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63 Cards in this Set
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Case: 52-year old man with a long history of smoking presents with dyspnea, increased sputum production, change in sputum character, and wheezing.
What is the most likely cause of his current symptoms? |
Acute exacerbation of chronic obstructive pulmonary disease (COPD) |
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Case: 52-year old man with a long history of smoking presents with dyspnea, increased sputum production, change in sputum character, and wheezing.
What are the appropriate classes of treatments at this time? |
- Antibiotic - Bronchodilators - Systemic corticosteroids |
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Case: 52-year old man with a long history of smoking presents with dyspnea, increased sputum production, change in sputum character, and wheezing.
What interventions could be done to reduce the number of exacerbations? |
- Smoking cessation - Long-acting bronchodilator - Inhaled corticosteroid - Influenza and pneumococcal polysaccharide vaccinations |
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What are the two most common causes of dyspnea and wheezing in adults? |
- Asthma - COPD |
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What is the classic presentation of asthma? |
- Usually presents earlier in life - May or may not be associated with smoking - Episodic exacerbations with return to relatively normal baseline lung functioning |
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What ist he classic presentation of COPD? |
- Presents in midlife or later - Usually the result of a long history of smoking - Slowly progressive disorder in which measured pulmonary functioning never returns to normal |
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How should you assess a patient presenting with dyspnea? |
Start with the ABCs: - Airway - Breathing - Circulation
- Also assess level of oxygenation |
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When should you intubate a patient with an acute exacerbation of COPD or asthma?
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- When pt is unable to protect their own airway (eg, reduced level of consciousness) - When pt is tiring due to the work required to overcome their airway obstruction - When adequate oxygenation cannot be maintained |
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What are the mainstays of medical therapy for both COPD and asthma? |
- Oxygen - Bronchodilators - Steroids |
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What are the clinical signs of hypoxemia? |
Cyanosis of perioral region or digits |
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How should you address hypoxemia in a patient with dyspnea? |
Administer supplemental O2 |
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What can rapidly cause bronchodilation? Mechanism? |
Inhaled albuterol - beta-2 agonist |
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What drug can be administered along with albuterol to work synergistically? Mechanism? |
Inhaled Ipratropium - anti-cholinergic agent
(When combined, this is called a "duoneb") |
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How can you reduce the airway inflammation that underlies an acute exacerbation? |
Corticosteroids - given systemically (oral, IM, or IV), this takes hours to work |
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What is the definition of chronic bronchitis? |
Cough and sputum production on most days for at least 3 months during at least 2 consecutive years |
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What is the definition of emphysema? |
Shortness of breath caused by the enlargement of respiratory bronchioles and alveoli caused by destruction of lung tissue |
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How significant is the association between smoking and COPD? |
Approximately 90% of cases of COPD are associated with smoking |
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What are some alternative causes of COPD? |
- Exposure to cigarette smoke (second-hand smoke) - Occupational exposures to dusts or chemicals - Genetic deficiency in alpha-1 antitrypsin (more common in Caucasians, may present <45 years old, especially in non-smokers) |
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When should you suspect alpha-1 antitrypsin deficiency? |
Caucasian non-smoker who presents with signs of COPD at age <45y |
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What are the pathologic changes associated with COPD? |
- Mucus gland hypertrophy with hypersecretion - Ciliary dysfunction - Destruction of lung parenchyma - Airway remodeling - Causes airway narrowing, a fixed airway obstruction, poor mucus clearance, cough, wheezing, and dyspnea |
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What is the most common initial symptom of COPD? |
Cough (first intermittent, then frequently becomes a daily occurrence) |
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What are the characteristics of coughing in COPD? |
Often productive of thick white mucus
May have intermittent worsening of cough with change in mucus from clear to yellow/green, often with wheezing |
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What causes exacerbations of COPD? |
Viral or bacterial infections |
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At the time of diagnosis of COPD in a patient who presented with dyspnea, what is the level of lung function? |
Lung function (as measured by FEV1) has been reduced by about half and COPD has been present for years |
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What exam findings are associated with COPD? |
- Exam in pt with mild or moderate COPD without an exacerbation may be normal - As it progresses, may become "barrel chested" (increased AP chest diameter), develop distant heart sounds (d/t hyperinflation of lungs) - Breath sounds may also be distant and expiratory wheezes with a prolonged expiratory phase of respiration |
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Why might a patient with COPD have distant heart sounds? |
Due to hyperinflation of the lungs |
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How might a patient with an acute exacerbation present? |
- Anxious and tachypneic - May require use of accessory muscles of respiration - Usually have wheezes or rales - May have signs of cyanosis |
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What are the typical CXR findings in a patient with COPD? |
- Typically normal until disease is advanced - In severe cases, hyperinflation of lungs with increased PA diameter and flattening of diaphragm - In more severe disease may see bullae (areas of pulmonary parenchymal destruction) |
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What are "bullae" on CXR? |
Areas of pulmonary parenchymal destruction |
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What is the primary diagnostic test for COPD? |
Spirometry |
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What happens to spirometry measurements in normal aging? |
Both FVC (measure of total amount of air that can be expired after a max inspiration) and FEV1 (volume of air exhaled in first second) reduce GRADUALLY over time
Ratio of FEV1 / FVC is >0.7 |
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What happens to spirometry measurements in a patient with COPD? |
FVC and FEV1 are reduced
Ratio of FEV1/FVC is <0.7 (indicates airway obstruction) |
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What spirometry value indicates airway obstruction? |
Ratio of FEV1/FVC is <0.7 (normal is >0.7) |
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How can you determine reversibility of airway obstruction? |
Increase in FEV1 by greater than 12% or 200 mL |
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How can spirometry measurements change in a patient with COPD when they use a bronchodilator? |
May result in some improvement of both FVC and FEV1 but neither will return to normal (making the diagnosis of a FIXED obstruction) |
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How can you classify COPD? |
Stages determined by spirometry and symptoms |
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What does stage 0 COPD represent? How do you diagnose and treat? |
"At risk": - Findings: cough, sputum production, normal spirometry - Treatment: vaccines and address risk factors (exposure to tobacco smoke, occupational dust/chemicals, or smoke from home cooking/heating fuel) |
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What does stage 1 COPD represent? How do you diagnose and treat? |
"Mild COPD": - Findings: FEV1 / FVC <0.7; FEV1 ≥80% predicted; with or without symptoms - Treatment: short acting bronchodilators |
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What does stage 2 COPD represent? How do you diagnose and treat? |
"Moderate COPD": - Findings: FEV1/FVC <0.7; FEV1 50-80% predicted; with or without symptoms - Treatment: long-acting bronchodilators |
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What does stage 3 COPD represent? How do you diagnose and treat? |
"Severe COPD": - Findings: FEV1/FVC <0.7; FEV1 30-50% predicted; with or without symptoms - Treatment: inhaled steroids |
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What does stage 4 COPD represent? How do you diagnose and treat? |
"Very severe COPD": - Findings: FEV1/FVC <0.7; FEV1 <30% predicted or FEV1 <50% predicted with chronic hypoxemia - Treatment: long term O2 therapy and consider surgical intervention |
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How can you diagnose the different stages of COPD? |
- 0: normal spirometry - I-IV: FEV1/FVC <0.7 - I: FEV1 ≥80% predicted - II: FEV1 50-80% predicted - III: FEV1 30-50% predicted - IV: FEV1 <30% predicted or <50% predicted with chronic hypoxemia |
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How should you treat the different stages of COPD? |
- 0: vaccines and address risk factors - I: short-acting bronchodilators - II: long-acting bronchodilators - III: inhaled steroids - IV: long-term O2 therapy and consider surgical interventions |
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What are the goals of COPD management? |
- Relieve symptoms - Prevent/slow disease progression - Reduce/prevent/treat exacerbations - Reduce/prevent/treat complications |
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What recommendations are made to all patients with COPD? |
- Quit smoking - Vaccinations: pneumococcal vaccination, influenza vaccination (reduces frequency and complications of exacerbations) - Regular exercise and efforts to maintain a normal body weight |
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What are the benefits of quitting smoking for a patient with COPD? |
- Pulmonary function of smokers declines more rapidly than that of non-smokers - Smoking cessation does NOT result in significant improvement in pulmonary function, it does reduce the rate of deterioration to that of a non-smoker!!! - Reduces the risks of other co-morbidities including CV disease and cancer |
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For whom is the influenza vaccine recommended? |
Annually for all those older than 6 months |
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What medications are recommended for a patient with a FEV1/FVC <0.7 but a FEV1 >80% predicted? |
Short-acting bronchodilators: - Beta-2 agonists (albuterol) - Anticholinergics (ipratropium) - Inhaled meds preferred over oral meds because they have fewer side effects |
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What medications are recommended for a patient with a FEV1/FVC <0.7 and a FEV1 50-80% predicted? |
Short-acting bronchodilators should be used for rescue therapy in exacerbations: - Beta-2 agonists (albuterol) - Anticholinergics (ipratropium)
Long-acting bronchodilator should be added: - Beta-2 agonist (salmeterol / Serevent) - Anticholinergics (tiotropium / Spiriva)
Oral methylxanthines (aminophylline, theophylline) are also options but have narrow therapeutic windows (high toxicity) and multiple drug-drug interactions |
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What medications are recommended for a patient with a FEV1/FVC <0.7 and a FEV1 30-50% predicted? |
Short-acting bronchodilators should be used for rescue therapy in exacerbations: - Beta-2 agonists (albuterol) - Anticholinergics (ipratropium)
Long-acting bronchodilator should be added: - Beta-2 agonist (salmeterol / Serevent) - Anticholinergics (tiotropium / Spiriva)
Oral methylxanthines (aminophylline, theophylline) are also options but have narrow therapeutic windows (high toxicity) and multiple drug-drug interactions
INHALED STEROIDS (fluticasone, triamcinolone, mometasone, etc) should be given to patients in stage III and IV COPD with frequent exacerbations |
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Should long-term oral steroids be used in any patients with COPD? |
Long-term treatment with oral steroids is not recommended, as there is no evidence of benefit, and there can be multiple complications (myopathy, osteoporosis, glucose intolerance, etc) |
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When is oxygen therapy recommended for patients with COPD? |
Recommended in stage IV COPD if there is evidence of hypoxemia (PaO2 ≤55 mmHg or SaO2 ≤88% at rest) OR PaO2 is ≤60 mmHg and there is polycythemia, pulmonary hypertension, or peripheral edema suggesting heart failure |
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When is the only intervention for COPD that has shown to decrease mortality? |
Oxygen therapy - worn for at least 15 hours/day |
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How do acute exacerbations of COPD present? |
- Change in sputum color or amount - Cough - Wheezing - Increased dyspnea |
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What are diagnoses that can cause similar symptoms as an acute exacerbation of COPD? |
- Pulmonary embolism - CHF - Myocardial infarction |
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How should you treat a patient with a COPD exacerbation? |
- Oxygen therapy to keep SaO2 >90% or PaO2 >60 mmHg - Short-acting bronchodilators (beta-agonist and anticholinergic = DuoNeb) - Systemic steroids reduce the course of exacerbation and risk for relapse (40 mg prednisolone for 10-14 days) - Antibiotics for patients with increased sputum or purulent sputum - Hospitalize patients with more severe symptoms, comorbidities, altered mental status, an inability to care for themselves at home, or whose symptoms fail to respond promptly to office or ER treatments |
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What is the standard oral steroid dose for a patient with an acute exacerbation of COPD? |
40 mg prednisolone for 10-14 days |
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How do you determine the need for antibiotics in a patient with a COPD exacerbation? |
If the sputum has increased or is purulent --> treat with antibiotics |
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What are the most common pathogens responsible for a COPD exacerbation? |
- Pneumococcus - Haemophilus influenzae - Moraxella catarrhalis
- In severe exacerbations, G- bacteria (Klebsiella, Pseudomonas) can also be involved |
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A 38-year old woman presents with progressively worsening dyspnea and cough. She has never smoked cigarettes, has no known passive smoke exposure, and does not have any occupational exposure to chemicals. Pulmonary function testing shows obstructive lung disease that does not respond to bronchodilators.
What is the most likely etiology? |
Alpha-1 antitrypsin deficiency
This patient has a fixed airway obstruction consistent with COPD. The airway obstruction of asthma would be at least partially reversible on testing with a bronchodilator. Alpha-1 antitrypsin deficiency should be considered in a patient who develops COPD at a young age, especially if there is no other identifiable risk factor. |
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A 60-year old man is diagnosed with moderately severe (stage II) COPD. He admits to a long history of cigarette smoking and is still currently smoking. In counseling him about smoking cessation, what can you tell him are the benefits of quitting smoking? |
By quitting, his current pulmonary function will be unchanged, but the rate of pulmonary function decline will slow
Smoking cessation will not result in reversal of the lung change that has already occurred, but can result in a slowing in the rate of decline of pulmonary function. In fact, smoking cessation can resulting in the rate of decline returning to that of a non-smoker. |
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A 68-year old patient of your practice with known COPD has pulmonary function testing showing an FEV1 of 40% predicted. He has been having frequent exacerbations of his COPD. His SaO2 by pulse ox is 91%.
What medication regimen is the most appropriate? |
- Inhaled fluticasone BID (inhaled steroid to decrease frequency of exacerbations) - Inhaled tiotropium BID (long-acting bronchodilator) - Inhaled albuterol as needed (short-acting bronchodilator)
This patient has stage III COPD with frequent exacerbations. He is best treated by a long-acting bronchodilator and an inhaled steroid used regularly along with an inhaled, short-acting bronchodilator on an as-need basis. |
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A 59-year old man with a known history of COPD presents with worsening dyspnea. On exam he is afebrile. His breath sounds are decreased bilaterally. He is noted to have JVD and 2+ pitting edema of the lower extremities.
What is the most likely cause of his increased dyspnea? |
Cor pulmonale
JVD and lower extremity edema are suggestive of cor pulmonale, which is right heart failure due to chronically elevated pressures in the pulmonary circulation. Right heart failure causes increased right atrial pressures and right ventricular end-diastolic pressures, which then leads to liver congestion, jugular venous distention, and lower extremity edema. |
