Pathophysiology
Which guideline is available for COPD diagnosis & treatment?
Gold Report (2023/2024)
Define COPD exacerbation.
an exacerbation of COPD (ECOPD) is defined as an event characterized by increased dyspnea and/or cough and sputum that worsens in <14 days which may be accompanied by tachypnea and or tachycardia with an inc. local/systemic inflammation caused by infection, pollution, or insult to the airways.
Antibiotic prescribed to prevent COPD exacerbation?
Azithromycin
Does it really prevent an exacerbation? Controversial. Giving Azithromycin helps to prevent lung complications such as pneumonia, which can cause a COPD exacerbation. The idea is that if we ward off lung infections, we can decrease the patient's risk of a COPD exacerbation.
A 53-year-old woman presents to the ED with complaints of a ___________ and the medical resident wants a second opinion to classify the patient as having a COPD exacerbation. The resident asks you for the cardinal symptoms of a COPD exacerbation. What are they?
(list 3 of them)
- increased shortness of breath
- Coughing
- wheezing
- change in mucus color or thickness
- excessive fatigue
- chest tightness
- more frequent use of inhaler or nebulizer
- Fever
Tdap
Pneumococcal and Flu
COVID
Pertussis and Varicella Zoster
Abryso and Arexvy (if >60yo to reduce complications from RSV)
What are the 2 types of COPD?
Emphysema - gradually destroys the alveoli, causing shortness of breath.
Chronic Bronchitis - inflames the bronchi, causing frequent coughing (with or without) mucus and other symptoms.
How is a COPD exacerbation classified?
Types:
- GOLD 1 (Mild) = FEV1 >80% predicted
- GOLD 2 (Moderate) = 50% to <80% FEV1 predicted
- GOLD 3 (Severe) = 30% to 50% FEV1 predicted
- GOLD 4 (very severe) = FEV1 <30 v% predicted
***Refer to Guide***
mMRC - modified British Medical Council breathlessness scale - Grade 0 to 4 (higher score = worse outcome)
CAT - COPD Assessment Test = less symptoms it pt scores <10, if pt scores >10 more symptoms prevalent
Leukotriene modifier used to treat COPD.
Receptor antagonist:
- Montelukast 10 mg QHS
(BBW: serious mental health side effects- suicidality in adults and adolescents)
- Zafirlukast 20 mg BID
Leukotriene synthesis inhibitor:
- Zileuton 600 mg QID (or Zileuton CR BID) -
If a patient's FEV1 is 3L (predicted 4.2L), what GOLD grade does the patient have?
Answer: Grade 2
3/4.2 = 71%
GOLD Grade 50-79% = Grade 2
What are the types of smoking cessation products available to patients?
Patch: "transdermal nicotine patches" - comes in 3 steps, step 1 = 21 mg, step 2 = 14 mg, step 3 = 7 mg. If you smoke <10 cigs/day start with step 2 or 3. Expect each step to last 8-12 weeks, lower the dose as you graduate steps.
Gum: "nicotine gum" = chew until you feel a tingle, park the gum between inside of cheek and gum, hold for ~1 min for absorption, chew gum, do NOT swallow; chew 1 piece every 1-2 hours for weeks 1-6, weeks 7-9 chew one piece every 2-4 hours, weeks 10-12 chew one piece every 4-8 hours.
Lozenge: "nicotine lozenge" = 2 or 4 mg, place lozenge in mouth between gums and cheek, allow it to dissolve slowly over 20-30 minutes, move it around form one side of the mouth to the other, do NOT chew, suck or swallow it. Do not use more than 20 lozenges/day. After 6 weeks of use, patient can reduce to 1 lozenge every 2-4 hours, then 1 lozenge every 4-8 hours.
How is COPD classified? What types of pulmonary tests are available to to assess lung function?
Classified: 4 stages based on severity, Stage 1 =mild to Stage 4 = very severe
Pulmonary Function Tests:
- spirometry test - clipped placed over the nose, you inhale as much air as you can, seal your lips around the mouthpiece of a spirometer device, exhale forcefully as quickly as you can for several seconds, repeat test x3 times.
- FEV1 - the volume you exhale in the 1st second during spirometry test
- FVC - measures the total volume of air you exhale during spirometry test
- FEV1:FVC ratio - the percentage of a person's FVC that they exhale in the first second. Normal > 75-80% but can vary by age. A low FEV1/FVC ratio indicated an obstructive pattern, normal ratio indicated a normal pattern. If the ratio is 10 or more below the predicted value, it is considered obstructed.
- 6 minute walk test - assess how far a patient can walk in 6 minutes, essentially evaluating their functional exercise capacity. The shorted the distance walked, the worse the lung function correlation.
- mMRC assessment - a self-reported questionnaire that asks patients to rate their level of breathlessness during everyday activities on a scale from 0 to 4. (0 indicates no breathlessness, 4 signifies being too breathless to leave the house or do tasks like dressing themselves)
- CAT assessment - a self-reported questionnaire to assess symptoms like coughing, chest tightness, and breathlessness during daily activities. Score ranges from 0 to 40, with 40 indicating more symptoms, more severe impairment.
How do you manage a COPD exacerbation?
***SEE Guide***
Administer supplemental O2
Inc. doses and/or frequency of short-acting bronchodilator; combine short-acting beta-2 agonists AND anticholinergics; consider use of long-term bronchodilators when pt is stable; use spacers or air-driven nebulizers when appropriate
Consider oral corticosteroid (prednisone)
Consider antibiotics (oral) when signs of bacterial infection are present
Consider non-invasive mechanical ventilation
Which type of steroid is commonly used when treating a COPD exacerbation?
Oral Corticosteroid
Prednisone
Dose: 40-60 mg/day x 3-10 days
DDI: live vaccines, other immunosuppresants
If a patient has 1 hospitalization for COPD 5 months ago and a mMRC score of 1, what group is he in?
Group E
What type of infections have been associated with reduced lung function and increased respiratory symptoms?
1. Chronic Bronchial Infections - Pseudomonas aeruginosa (inc. FEV1 decline)
2. Tuberculosis (potential comorbidity)
3. HIV (inc. risk of COPD due to methylation disruptions in airway epithelium)
4. IgG subclass deficiency (inc. risk of mortality)
5. Pneumonia
What are at least 3 risk factors for developing COPD?
1. Smoking
2. Air Pollution (chemical fumes, dust, smoke)
3. h/o childhood respiratory infections
4. Smoke exposure from coal or wood burning
5. Age >40
6. Asthma
7. Structural differences within the lungs
8. Tuberculosis infection
9. Men > women
10. Lower social economic status
11. Alpha-antitrypsin deficiency (genetic disorder that may lead to lung disease or liver disease)
Should you obtain a sputum culture if a patient has a suspected COPD exacerbation?
Yes, according to the NIH, about 40-50% of COPD exacerbations are caused by bacteria, alone or in combination with a virus.
Which inhaled medications are considered SABA's, and SAMA's?
SABA: albuterol, levalbuterol
SAMA: Ipratropium Bromide (Atrovent HFA and nebs), ipratropium/abuterol (Combivent Respimat, DuoNebs)
If a patient is in group B, which types of inhaler(s) should the patient utilize?
LAMA + LABA
What are the 5 A's of smoking cessation?
Ask - ask patient about tobacco use at every visit
Assess - ask if patient is willing to quit within the next 30 days
Advice - in a clear, strong, personalized manner advise patient of the dangers of smoking and the benefits assoc. with cessation.
Assist - with help from patient, assist in creating an individualized plan for smoking cessation
Arrange - make plans to follow-up with patient regarding their smoking cessation goals
Are symptoms enough to diagnose COPD? If not, how is COPD diagnosed?
No, sx are not enough to diagnose.
Spirometry Test, symptoms, absence of HF, TB, Bronchiectasis, and other diseases.
What are the Goals of Therapy for a COPD exacerbation?
Reduce Symptoms:
- relieve symptoms
- improve exercise tolerance
- improve health status
Reduce Risk:
- prevent disease progression
- prevent and treat exacerbations
- reduced mortality
Which inhaled medications are considered LABA's and LAMA's?
LABAs = Salmeterol (Servent Diskus), Formoterol, Vilanterol (in combination as Breo and Trelegy)
LAMAs = Spiriva Respimat/handihaler, Incruse Elipita
If a patient is in Group E, what type of medication can you add on in addition to an LABA + LAMA?
ICS = inhaled corticosteroid
Who should be screened for Lung Cancer? Who sets these recommendations?
Screened: those with a 20 pack/year or more smoking history, current smokers or those who have quit within the past 15 years, patients ages 50-80 years.
Institution: US Preventative Services Task Force