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43 Cards in this Set
- Front
- Back
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Q1 |
WOF are identified systemic consequences of COPD Skeletal muscle weakness in early COPD Diastolic cardiac dysfunction Osteoporosis GORD Cognitive impairment
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What is the defining feature of COPD |
The defining feature of COPD is irreversible airflow limitation during forced expiration. This may result from a loss of elastic recoil due to lung tissue destruction or from an increase in the resistance of the conducting airways. |
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What is COPD |
Patients typically have symptoms of chronic bronchitis and emphysema, but the classic triad also includes asthma or a combination of the above (see the image below). Chronic obstructive lung disease is a disorder in which subsets of patients may have dominant features of chronic bronchitis, emphysema, or asthma. The result is airflow obstruction that is not fully reversible. |
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What is chronic bronchitis |
Chronic bronchitis is defined clinically as the presence of a chronic productive cough for 3 months during each of 2 consecutive years (other causes of cough being excluded). |
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What is emphysema |
Emphysema is defined pathologically as an abnormal, permanent enlargement of the air spaces distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis. |
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What are the clinical features of COPD |
Patients typically present with a combination of signs and symptoms of chronic bronchitis, emphysema, and reactive airway disease. Symptoms include the following: • Cough, usually worse in the mornings and productive of a small amount of colorless sputum • Breathlessness: The most significant symptom, but usually does not occur until the sixth decade of life • Wheezing: May occur in some patients, particularly during exertion and exacerbations |
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What makes it easy to diagnose with the time |
While the sensitivity of physical examination in detecting mild-to-moderate COPD is relatively poor, the physical signs are quite specific and sensitive for severe disease. Findings in severe disease include the following :•Tachypnea and respiratory distress with simple activities •Use of accessory respiratory muscles and paradoxical indrawing of lower intercostal spaces (Hoover sign) •Cyanosis •Elevated jugular venous pulse (JVP) •Peripheral edema
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What are the signs that can be seen on thoracic examination |
• Hyperinflation (barrel chest) • Wheezing – Frequently heard on forced and unforced expiration • Diffusely decreased breath sounds • Hyperresonance on percussion • Prolonged expiration • Coarse crackles beginning with inspiration in some cases |
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What are characteristics of chronic bronchitis |
•Patients may be obese •Frequent cough and expectoration are typical •Use of accessory muscles of respiration is common •Coarse rhonchi and wheezing may be heard on auscultation •Patients may have signs of right heart failure (ie, cor pulmonale), such as edema and cyanosis
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What are the characteristics of emphysema |
•Patients may be very thin with a barrel chest•Patients typically have little or no cough or expectoration•Breathing may be assisted by pursed lips and use of accessory respiratory muscles; patients may adopt the tripod sitting position•The chest may be hyperresonant, and wheezing may be heard•Heart sounds are very distant
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What is the office test done to detect COPD |
The formal diagnosis of COPD is made with spirometry; when the ratio of forced expiratory volume in 1 second over forced vital capacity (FEV1/FVC) is less than 70% of that predicted for a matched control, it is diagnostic for a significant obstructive defect. |
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What are the stages of COPD according to spirometry findings |
Criteria for assessing the severity of airflow obstruction (based on the percent predicted postbronchodilator FEV1) are as follows: • Stage I (mild): FEV1 80% or greater of predicted • Stage II (moderate): FEV1 50-79% of predicted • Stage III (severe): FEV1 30-49% of predicted • Stage IV (very severe): FEV1 less than 30% of predicted or FEV1 less than 50% and chronic respiratory failure |
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How are ABG findings used to determine the severity of disease |
• ABGs provide the best clues as to acuteness and severity of disease exacerbation • Patients with mild COPD have mild to moderate hypoxemia without hypercapnia • As the disease progresses, hypoxemia worsens and hypercapnia may develop, with the latter commonly being observed as the FEV1 falls below 1 L/s or 30% of the predicted value • pH usually is near normal; a pH below 7.3 generally indicates acute respiratory compromise • Chronic respiratory acidosis leads to compensatory metabolic alkalosis |
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Q2 |
WOf rx strategies would prolong the life of a 65 yr old man with COPD Smoking cessation Long term o2 thrrapy Inhaled steroid therapy Inhaled bronchodilator therapy Oral steroid therapy
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What are the risk factors for mortality in patients with COPD |
patients with moderate-to-severe COPD, In addition to smoking, pulmonary hypertension, and declining lung function (known risk factors for mortality in patients with COPD), bronchiectasis (which is common in patients with moderate-to-severe COPD) is independently associated with increased risk of all-cause mortality.In this study, those who had bronchiectasis were found to be 2.5 times more likely to die than those who did not. Bronchiectasis remained an independent factor. |
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What are the risk factors for mortality with COPD |
Presence of Smoking Pulmonary HTN Declining lung function Bronchiectasis The presence of systemic manifestations Anaemia Osteoporosis Depression Reduced muscle function Reduced fat free mass Pulmonary hypertension Co- pulmonale Heart failure
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What is the significance of systemic manifestations |
With disease progression, intervals between acute exacerbations become shorter, and each exacerbation may be more severe. The rate of COPD exacerbations appears to reflect an independent susceptibility phenotype.COPD is now known to be a disease with systemic manifestations, and the quantification of these manifestations has proved to be a better predictor of mortality than lung function alone. Many patients with COPD may have decreased fat-free mass, impaired systemic muscle function osteoporosis anemia depression pulmonary hypertension, cor pulmonale, and even left-sided heart failure. Depression is not uncommon in subjects with COPD. In a study by Spitzer et al in Germany, airflow limitation as measured by spirometry was significantly more common in adults with posttraumatic stress disorder than in controls. Results were adjusted for lifestyle, clinical, and sociodemographic factors.
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What are the treatment options in COPD depending on it's severity |
Smoking cessation continues to be the most important therapeutic intervention for COPD. Risk factor reduction (eg, influenza vaccine) is appropriate for all stages of COPD. Approaches to management by stage include the following:•Stage I (mild obstruction): Short-acting bronchodilator as needed•Stage II (moderate obstruction): Short-acting bronchodilator as needed; long-acting bronchodilator(s); cardiopulmonary rehabilitation•Stage III (severe obstruction): Short-acting bronchodilator as needed; long-acting bronchodilator(s); cardiopulmonary rehabilitation; inhaled glucocorticoids if repeated exacerbations•Stage IV (very severe obstruction or moderate obstruction with evidence of chronic respiratory failure): Short-acting bronchodilator as needed; long-acting bronchodilator(s); cardiopulmonary rehabilitation; inhaled glucocorticoids if repeated exacerbation; long-term oxygen therapy (if criteria met); consider surgical options such as lung volume reduction surgery (LVRS) and lung transplantation
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COPD Exacerbations management guidelines |
•A COPD exacerbation is defined as acute respiratory symptom worsening with the need for additional therapy. Several factors can lead to an exacerbation, the most common being respiratory tract infections. •The recommended initial bronchodilators to treat an exacerbation are short-acting beta2-agonists, with or without short-acting anticholinergics. •As soon as possible before hospital discharge, initiate maintenance therapy with a long-acting bronchodilator. •Systemic corticosteroids can improve lung function and oxygenation. They also shorten recovery time and hospital duration. The duration of systemic corticosteroid therapy should not exceed 5-7 days. •If indicated, antibiotic therapy can shorten recovery time, reduce the risk of early relapse and treatment failure, and reduce hospitalization duration. The duration of antibiotic therapy should not exceed 5-7 days. •Owing to increased adverse effect profiles, methylxanthines are not recommended. •The first mode of ventilation used in COPD with acute respiratory failure and without contraindications is noninvasive mechanical ventilation. It improves gas exchange, reduces the work of breathing, decreases the need for intubation, decreases hospitalization duration, and improves survival.
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COPD Exacerbations management guidelines |
•A COPD exacerbation is defined as acute respiratory symptom worsening with the need for additional therapy. Several factors can lead to an exacerbation, the most common being respiratory tract infections. •The recommended initial bronchodilators to treat an exacerbation are short-acting beta2-agonists, with or without short-acting anticholinergics. •As soon as possible before hospital discharge, initiate maintenance therapy with a long-acting bronchodilator. •Systemic corticosteroids can improve lung function and oxygenation. They also shorten recovery time and hospital duration. The duration of systemic corticosteroid therapy should not exceed 5-7 days. •If indicated, antibiotic therapy can shorten recovery time, reduce the risk of early relapse and treatment failure, and reduce hospitalization duration. The duration of antibiotic therapy should not exceed 5-7 days. •Owing to increased adverse effect profiles, methylxanthines are not recommended. •The first mode of ventilation used in COPD with acute respiratory failure and without contraindications is noninvasive mechanical ventilation. It improves gas exchange, reduces the work of breathing, decreases the need for intubation, decreases hospitalization duration, and improves survival.
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COPD and comorbidity recommendations |
•Treat COPD comorbidities with the usual standard of care, regardless of the presence of COPD. COPD treatment should not be altered by the presence of comorbidities.•Lung cancer is a common comorbidity with COPD and is a main cause of mortality.•Cardiovascular disease is an important frequent COPD comorbidity, as are osteoporosis and anxiety/depression. The latter two are underdiagnosed and associated with poor health status and prognosis.•Gastroesophageal reflux disease can increase the risk of exacerbations and poor health status.•Simplicity of treatment and minimization of polypharmacy are emphasized in a multimorbidity and COPD treatment plan.
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Diagnosis and initial assessment |
•COPD should be considered in any patient with dyspnea, chronic cough or sputum production, and/or a history of exposure to risk factors .•Spirometry is required to make the diagnosis; a postbronchodilator FEV 1/FVC ratio of less than 0.70 confirms the presence of persistent airflow limitation. •COPD assessment goals are to determine the level of airflow limitation, the impact of disease on the patient’s health status, and the risk of future events (eg, exacerbations, hospital admissions, death) to guide therapy .•Concomitant chronic diseases occur frequently in COPD patients and should be treated because they can independently affect mortality and hospitalizations .•Prevention and maintenance therapy recommendations are as follows: •Smoking cessation is key. Pharmacotherapy and nicotine replacement increase long-term smoking abstinence rates, as do legislative bans on smoking. The effectiveness and safety of e-cigarettes as a smoking cessation aid is uncertain. •Pharmacologic therapy can reduce the symptoms of COPD, can reduce the severity and frequency of exacerbations, and can improve exercise tolerance and health status. •Pharmacologic treatment regimens should be individualized. They should be guided by symptom severity; exacerbation risk; adverse effects; comorbidities; drug availability and cost; and patient response, preference, and ability to utilize the various drug delivery devices. •Inhaler technique should be assessed regularly. •Pneumococcal and influenza vaccinations decrease the incidence of lower respiratory tract infections. •Pulmonary rehabilitation improves symptoms, physical and emotional participation in everyday activities, and quality of life. •Patients with severe resting chronic hypoxemia have improved survival with long-term oxygen therapy.•In patients with stable COPD and resting or exercise-induced moderate desaturation, routine long-term oxygen treatment is not recommended; however, consider individual patient factors regarding the need for supplemental oxygen.•With severe chronic hypercapnia and a history of hospitalization for acute respiratory failure, long-term noninvasive ventilation may prevent rehospitalization and decrease mortality.•Select patients with advanced emphysema refractory to optimized medical care may benefit from surgical or bronchoscopic interventional treatments.•In advanced COPD, palliative approaches are effective in controlling symptoms.
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Q |
Mx of acute exacerbation of COPDABG is a mustTarget saturation is 88-92%High concentrate oxygen should be usedType 2 respiratory failure with PCO2 >6kPa and pH less than 7.35 is an indication for NIVdetail hx on premorbid personality is inidicated
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Acute management of COPD steps |
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What is respiratory failure |
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What are the types of respiratory failure |
Type 1 Type 2 |
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What is the type of respiratory failure seen in COPD |
A |
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How do you manage acute exacerbations of COPD |
Prehospital CareThe mainstays of therapy for acute exacerbations of chronic obstructive pulmonary disease (COPD) are oxygen, bronchodilators definitive airway management. .Supply the patient with enough oxygen to maintain a near normal saturation (above 90%) and do not be concerned about oxygen supplementation leading to clinical deterioration. If the patient's condition is that tenuous, intubation most likely anyway. .If necessary and available, continuous positive airway pressure (CPAP) may be used
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What is the place of O2 in managing acute exacerbations |
OxygenAdequate oxygen should be given to relieve hypoxia. A belief (ingrained from medical school) is held widely that too much oxygen causes significant respiratory depression. Multiple studies in the literature dispute this view. With administration of oxygen, PO2 and PCO2rise but not in proportion to the very minor changes in respiratory drive. However, a prehospital study of patients with acute exacerbations of chronic obstructive pulmonary disease by Austin et al documented lower morbidity and mortality with titrated versus standard high-flow oxygen treatment. In a cluster randomized controlled parallel group trial in 405 patients, titrated oxygen treatment significantly reduced mortality, hypercapnia, and respiratory acidosis. [6] |
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What are the indications for intubation |
The need for intubation can be established quickly at the bedside by asking the patient to hold the nebulizer in his or her hand. If the patient becomes so sleepy that the nebulizer starts to fall away, consider intubation regardless of PCO2 level. The cause of increased CO2production is not decreased respiratory drive but probably reversal of hypoxic arterial vasoconstriction in areas of less-ventilated lung tissue, which increases the extent of ventilation/perfusion defects and thus CO2. "Stated another way, there is probably no single value for arterial PCO2, pH, or PO2 that by itself constitutes an indication for [intermittent positive pressure ventilation (IPPV)]." Occasionally, large increases in CO2 can lead to deterioration of mental status, causing stupor and obtundation. In such cases, decreasing O2 delivery is the wrong action. The CO2 narcosis inhibits respiratory drive to the point that decreasing O2 delivery leads only to worsening of hypoxia. The correct action is immediate intubation and oxygenation Of course, in times of respiratory failure, patients may need intubation in the field. |
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Bronchodilators |
BronchodilatorIn the prehospital setting, administer short-acting beta-agonist nebulizer therapy, which should be given as needed. In addition, short-acting anticholinergics, such as ipratropium, can be given |
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Emergency Department care |
In addition to oxygen, proper ED care may comprise bronchodilators, antibiotics, magnesium, CPAP or biphasic positive airway pressure (BiPAP), Heliox (ie, mixture of helium and oxygen), and definitive airway management via intubatiqon. All of these should be considered in the context of the individual patient's condition. .ConsultationsConsult a pulmonologist.Medical Care |
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What are the pitfalls in bronchodilator treatment |
Not all chronic obstructive pulmonary disease (COPD) exacerbations have a reversible (bronchospastic) component to their process, but predicting which ones will and which ones will not is an exercise in futility. Some evidence even shows that the amount of bronchospasm and response to bronchodilators may vary with the same patient from exacerbation to exacerbation |
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What is the contraindication for BiPAP |
Keep in mind that altered level of consciousness is a contraindication for BiPAP, so carefully examine patients to determine appropriateness of its use. |
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How do CPAP and BIPAP work on a patient with COPD |
Continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP) These devices help to decrease the work of breathing and maintain positive end-expiratory pressure (PEEP). In patients with chronic obstructive pulmonary disease (COPD) who are in extremis, CPAP or BiPAP may be attempted prior to intubation. This can be started in the ED and continued for several hours in the hospital. Usual recommended settings are an inspiratory positive airway pressure (IPAP) of 10 cm water and an expiratory positive airway pressure (EPAP) of 2 cm water, with further adjustments based on the individual. This is contingent on the patient's ability to withstand the mask. This treatment is not a substitute for intubation; rather, it is a means of trying to avoid intubation. Keep in mind that altered level of consciousness is a contraindication for BiPAP, so carefully examine patients to determine appropriateness of its use. |
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What are the strategies that can be attempted prior to intubation |
CPAP BIPAP HELIOX |
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What is the place of Heliox in copd |
Heliox is an additional strategy that can be attempted prior to intubation. Whether Heliox or CPAP is used will depend on the individual patient and local hospital availability. Again, like several other therapies mentioned in this article, study results both for and against Heliox have been published. The current summation of that literature indicates that Heliox may actually decrease the work of breathing while the patient is breathing the mixture, but its effects are not long lasting once it is removed. The proper mixture of the gases and the ability to deliver enough oxygen to the patient are also issues |
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What are the other treatment options |
Inhaled nitric oxide has been suggested, but at this point does not seem to have a role in acute treatment. Lung volume reduction surgery has also been touted as effective, but most recent studies demonstrate varying levels of success. |
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How can you prevent exacerbations |
For the vast majority of patients, cessation of smoking is the only true means of prevention |
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How is the long-term monitoring carried out |
Disposition from the ED depends on the clinical picture for each patient more than any single laboratory value or test. In general, the longer the exacerbation, the more airway edema and debris are present, making resolution in the ED increasingly more difficult. Patients who state that they "feel back to normal" and have no overt reason for admission can reasonably be discharged home with follow-up arrangements. The corollary to this is that patients who state they "do not feel comfortable," regardless of the numbers, are the best predictors of outcome and probably should be admitted. Data on risk factors for relapse and need for admission are limited at present.For patients who are sent home, nearly all should receive a short steroid burst and an increase in the frequency of inhaler therapy. Close follow-up should be arranged with the patient's regular care provider. Other therapies should be considered on a case-by-case basis.Patients with severe or unstable disease should be seen monthly.When their condition is stable, patients may be seen biannually .Check theophylline level with each dose adjustment, then every 6-12 months.For patients on home oxygen, check ABGs yearly or with any change in condition. Monitor oxygen saturation more frequently than ABGs. Guidelines |
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Guidelines |
GOLD general clinical practice guidelinesThe 2018 the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines on COPD are summarized. [8, 9]Diagnosis and initial assessment recommendations are as follows:COPD should be considered in any patient with dyspnea, chronic cough or sputum production, and/or a history of exposure to risk factors.Spirometry is required to make the diagnosis; a postbronchodilator FEV 1/FVC ratio of less than 0.70 confirms the presence of persistent airflow limitation.COPD assessment goals are to determine the level of airflow limitation, the impact of disease on the patient’s health status, and the risk of future events (eg, exacerbations, hospital admissions, death) to guide therapy.Concomitant chronic diseases occur frequently in COPD patients and should be treated because they can independently affect mortality and hospitalizations.Prevention and maintenance therapy recommendations are as follows:Smoking cessation is key. Pharmacotherapy and nicotine replacement increase long-term smoking abstinence rates, as do legislative bans on smoking. The effectiveness and safety of e-cigarettes as a smoking cessation aid is uncertain.Pharmacologic therapy can reduce the symptoms of COPD, can reduce the severity and frequency of exacerbations, and can improve exercise tolerance and health status.Pharmacologic treatment regimens should be individualized. They should be guided by symptom severity; exacerbation risk; adverse effects; comorbidities; drug availability and cost; and patient response, preference, and ability to utilize the various drug delivery devices.Inhaler technique should be assessed regularly.Pneumococcal and influenza vaccinations decrease the incidence of lower respiratory tract infections.Pulmonary rehabilitation improves symptoms, physical and emotional participation in everyday activities, and quality of life.Patients with severe resting chronic hypoxemia have improved survival with long-term oxygen therapy.In patients with stable COPD and resting or exercise-induced moderate desaturation, routine long-term oxygen treatment is not recommended; however, consider individual patient factors regarding the need for supplemental oxygen.With severe chronic hypercapnia and a history of hospitalization for acute respiratory failure, long-term noninvasive ventilation may prevent rehospitalization and decrease mortality.Select patients with advanced emphysema refractory to optimized medical care may benefit from surgical or bronchoscopic interventional treatments.In advanced COPD, palliative approaches are effective in controlling symptoms.Stable COPD recommendations are as follows:In stable COPD, base the management strategy on an individualized assessment of the symptoms and risk of exacerbations.Strongly urge smoking cessation in patients who smoke.Treatment goals are symptom reduction and reduction in future exacerbations. Pharmacologic treatments should be complemented by nonpharmacologic interventions.Exacerbation recommendations are as follows:A COPD exacerbation is defined as acute respiratory symptom worsening with the need for additional therapy. Several factors can lead to an exacerbation, the most common being respiratory tract infections.The recommended initial bronchodilators to treat an exacerbation are short-acting beta2-agonists, with or without short-acting anticholinergics.As soon as possible before hospital discharge, initiate maintenance therapy with a long-acting bronchodilator.Systemic corticosteroids can improve lung function and oxygenation. They also shorten recovery time and hospital duration. The duration of systemic corticosteroid therapy should not exceed 5-7 days.If indicated, antibiotic therapy can shorten recovery time, reduce the risk of early relapse and treatment failure, and reduce hospitalization duration. The duration of antibiotic therapy should not exceed 5-7 days.Owing to increased adverse effect profiles, methylxanthines are not recommended.The first mode of ventilation used in COPD with acute respiratory failure and without contraindications is noninvasive mechanical ventilation. It improves gas exchange, reduces the work of breathing, decreases the need for intubation, decreases hospitalization duration, and improves survival.COPD and comorbidity recommendations are as follows:Treat COPD comorbidities with the usual standard of care, regardless of the presence of COPD. COPD treatment should not be altered by the presence of comorbidities.Lung cancer is a common comorbidity with COPD and is a main cause of mortality.Cardiovascular disease is an important frequent COPD comorbidity, as are osteoporosis and anxiety/depression. The latter two are underdiagnosed and associated with poor health status and prognosis.Gastroesophageal reflux disease can increase the risk of exacerbations and poor health status.Simplicity of treatment and minimization of polypharmacy are emphasized in a multimorbidity and COPD treatment plan.GOLD classificationIn the 2016 update of the GOLD guidelines, a rubric is used that assesses symptoms, breathlessness, spirometric classification, and risk of exacerbations to classify patients according to the following groups [10] :Group A (low risk/less symptoms): Stage I or II, 1 or fewer exacerbation per year no hospitalization, modified Medical Research Council (mMRC) 0-1 or COPD Assessment Test (CAT) less than 10Group B (low risk/more symptoms): Stage I or II, 1 or fewer exacerbation per year no hospitalization, mMRC 2 or higher or CAT 10 or higherGroup C (high risk/less symptoms): Stage III or IV, 2 or more per year 1 or more exacerbation with hospitalization, mMRC 0-1 or CAT less than 10Group D (high risk/more symptoms): Stage III or IV, 2 or more per year 1 or more exacerbation with hospitalization, mMRC 2 or higher or CAT 10 or higherGOLD patient groupingThe GOLD patient group-based management recommendations include the following [10] :Group A-D: Reduction of risk factors (influenza and pneumococcal vaccine); smoking cessation; physical activity; short-acting anticholinergic or short-acting beta-adrenergic agonists as neededGroup B: Long-acting anticholinergics or long-acting beta-adrenergic agonists; cardiopulmonary rehabilitationGroup C: Inhaled corticosteroid and long-acting beta-adrenergic agonists or long-acting anticholinergics; cardiopulmonary rehabilitationGroup D: Inhaled corticosteroid and long-acting beta-adrenergic agonists and/or long-acting anticholinergics; cardiopulmonary rehabilitation; long-term oxygen therapy (if criteria met); consider surgical options such as lung volume reduction surgery |
