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COPD Flashcards

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1
Q

Define COPD.

A
  • Progressive, partially reversible airway obstruction, which leads to air-trapping and lung hyperinflation
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2
Q

What rank is COPD in causes of death in Canada?

A
  • 4th
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3
Q

What is the pathophysiological hallmark of COPD?

A
  • Expiratory flow limitation
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4
Q

What are risk factors for COPD? (DFCM/GOLD)

A
  • Exposure
    • Tobacco smoke (includes cigarettes, pipe, cigar)
    • Indoor air pollution (biomass fuel used for cooking and heating in poorly vented dwelling)
    • Occupational dusts and chemicals
    • Outdoor air pollution
    • Perinatal or Childhood illness (e.g. low birth weight, respiratory infections)
    • Atopy
    • Social factors
  • Host
    • Genetics (e.g. alpha-1-antitrypsin deficiency)
    • Gender
    • Airway (e.g. severe asthma)
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5
Q

What are 6 comorbidities commonly seen in patients with COPD? (GOLD)

A
  • Cardiovascular disease
  • Osteoporosis
  • Depression and Anxiety
  • Skeletal muscle dysfunction
  • Metabolic syndrome
  • Lung cancer
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6
Q

According to the GOLD report 2016, are cardioselective beta-blockers contraindicated in COPD? (GOLD)

A
  • No (i.e. not contraindicated)
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7
Q

What is the most frequent cause of death in patients with mild COPD? (GOLD)

A
  • Lung cancer
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8
Q

What are the symptoms and investigations compatible with the diagnosis of COPD?

A
  • Symptoms
    • Dyspnea at rest or on exertion
    • Cough with or without sputum production
    • Progressive limitation of activity
  • Spirometry
    • FEV1/FVC ratio less than 0.70 or less than the lower limit of normal
    • Incompletely reversible with inhaled bronchodilator
  • Absence of an alternative explanation for the symptoms and airflow limitation
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9
Q

What is the ratio FEV1/FVC in normal adults? (GOLD)

A
  • Between 0.70 and 0.80
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10
Q

What are 4 factors that FEV1 is influenced by? (GOLD)

A
  • Age
  • Sex
  • Height
  • Ethnicity
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11
Q

What is the youngest age at which children are usually able to cooperate with PFT procedures? (AFP)

A
  • 5 years
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12
Q

What 3 factors must be confirmed before PFT results can be reliably interpreted? (AFP)

A
  1. Volume-time curve reaches a plateau, and expiration lasts at least 6 seconds
  2. Results of the 2 best efforts on the PFT are within 0.2 L of each other
  3. The flow-volume loops are free of artifacts and abnormalities
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13
Q

What are the 8 steps to interpreting a PFT results? (AFP)

A
  1. Determine if the FEV1/FVC ratio is low
  2. Determine if the FVC is low
  3. Confirm the restrictive pattern
  4. Grade the severity of the abnormality
  5. Determine the reversibility of the obstructive defect
  6. Bronchoprovocation
  7. Establish the differential diagnosis
  8. Compare current and prior PFT results
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14
Q

What are the different criteria for a low FEV1/FVC ratio? (AFP)

A
  • GOLD
    • < 70%
  • National Asthma Education and Prevention Program
    • < 85% (children 5 to 18 years of age)
  • ATS
    • LLN (<5%ile based on NHANES III)
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15
Q

Which criteria should be used to diagnose obstructive lung disease? (AFP)

A
  • GOLD = 65+ with smoking history (current or previous)
  • ATS = <65 or 65+ nonsmokers
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16
Q

What is considered a low FVC on spirometry? (AFP)

A
  • <lln>
    <li>&lt;80% predicted for children 5 to 18 years of age</li>
    </lln>

</lln>

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17
Q

For patients whose initial PFT result indicates a restrictive pattern, what should be done? (AFP)

A
  • Referral for PFTs with DLCO testing (diffusion capacity of the lung for carbon monoxide testing)
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18
Q

What test needs to be done before performing a DLCO test? (AFP)

A
  • Baseline hemoglobin
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19
Q

How does the ATS grade severity of a PFT abnormality? (AFP)

A

Severity

FEV1 % of predicted

Mild

>70

Moderate

60 to 69

Moderately severe

50 to 59

Severe

35 to 49

Very severe

<35

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20
Q

What are the criteria for reversibility of an obstructive defect on PFTs? (AFP)

A
  • +12% in patients 5 to 18 years of age
  • +12% and +200mL in adults
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21
Q

If a PFT result is normal but exercise- or allergen-induced asthma is still suspected, what tests can be performed? (AFP)

A
  • Bronchoprovocation
    • Methacholine challenge
    • Mannitol inhalation challenge
    • Exercise testing
    • Eucapnic voluntary hyperpnea testing
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22
Q

What is the difference in test accuracy between methacholine and mannitol? (AFP)

A
  • Methacholine = Highly sensitive but low specificity (FP results)
  • Mannitol = Lower sensitivity but higher specificity (FN results)
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23
Q

What is a differential diagnosis for obstructive lung disease? (AFP)

A
  • Alpha1-antitrypsin deficiency
  • Asthma
  • Bronchiectasis
  • Bronchiolitis obliterans
  • COPD
  • Cystic fibrosis
  • Silicosis (early)
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24
Q

What is a differential diagnosis for restrictive lung disease? (AFP)

A
  • Chest wall
    • Ankylosing spondylitis
    • Kyphosis
    • Morbid obesity
    • Scoliosis
  • Drugs (adverse reaction)
    • Amiodarone
    • Methotrexate
    • Nitrofurantoin
  • Interstitial lung disease
    • Asbestosis
    • Berylliosis
    • Eosinophilic pneumonia
    • Hypersensitivity pneuomonitis
    • Idiopathic pulmonary fibrosis
    • Sarcoidosis
    • Silicosis (late)
  • Neuromuscular disorders
    • Amyotrophic lateral sclerosis
    • Guillain-Barre syndrome
    • Muscular dystrophy
    • Myasthenia gravis
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25
**Differentiate between COPD and Asthma.**
26
**How can spirometry differentiate between Asthma and COPD? (DFCM)**
* Post-bronchodilator (Beta2 agonist) * Asthma: FEV1/FVC \> 0.70 or \> LLN * COPD: FEV1/FVC still \<0.70 or
27
**In patients with chronic asthma in which a clear distinction from COPD is not possible with current imaging and physiological testing techniques, how should management? (GOLD)**
* Similar to that of asthma
28
**What is the USPSTF recommendation for screening for COPD in asymptomatic adults?**
* Against
29
**For patients older than 40 years of age and who are current or ex-smokers, which should undertake spirometry? (DFCM)**
* Answer YES to any ONE of the following questions: * Do you cough regularly? * Do you cough up phlegm regularly? * Do even simple chores make you short of breath? * Do you wheeze when you exert yourself, or at night? * Do you get frequent colds that persist longer than those of other people you know?
30
**What is important to ask on history in patients with COPD?**
* Increase cough * Purulent sputum * Wheezing * Dyspnea * Fever * Frequency and severity of exacerbations * Occupational or environmental exposure to cigarettes and other lung irritants
31
**What is the Medical Research Council dyspnea scale?**
32
**What are the 3 stages of COPD severity?**
33
**How is the severity of airflow limitation in COPD classified based on GOLD? (GOLD)**
\*\*\*In patients with FEV1/FVC \< 0.70\*\*\* GOLD 1 Mild FEV1 ≥ 80% predicted GOLD 2 Moderate 50% ≤ FEV1 \< 80% predicted GOLD 3 Severe 30% ≤ FEV1 \< 50% predicted GOLD 4 Very Severe FEV1 \< 30% predicted
34
**What are the 4 categories of COPD based on GOLD, CAT and the mMRC?**
35
**Is clubbing typically seen in patients with COPD?**
* No * May suggest alternative diagnosis such as lung cancer, interstitial lung disease or bronchiectasis
36
**What signs may you find on the physical examination in mild-moderate, severe and end-stage COPD?**
Mild-Moderate * Hyperinflation (increased resonance to percussion) * Decreased breath sounds * Wheezes, crackles at the lung bases * Distant heart sounds Severe * Increased AP diameter of the chest (“barrel-shaped” chest) * Depressed diaphragm with limited movement based on chest percussion End-Stage * Tripod-ing * Accessory muscle use * Pursed lip breathing * Paradoxical retraction of the lower interspaces during inspiration * Cyanosis * Asterixis due to severe hypercapnia * Enlarged and tender liver due to right heart failure * Neck vein distribution may also be observed because of increased intrathoracic pressure, especially during expiration
37
**What would you find on spirometry for different stages of COPD?**
* TLC and RV increase as VC decreases * DC decreases with increased emphysema
38
**When would you consider performing an ABG in patients with COPD?**
* Forced expiratory volume in one second (FEV1) \<40% predicted * Oxygen saturation by pulse oximetry \<92% * Depressed level of consciousness * Acute exacerbation of COPD * Assessment for hypercapnia in at risk patients 30 to 60 minutes after initiation of supplemental oxygen
39
**To monitor disease progression in COPD, at what interval should spirometry measurements be performed? (GOLD)**
* At least 12 months apart
40
**What are 5 management goals for COPD? (TOP)**
1. Prevention of disease progression (smoking cessation) 2. Reduction of frequency and severity of exacerbations 3. Improvement of dyspnea 4. Improvement of exercise capacity (maintain active lifestyle) 5. Improvement in QOL
41
**Name 4 nonpharmacological interventions for COPD.**
1. Smoking Cessation 2. Vaccinations (Influenza yearly and Pneumococcal) 3. Pulmonary Rehabilitation 4. Education and Case Management with an Action Plan
42
**What is the evidence for telemonitoring for COPD to prevent COPE exacerbations compared to usual care? (AFP/ACCP-CTS)**
* No evidence to support telemonitoring
43
**Name 5 possible triggers for a COPD exacerbation?**
1. Infectious 2. MI and CHF 3. PE 4. Systemic infections and Anemia 5. Allergens and Irritants
44
**What are the most common pathogens responsible for a COPD exacerbation?**
* Viral * Influenza * Parainfluenza * RSV * Adenovirus * Rhinovirus * Bacterial * H. influenza * S. pneumoniae * M. catarrhalis
45
**What 3 findings are suggestive of a COPD exacerbation? (DFCM)**
1. Increase sputum volume 2. Increased cough 3. Increased dyspnea \*\*\*Increase sputum purulence (indication for antibiotics)\*\*\* * AECOPD further classified as either purulent or non-purulent
46
**How does the GOLD report 2016 define a COPD exacerbation? (GOLD)**
* An acute event characterized by a worsening of the patient’s respiratory symptoms that is beyond normal day-to-day variations and leads to a change in medication
47
**What 3 medications would you give acutely for a COPD exacerbation?**
1. Ventolin 1. 4-8 puffs of 100 mcg 2. 2.5 – 5 mg via Nebulizer q20 minutes 2. Atrovent 1. 4-8 puffs of 17 mcg (aerochamber) 2. 0.5 mg via Nebulizer q20 minutes 3. Prednisone 40 mg daily for 5 days
48
**What dose of oral steroids is recommended for a COPDE according to the GOLD report 2016? (GOLD)**
* Prednisone 40 mg daily for 5 days
49
**What is the benefit of systemic corticosteroids for managing a AECOPD?**
* Shortens recovery/hospitalization * Improves lung function * Reduces risk of relapse/repeat AECOPD in 30 days
50
**When would you give antibiotics during a COPD exacerbation?**
Winnipeg Criteria (more cough, more sputum, change sputum quality – if met, treat with antibiotics) * Purulent discharge * OR = 6.1 for non-resolution if not given antibiotics
51
**What laboratory test can suggest that antibiotics should be given for a COPD exacerbation?**
* CRP\>40 has OR = 13.4 for non-resolution if not given antibiotics
52
**What are 6 first-line antibiotics that can be given for a simple COPD exacerbation? (MUMS 2013)**
* Amoxicillin 500 mg TID x 5 days * Doxycycline 100 mg BID first day then 100 mg daily x 5 days * Tetracycline 250-500 mg QID x 5 days * Septra DS 1 tab BID x 5 days * Clarithromycin 500 mg BID x 7 days * \>20% S. pneumoniae resistance in Canada * Azithromycin 500 mg first day then 250 mg daily x 4 days * \>20% S. pneumoniae resistance in Canada
53
**What are 3 first-line antibiotics that can be given for a complicated COPD exacerbation? (MUMS 2013)**
* Amoxicillin/Clavulanate 500 mg TID x 7 days * Levofloxacin 500 mg daily x 7 days (or 750 mg daily x 5 days) * Moxifloxacin 400 mg daily x 7 days
54
**For patients at risk of a pseudomonas AECOPD, what antibiotic would you prescribe? (MUMS 2013)**
* Ciprofloxacin 500 mg BID x 7 days
55
**What are 5 findings that would suggest a complicated COPD exacerbation?**
* FEV1\<50% predicted * 4+ exacerbations per year * Ischemic heart disease * Use of home oxygen * Chronic oral steroid use
56
**What is the only intervention that can SLOW the rate of lung function decline in COPD?**
* Smoking cessation * Cessation results in normal FEV1 decrease by 30 mL/year * Smoking results in FEV1 decrease by 90-150 mL/year
57
**What are the smoking quit rates associated with a brief (3-minute) period of counseling? (GOLD)**
* 5-10%
58
**By how much does smoking cessation reduce the risk of mortality in COPD patients? (CFP)**
* 40%
59
**What are recommended smoking cessation aids according to the GOLD report? (GOLD)**
* NRT (nicotine gum, inhaler, nasal spray, transdermal patch, sublingual tablet, lozenge) * Varenicline * Bupropion * Nortripyline
60
**How much can vaccinations prevent hospital admission for COPDE? (CFP)**
* 40%
61
**How much can vaccinations reduce COPD mortality? (CFP)**
* 50%
62
**What vaccines are recommended for patients with COPD? (DFCM)**
* Flu shot * Pneumococcal at least once with a possible repeat at 5-10 years
63
**What does the CDC recommend regarding pneuomococcal vaccines for patients with COPD? (GOLD)**
* PCV-13 * Adults 65+ * PPSV-23 * Adults 65+ * Adults \<65 with COPD (**FEV1\<40%**), asthma, smoker, cardiac dx
64
**What is the ACCP-CTS guideline on the 23-valent pneumococcal vaccine for COPD to prevent exacerbations? (CTS)**
* Recommended * Did NOT find sufficient evidence that it prevents acute exacerbations
65
**When should pulmonary rehabilitation be initiated for COPD and why? (ACCP-CTS)**
* \<4 weeks following a recent exacerbation as prevent subsequent exacerbations * Does NOT reduce future exacerbations when started more than 4 weeks after * But still improves activity, walking distance and QOL as well as reduces shortness of breath
66
**What is the minimum length of an effective rehabilitation program for COPD? (GOLD)**
* 6 weeks
67
**What does pulmonary rehabilitation for COPD help with? (CFP)**
* Reduce dyspnea and anxiety associated with COPD * Improve QOL * Decrease hospitalizations for acute exacerbations
68
**What do the ACCP-CTS guidelines recommend in regards to education and case management to reduce COPD exacerbations? (ACCP-CTS)**
* Education and case management with a written action plan that includes direct access to a health-care specialist at least monthly
69
**What are 6 factors that increase the likelihood of death after a COPDE?**
1. FEV1 less than 30% predicted 2. Inspiratory capacity less than 80% predicted 3. Poor functional status (MRC Dyspnea scale grade 4 to 5) 4. Poor nutritional status (BMI less than 19 kg/m2) 5. Pulmonary hypertension 6. Recurrent severe acute exacerbations
70
**How does pharmacotherapy and treatment change with COPD progression?**
71
**What medication has been shown to slow the progression of COPD? (CFP)**
* None
72
**What % of patients with COPD use their inhalers incorrectly? (CFP)**
* 50-59%
73
**What medication is 1st line PRN in mild COPD and always available as PRN rescue medication? (DFCM)**
* Short acting bronchodilators (SABD) * SABA * SAAC
74
**What are two different SABA for COPD and their dose? (DFCM)**
* Salbutamol (Ventolin) MDI 100 mcg/inh or Diskus 200 mcg/inh * 1-2 puffs q4-6h prn, max 8/day (800 mcg/day) * Terbutaline Turbuhaler 0.5 mg/inh * 1 puff q4-6h prn, max 6 puffs/day
75
**What are the benefits of SABA for COPD? (DFCM)**
* Improves lung function, dyspnea, exercise endurance in moderate to severe COPD * No consistent effect on QOL * Duration of action 4-6 hours
76
**What are potential adverse effects of SABA use? (DFCM)**
* Tachycardia * Nervousness * Headache * Dizziness * Tremor * Palpitations * Increased QT * Decreased K * Tachyphylaxis * Hyperglycemia in DM
77
**What is the SAAC for COPD and its dose? (DFCM)**
* Ipratropium bromide (Atrovent) MDI 20 mcg/inh * 2-4 puffs q6-8h, max 12 puffs/day
78
**What are the benefits of SAAC for COPD? (DFCM)**
* Improves lung function, dyspnea, exercise endurance in moderate to severe COPD * No consistent effect on QOL * Duration of action 6-8 hours
79
**What are potential adverse effects of SAAC use? (DFCM)**
* Dry mouth * Metallic * Headache * More than SABA in elderly * Caution: glaucoma/urinary retention
80
**What medication is 1st line for moderate COPD or alternately for symptomatic mild COPD not responsive to a SABD? (DFCM)**
* Long-acting bronchodilators (LABD) * Long-acting Beta-2 Agonist (LABA) * Long-acting Anticholinergics (LAAC)
81
**What puffer has the greatest clinical impact on clinical outcomes as the first-line long-acting inhaled treatment for COPD? (TFP/CFP)**
* **Tiotropium** \> LABA * With HandiHaler device – large body of evidence and experience * **POET trial** * 1-year trial randomized Tiotropium 18 mcg daily vs Salmeterol 50 mcg BID * Tiotropium reduced exacerbations (**NNT = 19**) * No difference in mortality or QOL * **INSPIRE3 trial** * LABA and steroid (Advair) vs Tiotropium * No difference in exacerbations or QOL * Cochrane review * LABA vs Steroid * No difference in exacerbations or QOL
82
**What is the most commonly used LAAC for COPD and what is the dose? (DFCM)**
* Spiriva (Tiotropium bromide) Handi-Haler 18 mcg/cap for inhalation * 18 mcg (1 capsule) inhaled once daily
83
**What is the other LAAC (besides Tiotropium) used for COPD and what is the dose? (DFCM)**
* Glycopyyronium Breezhaler 50 mcg/cap * 1 puff/day (50 mcg)
84
**What are the benefits of LAAC for COPD? (DFCM)**
* **Better than LABA monotherapy** * Improves lung function, exercise tolerance, dyspnea * Chronic use may increase QOL, decrease exacerbations, decrease hospitalizations * No change in rate of decline in FEV1 * No increased risk CV event or death * Duration of action 24h
85
**What are potential adverse effects of LAAC (Spiriva) use? (DFCM)**
* Dry mouth * Bitter taste * Rarely: prostatic symptoms, SVT, glaucoma (if get in eye) * Glycopyyronium: caution with hiatus hernia, hyperthyroidism, ulcerative colitis
86
**What are 3 commonly used LABAs for COPD and what is their dose? (DFCM)**
* Salmeterol (Serevent) 50 mcg/inh Diskus or 50 mcg/blister Diskhaler * 1 puff (50 mcg) q12h (Onset 1 hr) * Formoterol (Oxeze) 6 or 12 mcg/inh Turbuhaler * 1-2 puffs q12h (Onset 5 min), Max 48 mcg/day * Indacaterol (Onbrez) Neohaler 75 mcg/capsule * 1 puff (75 mcg) per day
87
**What are the benefits of LABA for COPD? (DFCM)**
* Improves lung function, chronic dyspnea, and health status * Reduced frequency and severity of exacerbations (TORCH) * Duration of action 8-12 hours
88
**What are potential adverse effects of LABA use for COPD? (DFCM)**
* Generally well tolerated * Tachycardia * Nervousness * Headache * Dizziness * Tremor * Palpitations * Increased QT * Decreased K * CNS irritability * Insomnia * Muscle cramps
89
**Should ICS ever be used alone for COPD? (DFCM/GOLD)**
* No * Add to LABA for those with moderate-severe COPD and with ≥1 exacerbations per year * Long-term ICS monotherapy is less effective than the combination of inhaled ICS with LABA
90
**What are two commonly used LABA/ICSs for COPD and what is their dose?**
* Advair (Fluticasone + Salmeterol) 250mcg/50mcg Diskus 1 puff BID * Symbicort (Budesonide + Formoterol) 100 or 200 Turbuhaler 2 puffs BID
91
**What are potential adverse effects of LABA/ICS use for COPD? (DFCM)**
* Dysphonia, oral candidiasis/thrush 5-6% and skin bruising * Long-term use may be associated with: * Adrenal suppression * Osteoporosis * Posterior subcapsular cataracts * Glaucoma (increased intraocular pressure) * Pneumonia increased 3.5%/year
92
**According to the 2016 GOLD report, should oral corticosteroids be used as long-term monotherapy? (GOLD)**
* No
93
**For which patients does the GOLD report state may benefit from ICS? (GOLD)**
* FEV1 \< 60% predicted
94
**For which patients should the use of LABA-ICS be reserved for? (CFP)**
* 1 or more exacerbations per year OR * COPD is uncontrolled when taking combined LAMA and LABA with maximal nonpharmacologic management * Pulmonary rehabilitation * COPD education * Optimal use of inhalers * Treatment of OSA * Supplemental oxygen if appropriate
95
**What is the new anti-inflammatory drug for COPD and what is its dose? (DFCM)**
* Roflumilast (Daxas) – PDE4 inhibitor * 500 mcg PO daily
96
**What are the potential benefits of roflumilast for COPD? (DFCM)**
* Add-on therapy to bronchodilators for the maintenance treatment of severe COPD associated with chronic bronchitis * Modest benefit in airway function, FEV1, and decreased frequency and severity of exacerbation
97
**In which patients may roflumilast be beneficial for according to the GOLD report? (GOLD)**
* GOLD3 and GOLD4
98
**What are potential adverse effects of Roflumilast use for COPD? (TFP/DFCM)**
* Psychiatric (anxiety, depression, insomnia) – NNH = 28 * Weight loss – NNH = 17 * ~2 kg over 24-52 weeks on average * Diarrhea – NNH = 15 * Nausea – NNH = 30 * Headache – NNH = 45 * Caution if immunosuppressed, cancer, neuropsychiatric * Rare: depression/suicide, Increase AST * Drug interactions: carbamazepine, phenobarb, phenytoin
99
**What is the evidence for the use of Roflumilast for COPD? (TFP)**
* 2014 Cochrane systematic review of 15 trials * Decreases risk of COPD exacerbations with **NNT=25** * No reduction in mortality * No reduction in QOL * Statistical but not clinically important improvement in FEV1 (**52 mL**) * Minimum clinically important difference = 100 mL * Roflumilast similar to salmeterol or fluticasone in TORCH trial
100
**What does the 2016 GOLD report recommend for use of theophylline with COPD? (GOLD)**
* Treatment with Theophylline is NOT recommended unless: * Other bronchodilators are not available OR * Unaffordable for long-term treatment
101
**What do the ACCP-CTS guidelines recommend for use of mucolytics in COPD? (ACCP-CTS)**
* N-acetylcysteine * For patients with moderate to severe COPD and a history of 2 or more exacerbations in the previous 2 years, recommend oral NAC * Low risk of adverse effects from treatment * Oral carbocysteine * For stable outpatients with COPD who continue to experience acute exacerbations of COPD despite maximal therapy designed to reduce acute exacerbations of COPD, we suggest that oral carbocysteine could be used to prevent acute exacerbations where this therapy is available * The main adverse events reports in studies were mild GI symptoms
102
**In patients with severe COPD and recurrent exacerbations, what is the evidence for using daily prophylactic antibiotics? (TFP)**
* May reduce exacerbations by 1 in 10 (NNT = 10) * Increased risk of antibiotic resistance * Increased adverse events
103
**What antibiotics could be considered for daily prophylaxis in patients with severe COPD? (TFP)**
* Macrolides (also used for prophylaxis in CF and diffuse panbronchiolitis) * Azithromycin 250 mg daily * Erythromycin 250 mg BID
104
**When does home O2 offer a survival advantage for patients with COPD?**
* End-stage stable COPD
105
**For patients on home O2 for COPD, how long should they be on it per day? (GOLD)**
* \>15 hours/day
106
**What is the O2 saturation goal for home O2 in patients with COPD?**
* \>90%
107
**What are 2 indications for starting home O2 in patients with COPD? (GOLD)**
* Partial pressure of arterial oxygen 55 mmHg or less or SaO2 \<88% (with or without hypercapnia confirmed twice over a three-week period) * Partial pressure of arterial oxygen between 55 and 60 mmHg or SaO2 of 88% with evidence of pulmonary hypertension, peripheral edema suggesting CHF, or polycythemia (hct \> 55%)
108
**What is the purpose of surgery for patients with COPD?**
* To reduce 25% of most affected lung tissue to focus oxygenation to tissue with good V/Q match * Bullectomy * Lung volume reduction * Transplant
109
**What patients benefit most from lung volume reduction surgery for COPD? (GOLD)**
* Upper-lobe predominant emphysema and low exercise capacity prior to treatment
110
**What are 13 reasons to refer a patient with COPD? (DFCM)**
* Diagnostic uncertainty * Symptoms are disproportionate to the level of airflow obstruction * Accelerated decline of pulmonary function * FEV1\<50% * Suspicion of alpha1-antitripsin deficiency * Young age (onset \<40 years old) * Severe or recurrent exacerbations (\>2 exacerbations/year) * Failure to respond to therapy * Onset of comorbidities * Unintentional weight loss * Need for O2 therapy * Assessment for pulmonary rehabilitation * For surgery
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