Tutorial 2: COPD

Question 1

What are the subtypes of COPD?

Answer 1

emphysema, chronic bronchitis, and chronic obstructive asthma

Question 2

How does GOLD define COPD?

Answer 2

characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases

Question 3

What is chronic bronchitis?

Answer 3

chronic productive cough for three months in each of two successive years

(in a patient in whom other causes of chronic cough (eg, bronchiectasis) have been excluded )

Question 4

What is emphysema?

Answer 4

abnormal and permanent enlargement of the airspaces distal to the terminal bronchioles

accompanied by destruction of the airspace walls, without obvious fibrosis (ie, there is no fibrosis visible to the naked eye)

Question 5

What is Asthma?

Answer 5

chronic inflammatory disorder of the airways

associated with airway responsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing

Question 6

If a pt with asthma has airway obstruction that is not completely reversible, what disease do they have?

Answer 6

COPD

Question 7

What is asthma-COPD overlap?

Answer 7

“characterized by persistent airflow limitation with several features usually associated with asthma and several features usually associated with COPD”

(consensus statement from international societies on each)

Question 8

What changes are seen in pulmonary vasculature in COPD pathology?

Answer 8

• intimal hyperplasia and smooth muscle hypertrophy/hyperplasia thought to be due to chronic hypoxic vasoconstriction of the small pulmonary arteries
• loss of capillaries/distal vasculature due to destruction of alveoli

Question 9

What categories of emphysema are there (pathology)?

Answer 9

Proximal acinar
Panacinar
Distal acinar (aka paraseptal)

Question 10

What is the most common association with proximal acinar emphysema?

Answer 10

commonly associated with cigarette smoking, but can also be seen in coal workers’ pneumoconiosis

Question 11

What changes are seen in proximal acinar emphysema?

Answer 11

abnormal dilation or destruction of the respiratory bronchiole, the central portion of the acinus

Question 12

What is the most common association with panacinar emphysema?

Answer 12

alpha-1 antitrypsin deficiency

Can also be seen with proximal emphysema in smokers.

Question 13

What is the most common association with distal acinar emphysema?

Answer 13

When occurring alone: spontaneous pneumothorax in a young adult

Question 14

What airway abnormalities are seen on pathology in COPD?

Answer 14

• chronic inflammation
• increased numbers of goblet cells
• mucus gland hyperplasia
• fibrosis
• narrowing and reduction in the number of small airways
• and airway collapse due to the loss of tethering caused by alveolar wall destruction in emphysema

Question 15

What is the most important risk factor for COPD?

Answer 15

Cigarette smoking

Question 16

Below what pack-year threshold is COPD unlikely?

Answer 16

10-15 pack-years

Question 17

What % of COPD pt never smoked?

Answer 17

20%

Ask about second hand, occupational

Question 18

What are the 3 cardinal Sx of COPD?

Answer 18

dyspnea, chronic cough, sputum production

Question 19

What is the most common early Sx of COPD?

Answer 19

Exertional dyspnea

Question 20

What are the three typical ways pt with COPD present?

Answer 20

• sedentary, with fatigue: Hx elicits exertional dyspnea
• resp sx: dyspnea, cough. Insidious worsening of dsypnea and of sputum
• intermittent episodes of cough, purulent sputum, wheezing, fatigue, dyspnea

Question 21

What is the typical sputum pattern of someone presenting with COPD with sputum production?

Answer 21

• initially, only in morning; may progress to be present through the day
• volume rarely exceeds 60mL
• usually mucoid, but can be purulent during exacerbations

Question 22

What does finger clubbing indicate in COPD?

Answer 22

Not typical: suggests comorbidities such as lung cancer, interstitial lung disease, or bronchiectasis

Question 23

What exam findings present in early COPD?

Answer 23

physical examination may be normal, or may show only prolonged expiration or wheezes on forced exhalation.

Question 24

What exam findings present in progressed COPD?

Answer 24

• hyperinflation (eg, increased resonance to percussion)
• decreased breath sounds
• wheezes
• crackles at the lung bases
• distant heart sounds

Question 25

What additional exam findings present in severe COPD?

Answer 25

- increased anteroposterior diameter of the chest ("barrel-shaped" chest) - depressed diaphragm with limited movement based on chest percussion

Question 26

What additional exam findings present in end-stage COPD?

Answer 26

- positioning to relieve dyspnea - use of accessory muscles - expiration through pursed lips - Hoover's sign

Question 27

What is Hoover's sign and why does it happen?

Answer 27

paradoxical retraction of the lower interspaces during inspiration As diaphragm flattens, pulls horizontally --> pulling in ribs (instead of pulling down lungs)

Question 28

What is the diagnostic test used to diagnose COPD?

Answer 28

postbronchodilator FEV1/FVC < 0.70)

Question 29

What is the GOLD classification of COPD?

Answer 29

GOLD 1 (Class I): Mild Sx. FEV1 ≥ 80% predicted ``` GOLD 2 (Class II): Moderate Sx 50% ≤ FEV1 < 80% (of predicted) ``` ``` GOLD 3 (Class III): Severe Sx. 30% ≤ FEV1 < 50% ``` GOLD 4 (Class IV): Very severe Sx. FEV1 < 30% predicted Mnemonic: For GOLD categories according to the FEV1 %, remember that 30 + 50 = 80.

Question 30

What are the clinical features, PaO2, and PaCO2 of "pink puffers"?

Answer 30

``` Clinical features: Noncyanotic Cachectic Pursed-lip breathing Mild cough ``` PaO2: Slightly reduced PaCO2: Normal (possibly in late hypercapnia)

Question 31

What are the clinical features, PaO2, and PaCO2 of "blue bloaters"?

Answer 31

Clinical features: Productive cough Overweight Peripheral edema PaO2: Markedly reduced PaCO2: Increased (early hypercapnia)

Question 32

What is often different about the presentation of people with alpha1-antitrypsin deficiency?

Answer 32

Age of onset is generally younger (< 60 years) Also often have hepatic signs and symptoms (jaundice) related to hepatitis or cirrhosis