Endobronchial valve therapy**
1. Post-bronchodilator FEV1 of 15-45%
2. Evidence of Hyperinflation
69
Indications for **Lung Volume Reduction Surgery**
1. Hyperinflation
2. Severe Upper lobe predominant emphysema
3. Low exercise capacity **after Pulmonary rehabilitation**
70
Composite score that is a **better predictor for subsequent survival** than any single component
The BODE Index (BMI, Obstruction, Dyspnea, Exercise)
71
**Blood Eosinophil count** at higher risk for exacerbation, and more likely benefit from preventive treatment with inhaled corticosteroids
≥ 300 cells/μL
72
COPD Intervention that has the greatest capacity to influence the natural history of COPD.
Smoking Cessation
73
Nicotine replacement therapy reliably increases long-term smoking abstinence rates. Medical contraindications to nicotine replacement therapy include _____
recent myocardial infarction or stroke
74
Recommended Vaccinations for COPD
**1. Influenza vaccine** (annual)
**2. Pneumococcal vaccine**
-One dose PCV20
-One dose PCV15 followed by PPSV23
**3. Tdap vaccine** (if not vaccinated during adolescence)
**4. Zoster vaccine** ( >50 years old)
**5. Covid 19 vaccine**
75
PHARMACOLOGY OF STABLE COPD
**Medications that increase FEV1**
Bronchodilators
76
Effects of Bronchodilators
1. Alters airway smooth muscle tone
2. Reduce dynamic hyperinflation at rest and during exercise
3. Improves exercise performance
77
PHARMACOLOGY OF STABLE COPD
**Central to the symptom management of COPD**
Inhaled Bronchodilators
78
Once daily LABA that improves breathlessness, health status and exacerbation rate
Indacaterol
79
Side effects of beta-agonists
1. Resting sinus tachycardia
2. Potential to precipitate cardiac rhythm disturbances
3. Exaggerated somatic tremor
80
Main side effect of Inhaled Anticholinergic Drugs
Dry Mouth
81
What drug improves the effectiveness of pulmonary rehabilitation in increasing exercise performance?
Tiotropium (LAMA)
(better exacerbation reduction than LABA)
82
Bronchodilator
LABA and LABA are preferred over SAMA
83
Non-selective phosphodiesterase inhibitors
**METHYLXANTHINES**
-metabolized by cytochrome P450
-clearance declines with age
-Improved inspiratory muscle function
-toxicity is dose-related
-adverse effect: atrial & ventricular arrhythmia, gran mal convulsions
-interacts with erythromycin but not azithromycin
84
Lower blood and sputum eosinophils are associated with greater presence of ___
1. Proteobacteria (Haemophilus)
2. Increased bacterial infections
3. Increase rate of pneumonia
85
Independent of ICS use, blood eosinophil count of _____ is associated with increase risk of pneumonia
<2%
86
Oral glucocorticoids in COPD
No evidence of benefits
87
Drug that improves lung function and decreases exacerbation in patients who are in fixed dose LABA + ICS combinations
PDE4 inhibitor
88
Antibiotic associated with increased incidence of bacterial resistance and hearing test impairment
Azithromycin
89
Antibiotic therapy associated with reduced exacerbations over 1 year
Long term Azithromycin and Erythromycin therapy
90
COPD patient on ICS with increased risk for pneumonia
currently smoke
aged ≥ 55 years
have a history of prior exacerbations or pneumonia
a body mass index (BMI) < 25 kg/m2
a poor MRC dyspnea grade
severe airflow obstruction
blood eosinophil count < 2%
91
Indications to Add ICS to LABA + LAMA
History of Hospitalization for COPD exacerbation
≥ 2 exacerbations per year
Blood eosinophil count ≥ 300
History of concomitant asthma
92
ICS is NOT recommended if
Repeated pneumonia events
Blood eosinophil count <100
History of mycobacterial infection
93
______ reduces moderate and severe exacerbations treated with systemic corticosteroids in patients with chronic bronchitis, severe to very severe COPD, and a history of exacerbations.
Roflumilast (PDE4 inhibitors)
Note:
-Avoid in underweight patients (unexplained weight loss ~2 kg)
-Use in caution for patients with depression
94
In COPD patients **not** receiving ICS, regular treatment with mucolytics may reduce exacerbations. In contrast, this drug, ______, may have significant effect on exacerbations **irrespective** of concurrent treatment with ICS
Erdosteine
95
_____ may slow down progression of emphysema
IV augmentation therapy with Alpha 1-antitrypsin
(AATD and FEV1≤ 65)
96
Anti-tussives
No conclusive role
97
Vasodilators
Do not improve outcome
May worsen oxygenation
Contraindicated in Stable COPD
98
Treatment goals for patient with chronic bronchitis
1) reducing the overproduction of mucus
2) decreasing mucus hypersecretion by reducing inflammation
3) facilitating elimination of mucus by increasing ciliary transport
4) decreasing mucus viscosity
5) facilitating cough mechanisms
99
A comprehensive intervention based on **thorough patient assessment** followed by **patient-tailored therapies** that include, but are not limited to, exercise training, education, self-management intervention aiming at behavior change, **designed to improve the physical and psychological condition** of people with chronic respiratory disease and to p**romote the long-term adherence** to health-enhancing behaviors
Pulmonary rehabilitation
100
Optimum benefits of Pulmonary Rehabilitation in COPD
Achieved in programs lasting **6-8 weeks**
No additional benefits from extending pulmonary rehabilitation to 12 weeks
**Supervised exercise training at least twice weekly is recommended**
101
Vitamin supplementation that has been shown to improve antioxidant deficits, quadriceps strength, and serum total protein, without further improvement in quadriceps endurance.
Vitamin C
Vitamin E
Selenium
Zinc
102
COPD-Nutrition
Associated with worse outcomes in COPD
Low BMI
Low fat free mass
103
Other interventions that can improve feeling of breathlessness
Opiates
Neuromuscular Electrical Stimulation
Oxygen, even if non-hypoxemic (<92%)
Fans blowing air to face
104
Appropriate Inhalation device
**Dry powder inhalers**
only if patient can make a forceful and deep inhalation
**Metered-dose inhalers**
Coordination between device triggering and inhalation and patients needs to be able to perform a slow and deep inhalation
105
Proven to increase survival in patients with **severe, resting hypoxemia**
Long term administration of oxygen (**>15 hours per day**)
106
Patients on long term oxygen therapy should maintain in-flight paO2 of ____
60 mmHg (6.7 kPA)
107
COPD patients may travel (flights) without assessment if:
Resting Oxygenation is >95%
6-minute walk test oxygen saturation >84%
108
In COPD exacerbation: the **standard of care** for decreasing morbidity and mortality in patients hospitalized with an exacerbation of COPD and acute respiratory failure
Noninvasive ventilation (NIV)
109
Home NIV is beneficial in
COPD with persistent hypercapnia (pCO2 >53 mmHg)
110
Giant bullectomy done if
Bulla occupies >1/3 of hemithorax, and compresses adjacent viable tissues
111
Bilateral LVRS showed **improved survival** IN
Upper lobe emphysema
Low post-rehabilitation exercise capacity
112
Lung transplant
Improved Quality of Life
No survival benefit (except for COPD with AATD)
113
Endobronchial one-way valves (EBV)
1. Lower number of exacerbations and episodes of respiratory failure
2. Improved survival
**(Evidence A)**
114
Bronchoscopic interventions
Advanced emphysema, bronchoscopic interventions reduced the end-expiratory lung volume AND improves exercise tolerance, Health status and Lung function at 6-12 months following treatment
Endobronchial valves (Evidence A)
Lung coils (Evidence B)
Vapor Ablation (Evidence B)
115
When to repeat Spirometry in COPD
Anually
116
Preferred over SAMA
LABA and LAMA
117
Preferred initiating treatment with long acting bronchodilator
Combination therapy with LAMA + LABA
118
Monotherapy with ICS
Not recommended
119
INITIAL PHARMACOLOGIC TREATMENT
**GOLD A**
Bronchodilator (LABA or LAMA or SABA)
120
INITIAL PHARMACOLOGIC TREATMENT
**GOLD B**
LAMA + LABA
121
INITIAL PHARMACOLOGIC TREATMENT
**GOLD E**
LABA + LAMA
Consider adding ICS if blood eosinophil count ≥ 300
122
When to add Roflumilast
FEV <50%
Chronic Bronchitis
123
When to add Azithromycin (Long term)
Preferebly in previous smokers (currently not smoking)
124
When to consider **withdrawal of ICS**
pneumonia or other considerable side-effects develop
125
Indication for Long term oxygen therapy (LTOT)
paO2 below 55 mmHg or SO2 below 88%, with or without hypercapnia confirmed twice over 3 week period
paO2 between 55-60 mmHg, or SO2 88%, if there is evidence of pulmonary hypertension, peripheral edema suggesting congestive cardiac failure, or polycythemia (hematocrit > 55%).
126
Goal of LTOT
Keep SO2 ≥90%
127
After initiation of LTOT therapy
Recheck after 60 to 90 days to reassess if
1. Supplemental O2 is still needed
2. If prescribed supplemental oxygen is effective
128
In patients with **Severe COPD** (progressive disease, BODE score 7-10) and **not a candidate for LVRS**, **LUNG TRANSPLANTATION** may be considered for referral if:
**At least one**
1. History of hospitalization for exacerbation associated with acute hypercapnia with pCO2 >50 mmHg
2. Pulmonary hypertension and/or cor pulmonale, despite oxygen therapy
3. FEV1 <20% and either DLCO <20% or homogenous distribution of emphysema
129
NON-PHARMACOLOGIC MANAGEMENT OF COPD
**GOLD A**
Smoking Cessation
Physical Activity
Vaccinations
130
NON-PHARMACOLOGIC MANAGEMENT OF COPD
**GOLD B AND E**
Smoking cessation
Pulmonary Rehabilitation
Physical activity
Vaccination
131
An event characterized by dyspnea and/or cough and sputum that worsen over < 14 days.
COPD Exacerbation
132
What is the initial bronchodilators to treat an exacerbation.
Short-acting inhaled beta2-agonists, with or without short-acting anticholinergics
133
In patients with severe exacerbations, ______ can improve lung function (FEV1), oxygenation and shorten recovery time including hospitalization duration.
Systemic corticosteroids
134
Duration of treatment of Systemic Corticosteroids in Acute COPD exacerbation
5 days
135
Methylxanthine in Exacerbation
Not recommended
136
Usual recovery time of exacerbation
4-6 weeks
137
Most frequent confounders in patients with COPD in exacerbation
Pneumonia
Pulmonary embolism
Heart failure
Less Frequent:
Pneumothorax
Pleural effusion
Myocardial infarction and/or cardiac arrhythmias
138
What classifies patient as Severe ECOPD
Worsening acidosis
pH <7.35, pCO2 >45 mmHg
139
Potential indications for possible Hospital Assessment
Severe symptoms
Acute respiratory failure
Onset of new physical signs
Failure pf an exacerbation to respond to initial medical management
Presence of serious comorbidities
Insufficient home support
140
Management of Severe, Non-life threatening exacerbation
Administer O2
Start Bronchodilators
Consider Oral Corticosteroids
Consider Oral antibiotics if with signs of bacterial infection
Consider NIV
**At all times**
Monitor fluid balance
Consider subcutaneous heparin or LMW heparin for VTE prophylaxis
Identify and treat conditions
141
Long-term prognosis following hospitalization for COPD exacerbation is poor, with a five-year mortality rate of about __-
50%
142
Recommended dose of Oral Corticosteroids in Acute Exacerbation
Prednisone 40 mg OD x 5 days
143
Indications for ICU admission during Acute exacerbation
1. Severe dyspnea that responds **inadequately** to initial emergency therapy
2. Changes in mental status
3. Persistent or worsening **hypoxemia** (paO2 <40) and/or severe **respiratory acidosis** (pH <7.2) despite O2 and NIV
4. Need for NIV
5. Need for Vasopressors
144
Indications for NIV in acute exacerbation
At least **ONE**
1. Respiratory acidosis (pH ≤7.35, pCO2 ≥45)
2. Severe dyspnea with clinical signs suggestive of respiratory muscle fatigue, increased work of breathing, use of accessory muscles of breathing, paradoxical motion of the abdomen, retraction of intercostal space
3. Persistent hypoxemia despite Oxygen therapy
145
Indications for IMV in acute exacerbation
1. Unable to tolerate NIV or NIV failure
2. S/P respiratory or cardiac arrest
3. Diminished consciousness, psychomotor agitation, inadequately controlled by sedation
4. Massive aspiration or Persistent vomiting
5. Persistent inability to remove respiratory secretions
6. Severe hemodynamic instability without response to fluids or vasoactive drugs
7. Severe Ventricular or Supraventricular arrhythmias
8. Life-threatening hypoxemia in patients unable to tolerate NIV
146
After admission from ECOPD, when will you repeat spirometry?
12-16 weeks follow up
recheck FEV1
147
Recommended lung CA screening in people with COPD due to smoking
Annual low-dose Chest CT scan
148
Treatment with _____ improves heart failure in COPD patients
Beta 1-blocker
149
COPD with Ischemic heart disease
Treatment of IHD should be according to guidelines irrespective of the presence of COPD
150
Arrhythmia usually associated with COPD that is associated with lower FEV1
Atrial fibrillation
151
Most frequently occurring comorbidity of COPD
Hypertension
152
Risk factors for developing **Lung Cancer**
Age >55
>30 pack year smoker
(+) Emphysema on CT scan
FEV1/FVC <0.7
BMI <25
Family history of Lung CA
153
Independent Risk factor for exacerbation of COPD
GERD
154
___ is responsible for ~50% of the **attributable risk** for COPD in low and middle income countries
Air pollution
