COPD

Question 1

What is the definition of COPD?

Answer 1

A

• common,
• preventable, and
• treatable
• disease characterized by persistent respiratory symptoms and airflow limitation due to airway or alveolar abnormalities
• caused by significant exposure to noxious particles or gases.

Question 2

What are the two major subtypes of airflow limitation in COPD?

Answer 2

Chronic Bronchitis

Emphysema

Question 3

What are the criteria for chronic bronchitis?

Answer 3

daily cough with sputum production lasting for at least three months, two years in a row

Question 4

What are the findings in the airways in chronic bronchitis?

Answer 4

In the small airways:

• inflammation
• fibrosis
• luminal
• increased airway resistance

Question 5

What are the findings in the airways in emphysema?

Answer 5

In the parenchyma:

• alveolar destruction
• loss of alveolar attachments
• decrease of elastic recoil

Question 6

What are the answers to all the questions on the exam?

Answer 6

I don’t know

BUT

Question 7

COPD Epidemiology

Answer 7

• onset usually in mid-life >40 years
• symptoms slowly progressive
• usually long smoking / exposure history

Question 8

Asthma epidemiology

Answer 8

• usually diagnosed early in life (childhood)
• symptoms vary from day-to-day
• symptoms often worse at night/early morning
• allergy, rhinitis and eczema also present
• family history of asthma

Question 9

What percentage of smokers go on to develop COPD?

Answer 9

About 24% develop clinically significant COPD

Question 10

What are some other environmental causes of COPD?

Answer 10

exposure to pollution from biomass fuels

expsoure to smoke from fires or second hand

Question 11

What are common COPD phenotypes?

Answer 11

emphysema

chronic bronchitis

ACOS - Asthma/COPD overlap syndrome

emphysema interstitial fibrosis syndrome

Question 12

What are some risk factors for COPD?

Answer 12

lower socio-economic status

infections

genotype

female gender

Question 13

COPD is the ____ leading cuase of death in the world

Answer 13

4th

Question 14

Approximately how many adults in the US are living with COPD (2011 figure)?

Answer 14

24 million

Question 15

What symptoms and history should prompt you to consider COPD?

Answer 15

Symptoms (not all need to be present): dyspnea, chronic cough, sputum production

Risk factors: tobacco smoking, biomass smoke, occupation, indoor/outdoor pollution

Question 16

What other conditions are associated with COPD?

Answer 16

depression

anemia

pulmonary hypertension

cor pulmonale

osteoporosis

impaired systemic muscle function

decreased fat-free mass

Question 17

What should you do to diagnose COPD if suspected?

Answer 17

Spirometry/Pulmonary Function Testing

Question 18

How do you determine the severity of the disease?

Answer 18

Assessment of:

• risk factors
• symptoms
• severity of airflow limitation with spirometry
• impact on patient’s health status
• risk of future exacerbations

Question 19

What is the best single predictor of airflow obstruction?

Answer 19

40 pack-year smoking history

Question 20

What signs on PE are suggestive of COPD?

Answer 20

1. hyperinflation (barrel chest)
2. hyperresonance on percussion
3. decreased breath sounds
4. wheezing on regular and forced expiration
5. prolonged expiratory phase
6. crackles on inspiration (sometimes)

Question 21

What are some common signs seen suggestive of the chronic bronchitic phenotype?

Answer 21

• possible obesity
• signs of right heart failure - edema and cyanosis
• frequent cough and expectoration
• use of accessory muscles of respiration (SCM)
• coarse wheezes may be heard on auscultation

Question 22

what are some common signs of the emphysematic phenotype?

Answer 22

• may be thin with barrel chest
• litte to no cough
• pursed lips and use of accessory respiratory muscles
• tripod sitting position (in distress)
• hyperresonant chest with wheezing
• heart sounds very distant

Question 23

What is diagnostic on spirometry of obstruction?

Answer 23

FEV1/FVC < .70 post-bronchodilator

Question 24

What should you not give people with right-sided heart failure?

Answer 24

diuretics - it increases the pre-load volume and exacerbates the problem

Question 25

What are the GOLD criteria for assessment of COPD severity?

Answer 25

Question 26

What is DLCO in COPD?

Answer 26

Reduced due to obstruction

Question 27

What test should you perform in a patient under 45 who develops COPD or with a strong family history of COPD?

Answer 27

Alpha-1 Antitrypsin Deficiency Screening

Question 28

What is a COPD exacerbation?

Answer 28

worsening symptoms from stable state of dyspnea, cough and productive sputum.

Question 29

who is high risk for exacerbations?

Answer 29

patients in the past year who had two or more mild to moderate exacerbations one or more severe exacerbations

Question 30

when using systemic corticosteroids, what must you do?

Answer 30

keep use short-term only and taper

Question 31

What does the mMRC questionnaire assess?

Answer 31

Degree of breathlessness

Question 32

What score on the CAT questionnaire is considered symptomatic?

Answer 32

\> or equal to 10 = symptomatic

Question 33

How are the risk categories stratified o the GOLD combined assessment of COPD? (A-D)

Answer 33

A (low risk) - CAT\<10 and mMRC 0-1 with 0-1 exacerbations in the past 12 months that did not lead to hospital admission B (low risk) - CAT\> or equal to 10 and mMRC \> or equal to 2 with 0-1 exacerbations not leading to hospital admission C (high risk) - CAT \<10 and mMRC 0-1 with 2 or more exacerbations or one or more leading to hospitalization in the past 12 months D (high risk) - CAT \> or equal to 10 and mMRC \> or equal to 2 with 2 or more exacerbations or one or more leading to hospitalization in the past 12 months

Question 34

What are the two major objectives of COPD therapy?

Answer 34

Reduce symptoms - improve health status and exercise tolerance Reduce Risk - prevent progression, prevent and treat exacerbations and reduce mortality

Question 35

What is the most important thing people with COPD can do to slow the progression of the disease?

Answer 35

quit smoking

Question 36

What else, other than quitting smoking, is important for COPD patients to do?

Answer 36

get regular physical activity and remain active reduce exposure to pollutants get influenza and pneumococcal vaccinations

Question 37

What class of medications are central to the treatment of COPD?

Answer 37

bronchodilators

Question 38

What short acting Beta 2 agonists (SABAs) are used in the treatment of COPD?

Answer 38

albuterol levoalbuterol

Question 39

What long-acting beta 2 agonists are used in treatment of COPD?

Answer 39

salmeterol formoterol indacaterol vilanterol

Question 40

What muscarinic inhibitors (anticholinergics) are used in the management of COPD?

Answer 40

SAMA - ipotropium LAMA - tiotropium, aclidinium, umeclidinium, glycopyrrolate

Question 41

What inhaled corticosteriods are sometimes used in COPD?

Answer 41

fluticasone, mometasone, budesonide

Question 42

What are some infrequently used drugs in the management of COPD?

Answer 42

Methylxantines - theophylline phosphodisterase4 inhibitors - roflumist systemic corticosteriods - for exacerbations only. No more than 10 days with a taper.

Question 43

Which is preferred in treatment? Long-acting or short-acting formulations?

Answer 43

long-acting

Question 44

Long-term monotherapy with what class of drugs is NOT recommended in COPD?

Answer 44

inhaled corticosteroids

Question 45

what is roflumilast useful for?

Answer 45

to reduce exacerbations in patients with chronic bronchitis

Question 46

What antibiotic class may be useful to reduce exacerbations in patients with chronic bronchitis?

Answer 46

macrolides

Question 47

What are the preferred treatments for GOLD group A?

Answer 47

SAMA or SABA prn

Question 48

What is the preferred treatment for GOLD Class B?

Answer 48

LABA or LAMA (1st line) LAMA + LABA (2nd line)

Question 49

What is the preferred treatment for GOLD Class C?

Answer 49

LAMA + LABA or ICS + LABA (moving away from this)

Question 50

What is the preferred treatment for GOLD Group D?

Answer 50

LAMA + LABA (1st) LAMA + LABA + ICS (2nd) Roflumilast/Macrolide (exacerbation)

Question 52

What is NOT recommended for use in COPD?

Answer 52

NO antitussives mucolytics alpha-1 antitrypsin augmentation (unless genetically deficient)