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85 Cards in this Set
- Front
- Back
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This disease is includes emphysema and chronic bronchitis?
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COPD - Chronic Obstructive Pulmonary Disease
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This is an abnormal stretching and destructive changes of the alveoli.
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Emphysema
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Excessive sputum production w/chronic or recurrent cough on most days for a minimum of 3 mo/yr for at least two consecutive years means what?
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Chronic bronchitis
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What is the overwhelming risk factor for COPD?
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Smoking
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If COPD occurs in late 30's-eary 40's it could mean what problem?
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A1-antitrypsin deficiency
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What race and gender has the highest rate of COPD?
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White males
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This affects the lung parenchyma distal to terminal bronchioles, causes destruction of alveolar walls. There is no ventilation-perfusion, mismatch since both alveolar surface and blood vessels are lost.
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Emphysema
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In emphysema, there is an elastase stimulation tha tleads to what?
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Degenerative changes in elastin and alveolar structure
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What is released in emphysema?
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Cytotoxic oxygen radicals
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This is defined by the following eight things:
Smooth muscle hypertrophy Inflammation Mucosal edema Narrowing of airways Goblet and squamous cell metaplasia Mucus plugging of small airways (<2-3mm) Peribronchial fibrosis Progression to larger airways |
Chronic Bronchitis
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The multiple changes associated with chronic bronchitis lead to obstruction of the small airways. What is the next thing that this leads to?
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CO2 retention and hypoxemia
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In chronic bronchitis hypoxemia and acidemia (from respiratory acidosis) lead to what two things?
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Constriction of pulmonary arteries and an increase pulmonary arterial pressure
Pulmonary HTN |
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This occurs in chronic bronchitis (COPD) when the right ventricular enlargement is caused by pulmonary hypertension.
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Core Pulmonale
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What is the smoking habit of people who usually present with chronic bronchitis?
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20 cigarettes a day for 20 years.
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What is the usual age (what decade) that people present with chronic bronchitis?
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50's
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What are the early Sx of chronic bronchitis? (3 of them)
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Chronic cough
Phlegm Wheezing |
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What are the late Sx (10-15yrs) associated with chronic bronchitis?
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Dyspnea on exertion
(indicated 20-30% irreversible lung tissue destruction) |
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This COPD patient will present with the following on Physical Exam:
Chronic bronchitis dominant dz Cyanotic from decreased O2 saturation and being overweight. Pedal edema, JVD, hepatomegaly, prolonged expiration, course ronchi, wheeze. |
Blue Bloater
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This COPD patient will present with the following on physical exam:
Emphysema dominant disease Pursed lip breathing, pink skin color and thin body habitus, barrel chest, dyspnea Prolonged expiration, decreased breath sounds, decreased diaphragmatic excursion. This patient is also seen leaning on their arms "tripoding" |
Pink Puffer
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When making a Dx of COPD via imaging (CXR), what are the two things that are key?
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Blacker areas in the lung spaces
Diaphragm appears to be flattened out |
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What are the three steps to adequate COPD management?
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Reduce risk factors
Manage stable COPD Manage exacerbation |
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What is involved in reducing risk factors for COPD? 2 things
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Reduction of total personal exposure to tobacco smoke, occupational dust and chemicals, and air pollutants.
Smoking cessation is the single most effective and cost effective intervention |
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Brief tobacco dependence Tx is efficient and every tobacco user should be offered this when?
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At every visit
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What are the 5 A's of smoking cessations counseling?
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Ask - systematically identify all tobacco users at every visit
Advise - Strongly urge all tobacco users to quit. Assess - Determinate willingness to make a quit attempt. Assist - Aid the pt in quitting. Arrange - Schedule follow-up contact |
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What are the three types of smoking cessation products available to patients?
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Nicotine: Gum, Inhaler, Transdermal patches, Nasal delivery
Bupropion (Zyban, Wellbutrin) Varenicline (Chantix) - New CNS nicotinic agonist, smoking cessation rates twice that of Zyban |
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What are few risk factors associated with the smoking cessation drug Chantix?
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Behavioral and mood changes, suicide risks are possible.
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In COPD management, what are two things that are a part of managing stable COPD?
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1. Stepwise increase in the Tx, depending on dz severity.
2. Health education improves ability to cope w/illness and health status. |
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None of the drugs for COPD do what?
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Modify the long term decline in lung function.
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COPD drugs (overall) decrease what two things?
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Decrease Symptoms and/or Complications
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What three things are used in managing stable COPD?
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Bronchodilator
Principal Bronchodilator Exercise programs - improves exercise tolerance as well as Sx of dyspnea and fatigue. |
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These are used on a prn basis and they are standing to reduce and prevent Sx in COPD?
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Bronchodilator
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In the Tx of COPD, principal bronchodilators are usually formulations of these two drugs?
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Beta 2 Agonists
Anticholinergics |
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Beta 2 agonists in bronchodilators are effective in treating what areas?
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The muscle tissue around the airways.
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Anticholinergics in bronchodilators are effective in treating what areas?
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Acetylcholine restricts airway, therefore anticholinergics open airway.
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What is the one good thing, and the one bad thing, about using a long acting inhaled bronchodilator for COPD management?
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1. Good - More convenient
2. Bad - Side effects |
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What are the side effects associated with long term bronchodilators?
Two things |
Increased risk of GI bleeds and Osteoporosis.
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What is something to avoid when managing stable COPD?
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Avoid chronic Tx w/systemic steroids (poor benefit to risk ratio)
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What are the stages associated with severity classification of COPD?
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0: At Risk
I: Mild II: Moderate III: Severe IV: Very Severe |
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This stage is normal spirometry, with chronic Sx (cough, sputum)
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O: At risk
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This stage FEV1/FVC is <70%, FEV1 > or equal to 80% predicted with or without Sx (cough, sputum, dyspnea)
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I: Mild
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This is FEV1/FVC <70%; 50% < or equal to FEV1<80% predicted.
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II: Moderate
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This is FEV1/FVC <70%; 30%< or equal to FEV1<50% predicted.
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III: Severe
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This is FEV1/FVC <70%; FEV1<30% predicted plus respiratory failure or clinical signs of R-sided heart failure.
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IV: Very Severe
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When predicting survival for COPD, what are two important things?
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Can't be based on FEV1 alone
Better to base survival on multiple factors such as BMI, FEV1, Dyspnea, exercise capacity etc. . . |
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These six things are important in managing stable COPD.
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Smoking cessation
Rehabilitation Inhaled bronchidilators Inhaled corticosteroids Oxygen therapy Future therapies |
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When managing stable COPD, what is a inhaler of choice? It combines two drugs, what are they?
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B2 Agnoist and Ipratropium = Albuterol and Ipatropioum
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This is a long acting 24 hour anticholinergic bronchodilator that increases spirometry results, decreases dyspnea, decreases COPD flares and decreases hospitalizations.
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Tiotropium (Spiriva)
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This was a recent serious side affect that has been noted with inhaled anticholinergics such as Tiotropium (Spiriva) and Atrovent
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Increase risk of fatal and non-fatal heart disease.
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These may decrease the number of COPD flairs, may improve cough and dyspnea, small one time increase in FEV1, may adversely affect bone density.
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Inhaled corticosteroids
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What are three examples of inhaled corticosteroids?
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Fluticasone (Flovent)
Salmeterol (Serevent) Or these two drugs combined = Advair |
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This shows demonstrated efficacy in patients with O2 sat at 88% or less, and if they have cor pulmonale or RVH.
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Continuous Oxygen Therapy
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How do you manage stage 0: at risk patients?
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No intervention is required
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How do you manage Stage 1: Mild COPD patients?
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Short acting bronchodilator prn
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How do you manage Stage II: Moderate COPD patients?
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Rehabilitation
Spiriva +/- additional bronchodilator prn Inhaled steroids if significant Sx |
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How do you manage Stage III: Severe COPD patients?
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Rehabilitation
Spiriva +/_ additional bronchodilator prn Inhaled steroids +/- LABA if signficant Sx (most patients) |
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How do you manage Stage IV: Very severe COPD patients?
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Rehabilitation
Spiriva +/- additional bronchodilator as needed Inhaled steroids + LABA Continuous O2 Tx if indicated Consider surgical options |
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When you are managing stable COPD, this increases survival in patients with chronic respiratory failure.
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Long term O2 (> 15 hours per day)
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What are the three surgical options for COPD management?
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1. Bullectomy
2. Lung Volume Reduction Surgery 3. Lung Transplantation |
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What are the three reasons for exacerbations of COPD?
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1. Infections of the tracheobroncheal tree
2. Air pollution 3. In about 1/3 of exacerbations no cause can be identified |
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What are two things that can be used to manage exacerbations in COPD?
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Inhaled bronchodilators (Beta2 agonists and/or anticholinergics)
Systemic glucocorticosteroids (preferably oral) |
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When do you consider ABX Tx to manage a pt who is having a COPD exacerbation?
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When there are Sx of airway infection, such as a change in sputum color and/or fever.
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What can be used in acute exacerbations of COPD?
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Non-invasive intermittent positive pressure ventilation (NIPPV).
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What does non invasive intermitten positive pressure ventilation (NIPPV) do when managing exacerbations of COPD? 4 things
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Increase blood gases and pH
Decrease in hospital mortality Decrease need for invasive mechanical ventilation and intubation Decrease length of hospital stay |
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This is a congenital or acquired disease of the large bronchi. Permanent, abnormal dilation and destruction of bronchial walls. Caused by recurrent inflammation or infections. May be localized or diffuse.
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Bronchectasis
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What four things make up the major causes of Bronchectasis?
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Cystic Fibrosis (50% of cases)
Lung Infections Abnormal lung defense mechanism Localized airway obstruction |
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What are the six signs associated with bronchectasis?
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Chronic cough w/copious amount of purulent sputum
Hemoptysis Pleuritic CP Dyspnea and wheezing (75% of pt) Weight Loss Anemia |
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With this you will see nonspecific symptoms, persistent basilar crackles, clubbing in severe dz, obstructive pulmonary dysfunction with hypoxemia in moderate-severe dz.
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Bronchectasis
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What are two things you see when doing a CXR in bronchectasis?
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Dilated, thickened bronchial walls (tram tracks)
Scattered, irregular opacities, atelectasis and focal consolidations |
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What is the imaging study of choice for bronchectasis?
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CT
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What are the three main Tx's for bronchectasis?
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ABX (based on sputum smear and Cx)
Chest physiotherapy w/postural drainage and chest percussion Inhaled Bronchodilators |
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What are the emperic ABX used for acute exacerbation of Bronchectasis?
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Amoxicillin or Augmentin
Ampicillin or Tetracycline Trimethoprim/Sulfamethoxazole (Bactrim) |
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When do you specifically give ABX in Bronchectasis?
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When there is a + sputum and culture
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What is the specific reason you give ABX to cystic fibrosis patients dealing with bronchectasis?
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In CF pts inhaled ABX improve FEV1 and decreases hospitalization rate.
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What are the complications associated with bronchectasis? 4 things
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Hemoptysis
Cor pulmonale Amyloidosis Secondary visceral abscesses at distant site (eg. brain) |
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What two things can be done to help Tx the complications of Bronchectasis?
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Bronchoscopy to remove secretions or embolize bronchial arteries
Surgical resection for localized bronchiectasis with adequate pulmonary function |
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This is pulmonary heart disease?
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Cor Pulmonale
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Pulmonary heart Dz and hypoxia, or pulmonary vascular dz (pulm HTN), leads to what?
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RV hypertrophy and failure
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The following cause what?
COPD Pneumoconiosis (coal miner's lung) Pulmonary fibrosis Kyphoscoliosis Pulmonary HTN Repeated pulmonary embolism Pickwickian syndrome Schistosomiasis Obliterative pulm capillary or lymphangitis infiltration from metastatic cancer. |
Cor Pulmonale causes
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What are the symptoms of cor pulmonale?
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Chronic productive cough
Exertional dyspnea Wheezing Easy fatigability Weakness |
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What are the signs of cor pulmonale? 7 things
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Dependent edema
RUQ pain secondary to enlarged liver Cyanosis Clubbing Distended neck veins RV heave or gallop Prominent lower sternal or epigastric pulsations |
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What are the two lab findings associated with cor pulmonale?
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Polycythemia
Arterial O2 saturation less than 89% |
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What is seen on the EKG in cor pulmonale? 5 things
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R axis deviation
Peaked P waves Deep S in lead V6 May mimic MI Supraventricular arrythmias |
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What is seen in CXR in cor pulmonale, two things?
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Pulmonary bump
Right ventricle over spine |
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What are two other studies apart from CXR and lab findings can be done in diagnosing cor pulmonale?
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PFT
Echo - normal LV, RV and RA dilation |
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What is the Tx for cor pulmonale, three things.
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O2
Salt and fluid restriction Diuretics |
