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Lecture 5: COPD Flashcards

1
Q

What are the two pathophysiologic categories of COPD?

A
  1. Chronic bronchitis
  2. Emphysema
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2
Q

What symptoms are characteristic of COPD?

A
  • Dyspnea
  • Cough
  • Sputum production
  • Airflow obstruction
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3
Q

How common is COPD?

A
  • > 10 million in the US
  • > 120k deaths annually
  • 4th leading cause of death

High burden due to high resource utilization

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4
Q

What are the key physiologic markers of COPD?

A
  • Airflow obstruction
  • Extensive airway destruction
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5
Q

What disease is characterized primarily by alveolar destruction in COPD?

A

Emphysema

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6
Q

What disease is characterized by increased sputum production and obstruction of more central airways in COPD?

A

Chronic bronchitis

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7
Q

What is a blue bloater usually describing?

A

Obese male that is constantly coughing.

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8
Q

What does a classic emphysema patient look like?

A
  • Barrel chest
  • Older and thinner
  • Hyperinflated diaphragm with flattened diaphragms.
  • Quiet chest
  • Severe dyspnea
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9
Q

What is the clinical diagnosis criteria for chronic bronchitis?

A
  • Daily productive cough > 3+ months
  • Must be in at least 2 consecutive years
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10
Q

What is the diagnostic criteria for emphysema?

A

Permanent enlargement and destruction of airspaces distal to terminal bronchioles.

Does not require a CXR, but CXR will be noticeably abnormal.

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11
Q

How does mild COPD often present on PE?

A
  • Usually normal
  • Maybe prolonged expiration or faint-end expiratory wheeze with forced expiration.
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12
Q

How does moderate/severe COPD typically present on PE?

A
  • Lung hyperinflation (via percussion)
  • Decreased breath sounds, wheezes (bilateral)
  • Crackles at lung bases (bilateral)
  • Distant heart sounds
  • Increased AP diameter (closer to 1:1)
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13
Q

How do end-stage COPD patients typically present?

A
  • Tripodding + calloused elbows
  • Accessory muscle use
  • Pursed lips
  • Hoover’s sign (lower intercostal space retraction during inspiration)
  • Cyanosis
  • Nail clubbing (rare)
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14
Q

What are the abnormal PE findings most characteristic of chronic bronchitis?

A
  • Coarse rhonchi/wheezing
  • Hepatomegaly
  • Increased JVP
  • Peripheral edema

Suggestive of R-sided HF

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15
Q

What are the abnormal PE findings most characteristic of emphysema?

A
  • Expiration with pursed lips
  • Hyperresonant percussion
  • Wheezing, rales
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16
Q

Who gets screened for COPD?

A
  • 1 of the 3 cardinal symptoms.
  • OR
  • Gradual decline in activities with risk factors for COPD.
  • CAPTURE questionnaire. (2-4 = clinically significant)

Cardinal symptoms:
Dyspnea
Sputum volume
Sputum production

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17
Q

What does COPD look like on spirometry in regards to BD administration?

A

COPD is defined by irreversible or partially reversible but limited airflow.

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18
Q

What labs/diagnostics are recommended in a patient with COPD?

A
  • Pulse ox every visit
  • CBC, BMP (or CMP), TSH, BNP/NT-proBNP, serum alpha-1-antitrypsin
  • CXR (not required to diagnose COPD)
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19
Q

What PFT findings suggest obstructive disease?

A
  • FVC > 80%
  • FEV1/FVC < 0.7
  • OR
  • FVC < 80% with TLC > 80%

AKA they either breath out very slowly or they cant breath out a lot in general even though their lung capacity is fine overall.

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20
Q

When should DLco be considered in PFT testing?

A
  • Severe FEV1
  • Resting O2 <= 92%
  • Exertional hypoxemia < 90% on 6MWT
  • Severe dyspnea (mMRC >= 2)

Mainly to assess severity of emphysema.

Lower DLco decreases in proportion to severity of disease

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21
Q

What are ABGs specifically used for?

A
  1. Determining pH levels
  2. Determining metabolic vs respiratory acidosis/alkalosis
  3. Determining compensation for above
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22
Q

In COPD, what generally becomes elevated in ABGs the worse the COPD?

A

pCO2 should increase.

Worsening pO2.

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23
Q

What does negative base excess suggest on ABG? Positive?

A
  • Negative = metabolic acidosis
  • Positive = metabolic alkalosis
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24
Q

When is a CXR indicated for COPD workup?

A
  • Dyspnea/cough etiology unknown
  • R/o complicating process during acute exacerbations
  • Comorbidity evaluation
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25
What is characteristic of emphysema on CXR?
* Hyperinflation * Flattened diaphragm * Increased retrosternal air space * Long, narrow heart shadow
26
How is COPD staged?
Global initiative for COPD (GOLD)
27
What is GOLD severity determined by and how many stages are there?
* Gold 1: Mild with FEV1 >= 80% * Gold 2: Moderate with FEV1 50-80% * Gold 3: Severe with FEV1 30-50% * Gold 4: Very severe with FEV1 < 30% | Requires spirometry
28
What are the two ways to assess symptoms for COPD staging?
* mMRC: severity of breathlessness (0-4) * CAT: assess multitude of symptoms present (0-40)
29
What are the GOLD ABE Assessment protocol steps?
1. Spirometrically confirmed COPD 2. GOLD assessment of obstruction 3. Exacerbation history per year 4. Assessment of symptoms/risk of exacerbations ## Footnote Example: CAT of 22 with 1 moderate exacerbation without hospitalization is B.
30
# Stage this patient FEV1 60%, ➔ 1 exacerbation ➔ No hospitalizations ➔ mMRC 2
GOLD 2B
31
# Stage this patient FEV1 45%, ➔ 3 exacerbation ➔ No hospitalizations ➔ CAT 13
GOLD 3E
32
What are the primary goals of managing COPD?
* Improving symptoms * Decreased number of exacerbations * Improve quality of life and functioning
33
What pharmacological support is available for smoking cessation?
* NRT * Bupropion (caution in eating disorders/seizure disorder) * Varenicline (Chantix)
34
What is the role of oxygen in COPD management?
* Good in patients with severe, chronic, resting arterial hypoxemia. * Careful with potential oxygen trapping in acute exacerbations.
35
In what classes of COPD is pulmonary rehabilitation indicated for?
Class B and E.
36
What does pulmonary rehab consist of?
* Exercise training * Promotion of healthy behaviors * Psychological support
37
What are the SABAs and their SEs?
* Albuterol and Levalbuterol. * Tachycardia, tremor, cardiac arrhythmias | Rescue inhaler
38
What is the SAMA and its SEs?
* Ipratropium bromide * Dry mouth/eyes, metallic taste, and prostatic symptoms.
39
What are the LABAs and their frequency of use?
* Arformeterol (NEB only, QD/BID) * Salmeterol (BID) * Formeterol (BID)
40
What are the LAMAs and their frequency of use?
* Tiotropium (Spiriva, QD) * Umeclinidium (Incruse ellipta, QD) * Revefenacin (Yupelri Neb, QD) * Aclinidium (Tudroza Pressair, BID) * Glycopyrrolate (Seebri Neohaler, BID)
41
What is the pharmacologic recommendation for Group A COPD? B? E?
* A: single BD * B: LABA + LAMA * E: LABA + LAMA (can add ICS if eosinophil > 300)
42
For followup of dyspnea, what should be the first step if the current medication regimen is not working?
Switch to a different inhaler combo.
43
What eosinophil count contraindicates ICS use in COPD?
Once it goes < 100, d/c ICS and use roflumilast or azithromycin.
44
When is ICS removal indicated in COPD?
* Pneumonia * Inappropriately added * Lack of response * Can attempt trial descalation if tolerating well.
45
What is roflumilast's MOA and drug class?
PDE-4 inhibitor to reduce inflammation and pulmonary remodeling. | Reduces exacerbations in severe COPD.
46
Who is roflumilast contraindicated in?
* Psychiatric patients
47
What is theophylline's drug class and MOA?
* Drug class: non-specific phosphodiesterase inhibitor * MOA: relaxes smooth muscle, which increases diaphragm contraction force. | Indicated in refractory COPD
48
What is the main concern regarding theophylline use?
Toxicity and hepatic impairment.
49
How often is COPD management/follow up?
* 1-3 months after initiating therapy. * 3-6 months once stabilized * Annual spirometry at minimum.
50
What is the concern with untreated COPD exacerbation?
Development of PNA
51
What historical findings characterize a COPD exacerbation?
* Worsening of symptoms over hours-days * More rapid course of symptoms and increased respiratory compromise. * Increased mucus production * Hemoptysis
52
What PE findings might suggest acute COPD exacerbation?
* Wheezing and tachypnea * Respiratory compromise * Abnormal breathing * Decreased mental status
53
What aspects of acute COPD exacerbation require changes in patient management?
* Severe symptoms * Acute respiratory failure * new PE findings (cyanosis, peripheral edema) * Failure to respond to standard therapy * Serious comorbidities (arrhythmias, CHF) * Insufficient home support
54
What are the treatment options for acute COPD exacerbation management?
* Adjust BD therapy * Spaces/nebs * Oral glucocorticoid (5 days max) * ABX for increased cough, sputum, or purulence. * Non-invasive mechanical ventilation (BiPAP) ## Footnote ABX treatment depends on exposure history.
55
What is the target spO2 level for acute COPD exacerbation patients admitted?
88-92% to prevent O2 trapping. | Do not over oxygenate if spO2 is fine.
56
What would prompt ICU admission for acute COPD exacerbation?
* Severe dyspnea unresponsive to initial treatment. * Mental status changes * Worsening hypoxemia w/ respiratory acidosis unresponsive to therapy. * Invasive ventilation * Hemodynamic instability.
57
What is the purpose of alpha-1 antitrypsin?
Protects the lungs from neutrophil (elastase) damage | Made in the liver, migrates via blood.
58
What are the two pathophysiologic processes of ATT1 deficiency?
* Loss of elastin in alveolar wall and early onset emphysema * Accumulation of ATT in liver, leading to liver damage.
59
How does ATT1 deficiency present?
* Symptoms of chronic liver disease * Young age with emphysema symptoms * Panniculitis: inflammation of SubQ tissue, resulting in hot and painful nodules on the thigh or butt
60
What workup is recommended for suspect ATT1 deficiency?
* Low serum ATT1 * PFT * CXR
61
How is ATT1 managed?
* Same as COPD + possible infusion of donor ATT. * Smoking cessation
62
What is bronchiectasis?
* Irreversible focal or diffuse dilation and destruction of the bronchial walls * Multifactorial etiology, generally inflammation of the airways.
63
How does bronchiectasis present typically?
* Chronic, daily productive cough * Copious, foul-smelling, thick, purulent sputum. * Rales/rhonchi/wheezing on PE. * Increased sputum volume/production in acute exacerbations
64
What are tram tracks and what are they associated with?
* Dilated airways. * Often associated with bronchiectasis.
65
What is a hallmark description of a CT chest for bronchiectasis?
Honeycomb/ballooned presence.
66
What are the most common risk factors associated with OSA?
* Age * Male * Obesity * Smoking * COPD
67
What is the pathophysiology of OSA?
* Recurrent and functional collapse of pharyngeal airflow in sleep. * Reduced airflow = fragmented sleep and gas exchange disturbances.
68
What is the workup for OSA?
* Sleep apnea questionnaires (Berlin or STOP-BANG) * In-lab polysomnography (FIRST LINE) * Home sleep apnea test * Overnight oximetry
69
What is the diagnostic criteria for OSA?
* 5+ obstructive respiratory events per hour of sleep + somnolence/snoring/gasping/HTN/CAD/CVA * 15+ obstructive respiratory events per hour of sleep. | Either criteria
70
What are the primary treatments for OSA?
* Weight loss * CPAP or APAP (mainstay) * Oral appliances * Upper airway surgery * Hypoglossal nerve stimulationo

Pulm (12 decks)

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