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Chronic Obstructive Pulmonary Disease (COPD)

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Chronic obstructive pulmonary disease or copd is the topic and copd essentially comprises two components there’s chronic bronchitis and then there is emphysema now chronic bronchitis is essentially a presentation of productive cough on a chronic basis whereas emphysema is talking more about the destruction of the lung parenchyma and what that can do over time is it

Can cause the lung to be hyper inflated and this is due to the air being trapped inside so keep those two components in mind in terms of etiology the most common reason that a person can develop copd is because of the smoking and there is a genetic component to copd as well in terms of pathophysiology there’s some key components to copd that you need to know the

First one of course is inflammation of the airways the next one is bronchoconstriction in addition to these two there is a hallmark of copd and this is detected on diagnostic tests and i will talk about a little later and that is airflow limitation essentially it’s very difficult for a person with copd to exhale with a maximal effort and the pft is the pulmonary

Function tests will demonstrate that another thing is airway obstruction and this happens because of all the mucus and edema that can collect in the airways in addition in acute exacerbations copd can lead to bacterial infection and this is an important thing to mention because it will dictate how it is treated and it is treated with antibiotics if this happens so

Keep these key pathophysiology aspects in mind in terms of symptoms well on a clinical vignette part of the history will almost always include smoking but symptoms of course include difficulty breathing wheezing on physical exam a barrel chest which essentially is an increased anterior posterior diameter of thorax cough a productive cough is often found if there is

A strong bronchitis component to the copd so now let’s talk about the diagnosis first @test is a chest x-ray and this will show hyperinflation of the lung and that will be seen on the chest x-ray as a flat diaphragm since the lung is essentially compressing the diaphragm there’s so much air inside now the key test to diagnosing copd is the spirometry or pft s which

Our pulmonary function tests now the pulmonary function test is going to be measuring some key components and those key components are as follows fev1 fv c and the ratio between these two and i’ll explain what each of these are now fev1 is the volume of air that is forcefully expired in the first second word of the exhale fev1 stands for forced expiratory volume

In one second fec which is forced vital capacity is the total volume of air that is expired with maximum force and then of course you have the ratio now in copd the fev1 will be decreased now how much decrease that depends on the level of severity and the ratio will also be decreased it will be less than 0.7 now the hallmark of copd is that you have a decreased

Forced expiratory effort so keep that in mind there’s one more lab test i wanted to mention very briefly it might show up is in copd your hematocrit will be very high sometimes as high as 50 and that essentially is known as polycythemia sometimes i mentioned that on clinical vignettes so now let’s get into the final part which is treatment and before i get into all

The medications i want to right in the corner here something that’s very important and that is smoking cessation that should definitely be part of the treatment so now let’s break this up into three categories patient group the findings and of course the treatment now we’re going to break this up into three categories you have mild copd you have moderate copd and

Then of course you have severe copd now the findings that will characterize which category is the fev1 if it’s greater than or equal to 80 percent of predicted value it’s known as mild if the fev1 is essentially between fifty and seventy nine percent and it’s moderate and if the fev1 is less than fifty percent it’s considered severe so what are the medications

First i’ll write the abbreviations and then i’ll explain what each of these are so i have s a b a plus s ac which is short acting beta agonist plus a short acting cholinergic and then you have la ba which is a long-acting via agonist and then finally the last medication is known as a ics which is inhaled corticosteroid so let’s go through this si ba what’s that

Short-acting beta test and an example of that is very famous albuterol so that is of course an in hit and inhaler si si is short acting anticholinergic and an example of that is i petroleum now when you say si ba plus si si basically it’s a combination so these two medications given in one and that is known as complement and that is of course a brand name but the

Generic names are albuterol plus ipratropium so that takes care of mild but what about moderate well moderate you keep the complement but then you add la ba well what’s with la ba well that’s long-acting beta agonist and an example of that is sal miro so you would add salmeterol to the treatment plan and then finally severe you keep your calm event but then you

Add la ba + ics ics is inhaled corticosteroid and an example of an inhaled corticosteroid is fluticasone so you would give a long-acting beta agonists with an inhaled corticosteroid so you’d give salmeterol with fluticasone and that is adverb advair is an inhaler that contains both salmeterol and fluticasone so that is essentially a very simple very structured way

Of remembering the treatment plan so let’s take a look at some vignettes 67 year-old comes to the office complaining of a twelvemonth history of shortness of breath at rest with mild exertion he also reports wheezing that seemed to correspond to the times when he is most out of breath he has cough that is persistent most of the year and occasionally productive a

Scant sputum he has a long smoking history of over a hundred packs here he has recently quit his only other medical history is hypertension hyperlipidemia chest x-ray shows hyperinflation but clear lung fields and no evidence of parenchymal or mediastinal mass the most appropriate next step is well let’s go through these obtain spirometry meaning do the pf ts yes

Definitely ct of the chest in terms of the next step a little too expensive they’re prescribed albuterol corticosteroids that might be but we don’t know that yet we have to do the pf t’s first so the answer for that would be a next question 67 year-old man comes to the clinic for annual visit he and his wife have just moved to the area from out of state he brought

Along his medical records which showed that he has a hypertension pvd and that he carries the diagnosis of emphysema he tells you that he smoked one pack of cigarettes per day but were friends from all but social alcohol his medications include thiazide capture per acquaintance and albuterol inhaler as needed he has never had a pulmonary function test temperatures

98 but pressures 135 pulse is 72 respirations are 14 he has diffuse bilateral expert ory wheezes and a mild prolonged expert ory time abdomen is obese but non tender is no fluid wave the most appropriate intervention for this patient is well let’s go through these change captopril to less than a pro i don’t know of what that’s going to do encourage him to quit

Smoking immediately that’s a very good one increases thiazide diuretic or initiate home oxygen therapy si doesn’t really his blood pressure’s normal so i don’t know why it increased that sits between b or d d we don’t know yet because he’s never had a pulmonary function test so we need to do that if his fev1 was perhaps less than 30 then maybe you would consider

Oxygen therapy but for now the best thing for him to do and the best advice to give him is to quit smoking next question 72 year old male with copd because the emergency department with acute exacerbation marked by increased sputum production and shortness of breath as oxygen is 88 on room air and he has diffused inspiratory and expiratory wheezes bilaterally in

Addition to oxygen and bronchodilators which of the following is the most important for this patient now remember this is an exacerbation exacerbations and he also has sputum that can lead to bacterial infection it’s part of the pathophysiology so you definitely should add antibiotics and to decrease inflammation in acute exacerbations definitely add corticosteroids

So the answer to this question would be d and then finally a 52 year old female sees you for the first time to establish care for stable copd since losing her insurance four months ago she has been off all medications except for a short-acting bronchodilators she stopped smoking two years ago she has frequent chronic cough and his dismay ik while climbing stairs

Pft reveals fvv 155 percent o2 saturation is 90% in addition to the short-acting inhaler bronchodilator recommended maintenance that mono therapy for this patient would be either inhaled long-acting anticholinergic agent or an inhaled what well her fev1 is 55% so she’s in the moderate category and for moderate cpd they recommend a short-acting beta-2 agonist plus

A short-acting cholinergic medication and the questions already told you about that so she’s already got the short-acting bronchodilators which is the short acting beta agonist and they’re saying either a short either a long-acting anticholinergic agent or long or short depending on severity the key thing is that it’s an anticholinergic agent or an inhaled what

Well in moderate copd in addition to these drugs that are listed here the short acting beta agonist and the anticholinergic agent you also give a long-acting beta agonist and that would be choice b and an example of a long-acting beta agonist is cell mineral

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Chronic Obstructive Pulmonary Disease (COPD) By CanadaQBank