1 - COPD Flashcards
1
Q
Definition of COPD
A
- Chronic (progressive, non-curable)
- Obstructive (blockage)
- Pulmonary (lungs)
- Disease
2
Q
How is COPD diagnosed?
A
- Symptoms
- History – smoking or other exposures, other lung disease
- Spirometry (obstruction and/or restriction that isn’t reversible = COPD)
- *No screening w/o sx
3
Q
Step 1 for COPD tx. Give examples
A
- Short acting bronchodilator; can be SAMA (muscarinic) or SABA (beta)
- Short acting muscarinic antagonist (SAMA) = ipratropium
- Short acting beta agonist (SABA) = salbutamol
4
Q
Compare and contrast SAMA vs. SABA
A
- Equivalent efficacy in COPD
- Improves sx, not exacerbations
- Schedule = QID then PRN
- Salbutamol cheaper
- Only MDI (requires aerochamber)
5
Q
Step 2 for COPD tx. Give examples
A
- Long acting bronchodilators; can be LAMA (muscarinic) or LABA (beta)
- Long acting muscarinic antagonists (LAMA) = glycopyrronium, tiotropium, aclidinium, umeclidinium
- Long acting beta agonists (LABA) = salmeterol, indacaterol, formoterol
- LAMA slightly better than LABA, so preferred for step 2 but depends on pt preference or cost
6
Q
Compare and contract short acting vs. long acting bronchodilators
A
- LAMA decreases exacerbations (~1 less exacerbation in 4 years), hospitalizations, adverse effects, and increases QOL
- LABA decreases sx and increases QOL and FEV1
- Smaller decrease in exacerbations vs. LAMA
- Schedule = OD or BID vs. QID
- Increased cost vs. SABD
- Devices = more variety, no aerochamber
7
Q
Examples of LAMA + LABA inhalers
A
- Glycopyrronium + indacaterol
- Umeclidinium + vilanterol,
- Aclidinium + formoterol
- Tiotropium + oladaterol
8
Q
Compare and contract LAMA vs. LAMA + LABA
A
- Efficacy vs LAMA = no difference in exacerbations, hospitalizations, or mortality; statistically significant increase in QOL (but not clinically significant on average); FEV1 increased by 0.06
- Schedule = mostly OD
- Increased cost
- Devices = same variety (pt can try the inhaler & see if it helps their sx & then decide if the cost is worth it)
9
Q
Describe the FLAME trial
A
- Studied LAMA + LABA vs. LABA + ICS x 1 year
- Results = LAMA + LABA better than LABA + ICS (less exacerbations, rescue puffs, & pneumonia)
10
Q
Describe the INSTEAD trial
A
- Intervention:
- Salmeterol/fluticasone x 3 or more months
- Then continue ICS + LABA or change to just LABA (indacaterol) for 6 more months
- Results = LABA monotherapy no worse than LABA + ICS
11
Q
Describe the WISDOM trial
A
- Intervention:
- Salmeterol + tiotropium + fluticasone (LABA/LAMA/ICS) x 6 weeks
- Then continue triple therapy, or taper off fluticasone (over 12 weeks)
- Then LAMA/LABA vs. LAMA/LABA/ICS x 1 year
- Results = in px on LAMA/LABA tapering off ICS didn’t change outcomes
12
Q
Describe the IMPACT trial
A
- LAMA/LABA/ICS vs. LAMA/LABA or LABA/ICS x 1 year
- Included px w/ asthma (steroids are 1st line for asthma, so obviously will help)
- Results = triple therapy better than LABA + ICS in COPD px who also have asthma (not relevant)
13
Q
Summarizes the efficacy of the different tx for COPD
A
- SABA = improves sx
- LAMA = improves exacerbations (decrease by ~1 q4years), hospitalizations, QOL, and adverse effects
- LAMA + LABA = improves FEV1, unknown effect on sx
- LAMA + LABA + ICS = unknown if produces any improvement, increases risk of pneumonia
14
Q
What are some non-pharms for COPD?
A
- Quit smoking – decreases mortality by 40%, improves sx & lung function, improves QOL
- Vaccines – annual flu & pneumonia
- Physical activity
- CVD risk reduction where applicable (statins, BP meds)
- *All have a larger impact on hard outcomes (mortality, hospitalizations, QOL) than inhalers
15
Q
What is the benefit of pulmonary rehab?
A
- Provides education, smoking cessation, exercise training, nutrition counseling, psychosocial support
- For anyone w/ disabling COPD, can be referred by anyone
- Proven improvements in sx, exercise tolerance, & QOL
16
Q
Define a COPD exacerbation
A
Acute worsening of sx over > 48 h
17
Q
Describe the tx for a COPD exacerbation
A
- Schedule SABD (salbutamol or ipratropium 2 puffs QID)
- - Continue maintenance inhalers
- - +/- oxygen - Systemic steroids (prednisone 50 mg x 5 days)
- Sometimes antibiotics (if change in sputum colour and increased sputum volume or increased dyspnea)
18
Q
Describe the use of systemic steroids for COPD. Efficacy, benefit, and is tapering required?
A
- Efficacy = increases FEV1 and decreases tx failure
- Largest trial (SCOPE) showed largest FEV1 benefit at 3 days
- 2 studies showed most effect in 5 days w/ little improvement beyond
- Tapering only required if using steroids > 14 days (will likely never have to taper for COPD exacerbations)
19
Q
Describe the use of antibiotics for COPD
A
- < 4 exacerbations/year = amoxicillin 1 g TID x 5-7 days or doxycycline 200 mg once, then 100 mg BID x 5-7 days
- 4 or more exacerbations/year OR failure of first line agents above OR antibiotics in past 3 months = amox/clav 875/125 BID x 5-10 days or cefuroxime 500-1000 mg BID x 5-10 days
20
Q
Describe the use of home O2 for COPD
A
- If O2 sats are low when maximized other therapy
- Absolutely can’t be a smoker (flammable)
- Efficacy = decreases sx & mortality and increases exercise
- Also decreases QOL, very high cost, & many adverse effects
21
Q
What is included in palliative care for COPD and when is it used?
A
- When no longer worried about mortality, exacerbations or hospitalizations, but sx
1. Oxygen (covered by Palliative care program)
2. Opioids – decreases sensation of breathlessness; low dose (morphine 1 mg q1-2h prn)
22
Q
Summary/ tips for COPD
A
- COPD inhalers don’t make huge improvements, but may be important to px
- Pt preference is important in inhaler choice
- Combo inhalers can be great for cost & adherence, but only when both drugs are needed (add 1 at a time to assess true effect after 2-3 months)
- ICS rarely justified (unless asthma coexists)
- Continually re-educate and re-assess adherence and technique
