COPD and Pneumonia: A Quick Guide PDF

Chronic Obstructive Pulmonary Disease (COPD) Progressive, not fully reversible, and associated with an abnormal inflammatory response of the lungs. The loss of small airways contributes to airflow limitation and mucociliary dysfunction (characteristic features). They present most comm...

Chronic Obstructive Pulmonary Disease (COPD) Progressive, not fully reversible, and associated with an abnormal inflammatory response of the lungs. The loss of small airways contributes to airflow limitation and mucociliary dysfunction (characteristic features). They present most commonly with dyspnea, cough, and sputum production (late in disease course, when irreversible changed have already occurred) Asthma NOT included- although it is small airway inflammation, it’s generally reversible Exacerbation: acute event characterized by dyspnea and/or cough and sputum that worsen over 6 sec indicates COPD To confirm diagnosis (gold standard): Spirometry performed pre- and post-bronchodilator administration to determine if airflow limitation is reversible. Not to be performed during exacerbations (inaccurate results) Patients with suspected COPD are evaluated with Pulmonary Function Tests (PFTs) FEV1 and all other measurement of expiratory airflow are reduced TLC, FRC, and RV may be increased FEV1/FVC < 0.70 and FEV1 < 80% indicates COPD and not fully reversible Pulse Oximetry, ECG to detect cor pulmonale CBC, ABGs (necessary), a1-Antitypsin CXR- a low, flattened diaphragm is common finding in COPD patients Flattening of diaphragm (should be dome shaped), blunting of the COPD costophrenic angle (PA), enlarged retrosternal space (lateral), hyperinflation (a lot of black) COPD (left) vs normal (right)  COPD Differential Diagnosis COPD (associated in midlife, smoking, slowly progressive) Asthma-COPD Overlap Syndrome (earlier in life, varying symptoms during early morning/night), family history of asthma/allergies, largely reversible airflow limitations, but can develop COPD later Congestive Heart Failure (fine crackles, pulmonary edema, dilated heart) Pulmonary Edema Bronchiectasis (large volumes of purulent sputum commonly associated with bacterial infection, crackles, bronchial thickening on xray) Tuberculosis (cough lasting > 3 weeks, pleuritic chest pain, hemoptysis with fatigue, weight loss, anorexia, fever, chills, night sweats) Nontuberculous mycobacterial lung disease Lung Cancer Classification of COPD by Severity ( see Buttaro pp 515) Stage 1Mild COPD- Mild airflow limitation (FEV1 > 80% predicated). Sometimes chronic cough/sputum production. May not be aware yet that lung function abnormal Stage 2Moderate COPD- Worsening airflow limitation (FEV1 < 50% and < 80% predicted, Progression of symptoms, with SOB developing with exertion Stage 3Severe COPD- Further worsening of airflow limitation (FEV1 < 30% and < 50% predicted), increased SOB, and repeated exacerbations (which can have an impact on quality of life/prognosis if FEV1 < 50% predicted) Stage 4Very Severe COPD- Severe airflow limitation (FEV1 < 30% predicted or < 50% predicted + chronic respiratory failure. Quality of life is very impaired and exacerbations may be life threatening  Pharmacologic Agents for COPD therapy Buttaro, pp. 519 Oral Corticosteroids Anticholinergics: bronchodilator first line for daily Methylprednisolone: 40-48 mg daily in 3-4 symptoms (SAMA and LAMAs) days divided doses Ipratropium bromide (SAMA): 20-40 mcg/inhalation Prednisone: 40 mg daily for 5 days (acute MDI 2-4 puffs q 6-8 hours. Must be used regularly (not exacerbations, replace with inhaled form prn) asap) Aclidinium bromide (LAMA): 400 mcg/inhalation DPI, one inhalation BID Inhaled Corticosteroids (combine with Tiotropium (LAMA): 18 mcg/inhalation DPI, once daily LABA) Beclomethasone dipropionate B2-Adrenergic Agonists: bronchodilator first line Budesonide if intermittent symptoms (SABA and LABA) Albuterol sulfate (SABA): 90 mcg/inhalation, 1-2 puffs Ciclesonide q 4-6 hours prn Mometasone furoate Bitolterol mesylate (SABA) Fluticasone propionate Levalbuterol (SABA): 45 mcg/inhalation MDI 2 puffs q Severe COPD: Combination LABA in One 4-6 hours Salmeterol xinafoate (LABA): 50 mcg DPI, 1 puff q 12 inhaler (Formoterol/budesonide 160/4.6 hr mcg, 2 inhalations q 12 hr) Formoterol (LABA): 20 mcg/2 mL NS nebulization (CAT SABA + SAMA: Ipratropium score < 10, low exacerbation frequency) Bromide/Albuterol 20/100 mcg 1 inhalation 4-6 hr duration, not exceed 4-12 inhalations/day for q 6 hr SAMA or 2 times for LAMA Methylxanthine (Theophylline): 10 mg/kg/day in 4 LAMA + LABA (CAT > 10, more doses symptomatic) Phosphodiesterase 4 Inhibitor: Roflumilast COPD Treatment and Patient Education Smoking Cessation Influenza vaccine yearly and PCV20, tdap, and zoster for COPD patients Avoidance of irritants or allergens Postural drainage may clear excess secretions Pulmonary Rehabilitation Exercise Training- extremity and strength training, 10-45 min sessions for 4-6 weeks, pursed lip breathing and controlled coughing startegies Nutritional Support- can have weight loss, eat small, frequent meals MAINSTAY of therapy: Inhaled Ipratropium bromide (Atrovent) or sympathomimetics Inhaled tiotropium bromide (Spiriva) promotes bronchodilators Palliative Care and Hospice services for end-of-life care Pneumonia A leading cause of morbidity and mortality in the US, especially in older adults and those with underlying chronic disease. Pneumonia is the 2nd leading cause of death in children younger than 5 years Pneumonia is classified as typical and atypical. Typical pneumonia caused by Streptococcus pneumoniae accounts for 60 to 70% of all bacterial Community Acquired Pneumonia (CAP). Atypical pneumonia organisms are not detectable on Gram stain, caused by Mycoplasma pneumoniae, Chlamydophila pneumoniae, Legionella species and respiratory viruses.  Pneumonia Clinical presentation In CAP, diagnosis is made by H&P exam, identification of causative agent is usually NOT necessary. CAP is most common cause of focal infiltrate on CXR Clinical manifestations include: Fever, chills or rigors, malaise, cough with or without sputum production May report hemoptysis, dyspnea, pleuritic chest symptoms, temp > 100.4, RR > 24, HR > 100 Upon auscultation crackles/rales do not clear with cough Consolidation, including dullness to percussion Bronchial breath sounds Egophony (E-to-A changes) Chest X-ray may be normal in early disease Headache and Sore throat Fatigue, lethargy, decreased appetite Increase in falls, altered mental status change(confusion, stupor, coma) Bacterial Pneumonia Syndrome Gram Positive Strep pneumonaie is the leading cause in any age group Abrupt onset with high fever, shaking chills, productive cough, pleuritic chest pains, green-rust colored sputum Upon exam: sign of consolidation (egophony, increased fremitus, rales, rhonchi) Gram Negative Hemophilus influenzae another cause of CAP is a small gram negative rod. There are 6 serotypes. Type B is the most severe and invasive causing meningitis and sepsis. Older adults with underlying causes (COPD) most susceptible. Abrupt onset with fever, chills, cough, pleuritic pain, and consolidation. Bronchopneumonia seen on CXR, ground glass opacities, bronchial wall thickening, confluent areas of consolidation, and centrilobular nodules Mortality rates relatively high with gram negative pneumonias  Atypical Pneumonia (Walking Pneumonia) Atypical Pneumonias caused by nonbacterial organisms Mycoplasma pneumonaie one of most common causes of atypical pneumonaie in US (less common are chlamydia and legionella) Infection rates highest among younger: school-age children, military recruits, college students Gradual onset characterized by low grade fever, headache, fatigue, myalgias, dry, nonproductive cough Physical exam reveals fine cackles/rales with no signs of consolidation, clear mucus Maculopapular eruptions, painful (TM) bullous myringitis CXR reveals bilateral patchy alveolar densities or segmental lobar infiltrates, atelectasis and small pleural effusions WBC count is normal or slightly elevated Gold diagnostic: PCR or sputum swab Full recovery expected without residual effects, however can be severe in those with Sickle cell disease or those in immunosuppression Treatment: Azithromycin 5 days or Clarithromycin 500 mg BID 7-10 days Doxycycline 100 BID 7-10 days Levofloxacin 750 mg 5-7 days Antitussives PRN  Pneumonia Essential Diagnostics CXR- Posteroanterior and lateral views to confirm new infiltrates. Gold standard for pneumonia diagnosis Bacterial: lobar consolidation (typical), cavitation, large pleural effusions, bilateral, diffuse infiltrates (atypical) May have a normal CXR- does not rule out pneumonia Pulse Oximetry Sputum analysis useful to identify causative organism (not for outpatient CAP but inpatient MRSA or P. aeruginosa) Culture and gram stain of a sputum sample from bronchial tree For CAP, do not get culture, obtain CXR Labs: CBC with differential, Blood chemistry, Arterial Blood gases, Liver function tests (likely to have bacteriemia with CAP in chronic liver disease) Blood cultures if hospitalized with CAP, MRSA or P. aeruginosa, or hospitalized/got parenteral antibiotics in last 90 days Other: Bronchoscopy CT Scan  Pneumonia Differential Diagnosis Pneumonia: Fever, tachypnea, tachycardia, productive cough. CXR shows lobar consolidation. May have pleuritic chest pain with cough Pulmonary Embolus: New onset of dyspnea, hemoptysis, pleuritic chest pain. Vital signs show tachycardia and tachypnea. May have signs of DVT Heart failure: SOB/dyspnea that worsens with exertion or exercise, pitting edema, and dry cough. Physical exam may show S3, elevated JVD Inflammatory lung disease (systemic vasculitis, sarcoidosis) Foreign body aspiration (especially in young children) Tuberculosis: fever, anorexia, fatigue, night sweats, productive cough with blood stained sputum and weight loss COVID-19 symptoms A fever, a dry cough, and shortness of breath are common early signs of COVID-19. Fatigue, Chills Nausea or vomiting Diarrhea Belly pain Muscle or body aches A headache Loss of smell or taste A sore throat Congestion or a runny nose Pinkeye Skin rashes CXR- infiltrates COVID-19 Pneumonia People who get COVID-19 pneumonia may also develop acute respiratory distress syndrome (ARDS) and require mechanical ventilation. The new coronavirus causes severe inflammation in the lungs. It damages the cells and tissue that line the alveoli in the lungs, where oxygen is delivered to blood. The damage causes tissue to break off and damage the lungs. The walls of the alveoli can thicken, making it very hard to breathe.  Types of COVID-19 tests COVID-19 tests are available that can test for current infection or past infection. A viral test indicates a current infection. Two types of viral tests can be used: nucleic acid amplification tests (NAATs) and antigen tests. An antibody test (also known as a serology test) might tell you if you had a past infection. Antibody tests should not be used to diagnose a current infection. Authorized and Recommended Vaccines in the US to prevent COVID-19 Pfizer-BioNTech People 12 years and older 2 shots Given 3 weeks (21 days) apart *Fully vaccinated after 2 weeks after your second shot Moderna People 18 years and older 2 shots Given 4 weeks (28 days) apart * Fully vaccinated after 2 weeks after your second shot Johnson & Johnson/Janssen People 18 years and older 1 shot- *Fully vaccinated after 2 weeks after your shot COVID-19 Vaccine Recent Information CDC Monitoring Reports of Myocarditis and Pericarditis CDC has received increased reports of myocarditis and pericarditis in adolescents and young adults after COVID-19 vaccination. The known and potential benefits of COVID-19 vaccination outweigh the known and potential risks, including the possible risk of myocarditis or pericarditis. CDC continues to recommend COVID-19 vaccination for individuals 12 years of age and Lobar/Bacterial Pneumonia: Grayish to white areas on a lobe or lobes of lung (consolidation) from purulent fluid  Pharmacologic Treatment for Typical Pneumonia Healthy patients 60 years, no recent antibiotic use in 90 days Combination therapy (beta lactam + macrolide or doxycycline): Amoxicillin Clavulanate 875/125 mg BID, macrolide (azithromycin 500 mg first day then 250 mg daily or clarithromycin 500 mg BID) or doxycycline 100 mg BID Fluoroquinolones such as levofloxacin (Levaquin) 750 mg daily, Gemifloxacin (Factive) 320 mg daily or moxifloxacin (Avelox) 400 mg daily Pharmacologic Treatment Atypical Pneumonia A macrolide, such as azithromycin (Zithromax), clarithromycin (Biaxin), erythromycin, fluoroquinolones or doxycycline Outpatient who are low risk for death are treated at outpatient settings Treatment of Pneumonia include use of severity assessment tools (CURB-65 criteria) and Pneumonia Severity Index to assist in determining patient who require hospitalization.  Pneumonia Patient and Family Education and Provide Health directions for use ofPromotion antibiotics and information of potential side effects of the drug Follow up in 24-48 hours by telephone or visit in office Drink adequate fluids and use of antipyretic to control fever and myalgias prn Use of cough medicines are avoided because it will prevent removal of secretions Use of codeine at night allows more restorative sleep, avoid cough medicines due to thick secretions and cough reflex Patients at risk should receive pneumonia vaccine, influenza vaccine annually Institute respiratory hygiene measures (hand sanitizer, masks, social distancing) Daily exercise and healthy diet plan, including vitamins, nutrients and fiber COVID patients at higher risk for DVT/PE  Which is characteristic of obstructive bronchitis and not emphysema? a. Damage to thealveolar wall b. Destruction of alveolar architecture c. Mild alteration in lung tissue compliance d. Mismatch of ventilation and perfusion  ANS: C Obstructive bronchitis causes much less parenchymal damage than emphysema does, so there is milder alteration in lung tissue compliance. theother symptoms are characteristic of emphysema  Which test is themost diagnostic for chronic obstructive pulmonary disease (COPD)? a. COPD Assessment Test b. Forced expiratory time maneuver c. Lung radiograph d. Spirometry for FVC and FEV1  ANS: D Spirometry testing is thegold standard for diagnosis and assessment of COPD because it is reproducible and objective. theforced expiratory time maneuver is easy to perform in a clinic setting and is a good screening to indicate a need for confirmatory spirometry. Lung radiographs are non-specific but may indicate hyperexpansion of lungs. theCOPD assessment test helps measure health status impairment in persons already diagnosed with COPD  A patient diagnosed with chronic obstructive pulmonary disease reports daily symptoms of dyspnea and cough. Which medication will theprimary health care provider prescribe? a. Ipratropium bromide b. Pirbuterol acetate c. Salmeterol xinafoate d. Theophylline  ANS: A Ipratropium bromide is an anticholinergic medication and is used as first-line therapy in patients with daily symptoms. Pirbuterol acetate and salmeterol xinafoate are both beta2-adrenergics and are used to relieve bronchospasm; pirbuterol is a short-term medication used for symptomatic relief and salmeterol is a long-term medication useful for reducing nocturnal symptoms. Theophylline is a third-line agent  A patient reports shortness of breath with activity and exhibits increased work of breathing with prolonged expirations. Which diagnostic test will theprovider order to confirm a diagnosis in this patient? a. Arterial blood gases b. Blood cultures c. Spirometry d. Ventilation/perfusion scan  ANS: C The patient has signs of either asthma or COPD. Spirometry is essential to both thediagnosis and management of these diseases. ABGs are useful when evaluating severity of exacerbations but are not specific to these diseases. Blood cultures are drawn if pneumonia is suspected. A ventilation/perfusion scan is performed to evaluate for pulmonary thromboembolic disease  An older adult patient diagnosed with chronic obstructive lung disease (COPD) is experiencing dyspnea and has an oxygen saturation of 89% on room air. thepatient has no history of pulmonary hypertension or congestive heart failure. What will theprovider order to help manage this patient’s dyspnea? a. Anxiolytic drugs b. Breathing exercises c. Opioid medications d. Supplemental oxygen  ANS: B Formal pulmonary rehabilitation programs, including breathing exercises, are used to manage long- term disease such as COPD. Anxiolytics and opioids must be used cautiously because of respiratory depression side effects. Medicare does not approve oxygen supplementation unless saturations are less than 88% on room air or for patients who have pulmonary hypertension or CHF who have saturations