1. What is the criteria for lung volume reduction surgery in a pt with COPD
    • Lung volume reduction surgery involves resecting parts of the lung to reduce hyperinflation. This type of surgery makes respiratory muscles more effective by improving their mechanical efficiency and improves expiratory flow rates by increasing the elastic recoil pressure of the lung. Because this procedure is expensive and high-risk, it is recommended only in carefully selected patients.
    • The surgery is most beneficial in patients with severe, predominantly upper lobe disease and a large amount of mildly emphysematous or normal middle and lower lung.
    • Patients with severe COPD who have had maximal medical treatment, including pulmonary rehabilitation, and have FEV1 greater than 20% of predicted, DLCO greater than 20% of predicted, and predominant upper lobe emphysema are likely to benefit from lung volume reduction surgery.
  2. What is the criteria for lung transplantation in a pt with severe COPD?
    Lung transplantation should be considered in patients hospitalized with COPD exacerbation complicated by hypercapnia (PCO2 greater than 50 mm Hg) and patients with FEV1 not exceeding 20% of predicted and either homogeneous disease on high-resolution CT scan or DLCO less than 20% of predicted who are at high risk of death after lung volume reduction surgery.. There are many exclusion criteria, including advanced age and comorbid conditions, and demand for suitable organs outstrips availability.
  3. In a hospitalized pt with COPD exacerbation, what is the recommended dose for steroid therapy?
    Initial treatment is intravenous methylprednisolone for 72 hours at 125 mg every 6 hours, followed by 2 weeks of an oral taper starting at 60 mg; however, prolonged treatment does not result in greater efficacy and increases the risk of side effects.
  4. What are the predominant bacteria recovered in COPD exacerbation?
    Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis
  5. What is the indication criteria for NIPPV use in the pt with COPD exacerbation?
    The indications for noninvasive ventilation include moderate to severe dyspnea with the use of accessory muscles of breathing and paradoxical abdominal motion, moderate to severe acidosis (pH less than 7.35) and/or hypercapnia (PCO2 greater than 45 mm Hg), and respiration rate greater than 25/min. Exclusion criteria include respiratory arrest, cardiovascular instability (hypotension, arrhythmias, myocardial infarction), change in mental status (lack of cooperation), high aspiration risk, viscous or copious secretions, recent facial or gastroesophageal surgery, craniofacial trauma, fixed nasopharyngeal abnormalities, burns, and extreme obesity
  6. What is the criteria for invasive ventilation in the pt with COPD exacerbation?
    Invasive mechanical ventilation is indicated for patients who cannot tolerate noninvasive ventilation and those with severe dyspnea with a respiration rate greater than 35/min, life-threatening hypoxia, severe acidosis (pH less than 7.25) and/or hypercapnia (PCO2 greater than 60 mm Hg), respiratory arrest, somnolence or impaired mental status, cardiovascular complications (hypotension, shock), and other complications such as metabolic abnormalities, sepsis, pneumonia, pulmonary embolism, barotrauma, and massive pleural effusion.
  7. What are required actios when pt with COPD is discharged?
    Patients should be discharged when they no longer require short-acting inhaled β2-agonist therapy more frequently than every 4 hours, can walk across the room, and can sleep without frequent awakening by dyspnea. Patients must have been clinically stable and had stable arterial blood gas levels for 12 to 24 hours and understand the correct use of medications. Follow-up and home care arrangements must be completed before discharge, and the patient, family, and physician must be confident that the patient can successfully manage at home. A follow-up visit should occur 4 to 6 weeks after hospital discharge. Subsequent treatment is the same as for stable COPD. If the patient required oxygen in the hospital and still needs it at discharge, follow-up at approximately 2 weeks with evaluation of the oxygen level on ambient air should be done to determine whether supplemental oxygen continues to be necessary.
  8. What are the first line maintenance therapy to control symptoms in COPD?
    Long-acting β2-agonists (salmeterol, formoterol, and arformoterol) have a duration of action of 12 hours or more and are first-line maintenance therapy to control symptoms.
  9. What is the primary side effect of the inhaled anticholinergic agents in COPD?
    dry mouth
  10. What medical conditions should cause you to be cautious with the use of anticholinergic agents in pts with COPD?
    urinary obstruction and narrow-angle glaucoma.
  11. Explain how short-acting β2-agonists and long-acting β2-agonists are used in the management of COPD?
    Short-acting β2-agonists are recommended at all stages of COPD for the alleviation of symptoms such as dyspnea and treatment of exacerbations. Long-acting bronchodilators, such as long-acting β2-agonists or tiotropium, are recommended as first-line maintenance therapy when patients require regular and frequent bronchodilatory management, beginning in Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage II and through GOLD stage IV.
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