COPD

COPD from Harrison's Internal Medicine 20th ed

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COPD by Mind Map: COPD

1. not fully reversible

1.1. persistent respiratory symptoms

1.2. airflow limitation

1.2.1. chronic airflow obstruction

1.2.1.1. spirometry

1.2.1.2. occurs

1.2.1.2.1. noxiuos environmental exposure

2. includes

2.1. Emphysema

2.1.1. destroyed alveoli

2.1.2. air space enlargement

2.2. Chronic Bronchitis

2.2.1. chronic cough

2.2.2. phlegm

2.3. Small airway disease

2.3.1. small bronchioles

2.3.1.1. narrowed

2.3.1.2. reduce in number

3. COPD Pathogenesis

3.1. airflow limitation

3.1.1. results

3.1.1.1. small airway dse

3.1.1.1.1. becomes narrowed by

3.1.1.2. emphysema

3.2. extensive small airway destruction

3.3. paradigm

3.3.1. Chronic exposure to cigarette smoke

3.3.1.1. genetically succeptible

3.3.1.1.1. triggers

3.3.2. Inflammatory cells

3.3.2.1. release

3.3.2.1.1. proteinases

3.3.3. Structural cell death

3.3.3.1. through

3.3.3.1.1. proteolytic loss of cellular-matrix attachment

3.3.3.1.2. cellular senescense

3.3.3.1.3. oxidant-induced damage

3.3.3.2. leads to

3.3.3.2.1. extensive loss of smaller airways

3.3.3.2.2. vascular prunning

3.3.3.2.3. alveolar destruction

3.3.4. Disordered repair of elastin + extracellular matrix components

3.3.4.1. air space elnargement

3.3.4.1.1. emphysema

4. CHRONIC OBSTUCTIVE PULMONARY DISEASE

4.1. COPD

4.1.1. AIRFLOW OBSTRUCTION

4.1.1.1. INFLAMMATION OF AIRWAYS

4.1.1.1.1. CHRONIC BRONCHITIS

4.1.1.2. DESTRUCTION OF THE ALVEOLAR WALL

4.1.1.2.1. DILATION OF THE AIRSPACE

5. Physical Findings

5.1. current smokers

5.1.1. active smoking signs

5.1.1.1. odor

5.1.1.2. staining of nails

5.2. severe

5.2.1. prolonged expiratory phase

5.2.2. expiratory wheezing

5.2.3. hyperinflation

5.2.3.1. barrel chest

5.2.3.2. percussion

5.2.3.2.1. enlarged lung volumes

5.2.4. use of accessory ms of respiration

5.2.5. sitting in tripod position

5.2.5.1. fascilitates actions of ms

5.2.5.1.1. scalene

5.2.5.1.2. sternocleidomastoid

5.2.5.1.3. intercostal ms

5.2.6. cyanosis

5.2.6.1. lips

5.2.6.2. nail beds

5.3. traditional (for exam purposes?)

5.3.1. pink puffers

5.3.1.1. thin

5.3.1.2. non-cyanotic at rest

5.3.1.3. prominent use of accessory ms

5.4. advanced disease

5.4.1. syndrome

5.4.1.1. due to

5.4.1.1.1. inadequate oral intake

5.4.1.1.2. elevated levels of inflammatory cytokines (TNF alpha)

5.4.1.2. which consists

5.4.1.2.1. significant wirght loss

5.4.1.2.2. bitemporal wasting

5.4.1.2.3. diffuse loss of subcutaneous adipose tissue

5.4.1.2.4. cachexia

5.4.1.3. poor prognostic factor

5.4.2. Hoover's sign

5.4.2.1. paradoxical inwardmovement of ribcage with inspiration

5.4.2.1.1. as a result of

5.4.3. cor pulmonale

5.4.3.1. right heart failure

5.4.4. clubbing of digit

5.4.4.1. NOT A SIGN OF COPD

5.4.4.2. newly developed lung cancer

6. Laboratory findings

6.1. hallmark

6.1.1. AIRFLOW OBSTRUCTION

6.1.1.1. REDUCED FEV1

6.1.1.2. reduced FEV1/FVC

6.2. worsening disease severity

6.2.1. increase lung volume

6.2.1.1. inc TOTAL LUNG CAPACITY

6.2.1.2. inc FUNCTIONAL RESIDUAL CAPACITY

6.2.1.3. inc FUNCTIONAL RESIDUAL VOLUME

6.3. ACUTE

6.3.1. pH with PCO2 is 0.08 units/10mmHg

6.4. CHRONIC

6.4.1. pH with PCO is 0.03

6.5. Ventilatory failure

6.5.1. PCO2>45 mmHg

6.6. CHRONIC HYPOXEMIA

6.6.1. Elevated Hematocrit

6.6.2. RIGHT Ventricular Hypertrophy

7. Radiography

7.1. emphysema

7.1.1. obvious bullae

7.1.2. paucity of parenchymal markings

7.1.3. hyperlucency on chest x-ray

7.2. hyperinflation

7.2.1. increase lung volume

7.2.2. flattening of the diaphragm

7.3. Chest CT scan

7.3.1. definitive test

7.3.1.1. emphysema

7.3.2. pattern of emphysema

7.3.3. presence of significant disease involving medium and large airway

7.3.4. coexisting diseases/ complications

7.3.4.1. interstitial lung disease

7.3.4.2. bronchiectasis

7.3.5. lung cancer

7.3.6. surgical therapy

8. Treatment

8.1. Pharmacologic

8.1.1. goals

8.1.1.1. symptomatic relief

8.1.1.1.1. reduce respiratory symptoms

8.1.1.1.2. improve exercise tolerance

8.1.1.1.3. improve health status

8.1.1.2. reduce future risk

8.1.1.2.1. prevent progression

8.1.1.2.2. prevent and treat exacerbation

8.1.1.2.3. reduce mortality

8.1.2. 3 interventions that improve survival

8.1.2.1. Smoking cessation

8.1.2.2. oxygen therapy

8.1.2.3. lung volume reduction surgery

8.1.3. bronchodilators

8.1.4. anticholinergic antimuscarinic Antagonist

8.1.4.1. SAMA

8.1.4.1.1. ipratropium

8.1.4.2. LAMA

8.1.4.2.1. tiotropium

8.1.5. Beta Agonist

8.1.5.1. SABA

8.1.5.2. LABA

8.1.5.2.1. formeterol

8.1.5.2.2. salmeterol

8.1.5.3. side effects

8.1.5.3.1. tachycardia

8.1.5.3.2. tremor

8.1.6. combined beta agonist and muscarinic antagonist

8.1.7. inhaled corticosteroids

8.1.7.1. increased rate of oropharyngeal candidiasis and pneumonia

8.1.7.2. increase rate of loss of bone density

8.1.8. oral glucocorticoids

8.1.8.1. not recommended

8.1.8.1.1. osteoporosis

8.1.8.1.2. weight gain

8.1.8.1.3. cataract

8.1.8.1.4. glucose intolerance

8.1.8.1.5. increased risk of infection

8.1.8.2. chronic low dose prednisone 10mg/d tapered off

8.1.8.2.1. less side effects

8.1.9. theophylline

8.1.9.1. modest improvement

8.1.9.2. not first line

8.1.9.3. side effects

8.1.9.3.1. nausea

8.1.9.3.2. tachycardia

8.1.9.3.3. tremor

8.1.9.3.4. drug interactions

8.1.9.4. needs blood level monitoring

8.1.10. PDE4 Inhbitors

8.1.11. antibiotics

8.1.12. oxygen

8.1.13. alpha 1 anti tripsin augmentation therapy

8.1.13.1. still controversial

8.2. non-pharmacologic

8.2.1. vaccine

8.2.1.1. influenza

8.2.1.2. pneumococcal

8.2.1.3. Bordetella Pertussis

8.2.2. pulmonary Rehabilitation

8.2.3. Lung volume reduction surgery

8.2.4. lung transplantation

8.2.4.1. second leading indication for lung transplant

9. exacerbations of COPD

9.1. bacterial/ superimposed

9.2. pulmonary embolus

9.3. mimicker: pneumothorax

9.4. frequent radiographic findings

9.4.1. congestive heart failure

9.4.2. pneumonia

9.5. hypercarbia

9.5.1. PCO2 >45 mmHg

9.6. treatment

9.6.1. bronchodilators

9.6.1.1. inhaled b agonist

9.6.1.2. muscarinic antagonist

9.6.2. antibiotic

9.6.2.1. Streptococcus pneumoniae

9.6.2.2. hemophilus influenzae

9.6.2.3. Moraxella catarrhalis

9.6.2.4. mycoplasma pneumoniae

9.6.2.5. Chlamydia pneumoniae

9.6.3. systemic glucocorticoids

9.6.3.1. 30-40mg of oral prednisolone

9.6.3.1.1. 2 weeks

9.6.4. supplemental O2

9.6.4.1. greater than or equal to 90%

9.6.5. NIPPV

9.6.5.1. for respiratory failure

9.6.5.1.1. PaCO2 > 45 mmHg

9.6.5.2. CI

9.6.5.2.1. vascular instability

9.6.5.2.2. impaired mental status

9.6.5.2.3. inability to cooperate

9.6.5.2.4. copious secretions

9.6.5.2.5. inability to clear secretions

9.6.5.2.6. trauma

9.6.5.2.7. craniofacial abnormalities

9.6.5.2.8. extreme obesity

9.6.5.2.9. significant burns

9.6.5.3. reduced mortality rate, need for intubation, and hospital stay