COPD DSA

Question 1

COPD is characterized by __________, with the predominant conditions being _________.

Answer 1

• Airway obstruction that is not fully reversible
• Chronic bronchitis and emphysema

Question 2

Chronic bronchitis is described as ____

Answer 2

Productive cough for 3 months in each 2 successive years in a patient where other causes of sputum production have been excluded.

Question 3

What is emphysema?

Answer 3

Permanent enlargement of airspaces distal to terminal bronchioles, with destruction of bronchiolar walls without fibrosis. During expiration, airways colapse.

Question 4

Both emphysema and chronic bronchitis are result in what?

Answer 4

• 1. Peripheral airway obstruction
• 2. Parenchymal destruction
• 3. Pulmonary vascular abnormalities that decrease gas exchange and cause hypoxemia, hypercapnia and cor pulmonae.

Question 5

What should we focus on differentiated from COPD?

Answer 5

Other conditions that limit airflow and are not fully reversible: Bronchiectasis, CF and bronchiolitis.

-Asthma

Question 6

What are risk factors for developing COPD?

Answer 6

• 1. a1-antitrypsin deficiency => too much elastase => destroys elasin => early onset COPD
• 2. Genes involves in detoxifying cigg smoking
• 3. Developmental risk factors (LBW)

Question 7

80-90% of the risk of developing COPD is attributable to ___________.

Answer 7

Cigarette smoking

Question 8

How does smoking cessation affect your lungs?

Answer 8

1. Decreases FEV1

2. Reduces mortality

Question 9

Who do we screen for COPD?

Answer 9

• Not done for asymptomatic patient.
• Screen the following patients for AAT deficiency
  
  • 1. Early-onset COPD (younger that 45 YO)
  • 2. Strong family hx of lung/liver disease.

Question 10

How many pack/years smoking hx, age, and maximum laryngeal height are the most predictive of COPD?

Answer 10

1. • >40 pack-year smoking hx
2. • ≥45 y/o
3. • Maximum laryngeal height ≤4 cm

Question 11

Cardiac exam of pt with COPD may show what?

Answer 11

• • Cor pulmonale
    
    • • ↑ intensity of the pulmonic sound, persistently split S2
    • • Parasternal lift due to RVH

Question 12

How is COPD confirmed and staged?

Answer 12

• Spirometry using the GOLD criteria

Question 13

All patients who have unexplained dyspnea and cough should be evaluated for what?

Answer 13

α1-AT deficiency

Question 14

Using the GOLD criteria for staging COPD what are the characteristics of stage I through stage IV?

Answer 14

• • I (mild) = FEV1 ≥80% of predicted w/ or w/o chronic sx (cough and sputum)
• • II (moderate) =
    
    • FEV1 is 50 - 80% of predicted w/ or w/o chronic sx (cough and sputum)
• - III (severe) =
  
  • FEV1 is 30-50% of predicted w/ or w/o chronic sx (cough and sputum)
• • IV (very severe) =
    
    • FEV1 is less than 30% of predicted or
    • FEV1 <50% of predicted + chronic respiratory failure
• *All have FEV1/FVC <70%

Question 15

What confirms the prescence of a non-reversible airflow obstruction?

Answer 15

• FEV1 less than 80% post-bronchodilator
• Forced vital capacity ratio (FEV1/FVC) less than 70%

Question 16

What else can be used to detect the severity of COPD?

Answer 16

BODE index.

Question 17

What does the BODE index entail and what is it used to evaluate?

Higher score means what?

Answer 17

Risk for hospitalization, long-term prognosis in COPD patients

1. • BMI
2. • Airflow Obstruction
3. • Dyspnea
4. • Exercise capacity (the 6-minute walk distance)

Higher score => greater risk of death.

Question 18

For patient with GOLD I: mild COPD what is the standard tx?

Answer 18

Short-acting bronchodilator when needed.

Question 19

For patient with GOLD II: moderate COPD what is the standard tx?

Answer 19

• Short acting bronchodilator +
• Regular treatment with 1 or more long-acting bronchodilators + pulmonary rehab

Question 20

For patient with GOLD III: severe COPD what is the standard tx?

Answer 20

• If repeated excerbation; add ICS (but never take alone).
• • With or without either roflumiast or theophylline

Question 21

For patient with GOLD IV: very severe COPD what is the standard tx?

Answer 21

• Add long-term oxygen therapy if chornic respiratory failure
• Consider surgery

Question 22

What are the 3 types of bronchodilators are used to treat patients with stable COPD?

Answer 22

1. B agonists

2. Anticholinergic agents

3. Methylxanthines (therophylline)

Question 23

What are the difference between short and long-acting B agonists?

Answer 23

• Short-acting B agonists (albuterol and levalbuterol) are rescue meds that act in a few minutes and last 4-6 hours.
• Long-acting B agonists (salmeterol, formoterol and arformoterol) have a more sustain and predictable imrpovement on lung.
  
  • Given every 12 hours alone, with other bronchodilators or w inhaled glucocorticoids.

Question 24

Mot comon side effect of B-ago?

Answer 24

Increased HR & tremor

Question 25

What **anticholinergic** **drugs** are used as bronchodilators?

Answer 25

* 1. **Short-acting** inhaled agents (**ipatropium**) * 2. **Long-acting** inhaled agents (**tiotropium**)

Question 26

When are **anticholinergics** recommened?

Answer 26

Combined with **short or long-acting B AGO** and/or **theophylline,** bc they are less potent.

Question 27

**Tiotropium** should not be given with \_\_\_\_\_\_\_.

Answer 27

**Short-acting anticholinergic** **drugs**

Question 28

What is the **primary SE** for **anticholinergic agents**? Use with **caution** in what patients?

Answer 28

* **Dry mouth** * **Urinary obstruction** and **narrow-angle glaucoma**

Question 29

What is **theophylline** and when is it used?

Answer 29

* **Nonspecific PDE inhibitor** that increases cAMP in smooth muscle of airway and inhibits intracellular Ca2+ release. * Trial for 1-2 months by adding to _inhaled bronchodilators_ and _glucocorticoids_.

Question 30

What is **Roflumilast** and when is it used?

Answer 30

* **Oral** **PDE-inhibitor** used in select patients with **severe COPD** to **reduce risk for exacerbations.**

Question 31

Which drug used in tx of COPD is **NEVER** used alone in COPD?

Answer 31

**Inhaled glucocorticoids**

Question 32

How can we improve the actions of **inhaled glucocorticoids** and **long-acting bronchodilators?**

Answer 32

**TAKE TOGETHER;** reduce exacerbations and improve health.

Question 33

Use of **inhaled glucocortoids s**hould be monitored in who?

Answer 33

**-Elderly patients** d/t osteopenia, cataracts, hyperglycemia and pneumonia

Question 34

When should **oxygen therapy for 15 hours a day** be given to a patient with COPD?

Answer 34

**Stage 4 COPD;** * Arterial PO2 \< 55 mmHg * O₂ sat less than 88% with or without hypercapnia.

Question 35

What treatment improves quality of life in patients with moderate =\> severe symptoms that persist depite medical management?

Answer 35

**Pulmonary rehabilitation**

Question 36

What **3 surgical interventions** may improve sx's of **COPD** in highly selected pt's?

Answer 36

- **Bullectomy** - **Lung volume reduction surgery** **- Lung transplantation**

Question 37

What are **COPD exacerbations?**

Answer 37

* **Sudden change** in patients baseline **dyspnea**, **cough** and or **sputum production** that is beyond day-to-day variations due to infection or air polluation.

Question 38

**Exacerbations** are classified as: **mild**, **moderate** and **severe**. How do we treat each?

Answer 38

* **Mild to moderate exacerbations: treat at home** * Mild: short-acting bronchodilators * Moderate: short-acting bronchodilators + systemic glucocorticoids and/or ABX. * **Severe: treat at hospital w oxygen therapy** *

Question 39

How are **severe exacerbations** defined as?

Answer 39

Loss of alertness or a combo of 2 or more of the following * 1. Dyspnea at rest * 2. RR over 25/min * 3. Pulse rate over 110/min * 4. Use of accessory respiratory muscles

Question 40

What is the goal of hospital therapy for **COPD** exacerbations?

Answer 40

1. **O2 therapy** * -check by measuring **arterial blood gas levels 30-60 min** after O2 therapy.

Question 41

Treatment of COPD is stepwise and largely based on what?

Answer 41

**PFT's**

Question 42

Why is there significant benefit in using **ABX** in patients with **moderate and severe COPD exacerbations?**

Answer 42

Bacteria are often recovered: 1. **- S. pneumoniae** 2. **- M. catarrhalis** 3. **- H. influenzae**

Question 43

How do we treat **bacterial infections** seen in **COPD exacerbations?**

Answer 43

1. **Cephalosporin + macrolide** 2. **Monotherapy with fluoroquinolone** _Sputum gram stain_ or _culture_ is **not** necessary.

Question 44

What other patients qualify for **O2 therapy**?

Answer 44

* 1. **Hematocrit** is more than 55% * 2. **Arterial pO2** less than 59 mmHg * 3. **O2 sat** **less than 89%** if pt has pulmonary HTN, cor pulmonale, edema