15.2 (15.2) Advanced diseases of the lung

Question 1

List SIX classes of drugs commonly used for COPD disease management (and name 1 example)

Answer 1

◆ short acting beta agonist (SABA, ex: salbutamol)
◆ short acting muscarinic/anticholinergic antagonist (SAMA, ex: ipratropium)
———————————
◆ long acting beta agonist (LABA, ex: salmeterol)
◆ long acting muscarinic/anticholinergic antagonist
(LAMA, ex: tiotropium)
———————————
◆ inhaled corticosteroid (ex: budesonide)/systemic steroid (ex: prednisone)
◆ phosphodiesterase 4 inhibitors (ex: roflumilast)
◆ prophylactic antibiotics (ex: azithromycin)
◆ mucolytics (ex: NAC)
———————————
◆ theophyllines (not in 6th edition)

Question 2

What are the indications for long term oxygen therapy (LTOT) in COPD?

Answer 2

◆ stable + non-smoking + severe resting hypoxaemia (PaO2 <55 mmHg or 7.3 kPa)

OR

◆ less severe hypoxaemia (PaO2 55–60 mmHg or 7.3–8 kPa) + coexisting:
- pulmonary hypertension
- CHF
- polycythaemia (haematocrit >55%)

Question 3

How does LTOT need to be used to confer a benefit?

What is the predominant benefit of using LTOT?

Answer 3

Worn at least 15 hrs/day

Reduce mortality in COPD patients with severe respiratory failure (Cranston et al., 2005)

Question 4

How does COPD impact depression risk?

Answer 4

◆ independent risk factor for dev of depression

Question 5

What non-pharm interventions are recommended by the Canadian Thoracic Society for management of dyspnea in COPD?

Answer 5

From CTS 2019 Pharm COPD update:
◆ self-management education
◆ smoking cessation
◆ exercise/active lifestyle
◆ vaccinations
◆ pulmonary rehab
◆ lung transplantation
- 6th Ed has lung transplant as “non pharm for ILD”

From 6th Ed:
◆ support groups
◆ oxygen therapy
◆ non-invasive ventilation
◆ sx procedures
- lung vol reduction surgery
- bronchoscopic endobroncial valve/lung coil
———————————
◆ neuromuscular electrical stimulation
◆ chest wall vibration
◆ pursed lip breathing
◆ energy conservation
◆ handheld fan
◆ walking aid

From CTS 2011 Manage Dyspnea COPD guideline, which 5th Ed references

FS:

(1) Breathlessness management - pursed lip breathing, tripoding, energy conservation

(2) Lifestyle - diet, exercise, no smoking, vaccination

(3) Equipment - fan, O2, noninvasive ventilation, walking aids

(4) Education, rehab, support group

Question 6

List FOUR examples of patient self management education for COPD

Answer 6

◆ smoking cessation
◆ diet
◆ physical activity
◆ breathlessness management
◆ respiratory medications
◆ palliative strategies for advanced disease
◆ decision making during exacerbations
◆ managing psychosocial issues
◆ ACP

Question 7

List THREE outcomes of pulmonary rehab for COPD.

Answer 7

◆ dec symptoms*
◆ dec exacerbations
◆ dec anxiety and depression
◆ inc health-related quality of life*
◆ inc muscle function*
◆ inc exercise capacity

(Bolton et al., 2013; Moore et al., 2016; Alison et al., 2017)

Question 8

When to discuss GOC/ACP with patients with chronic respiratory disease?

Answer 8

◆ FEV1<30%, O2 dependence
◆ one or more AECOPD hospital admissions in past year
◆ weight loss/cachexia
◆ decreased functional status
◆ increasing dependence on others
◆ age greater than 70
◆ lack of additional therapeutic options

Note: 6th Ed recommends separating ACP from prognosis or disease specific events

Question 9

Provide THREE pieces of advice (non pharm and pharm) for a COPD patient to incorporate in their breathlessness management plan.

Answer 9

1. Move into a comfortable position either:
   ◆ Sitting upright and leaning forwards with your elbows resting on a table (TRIPOD)
   ◆ Or stand and lean forward over a chair or table
   ◆ Try to relax your head, neck, and shoulders
2. Use a fan to blow air across your face or open windows
3. Take slow deep breaths in through your nose for 3 seconds and out through your mouth with pursed lips for 5 seconds. Breathe in and out very slowly and evenly. Try to focus on breathing out and let the breath in follow naturally
4. Use your reliever inhaler medication
5. If you use home oxygen, apply this as directed by your doctor
6. Try to relax and remain calm, as this will help you to breathe better. It may help to listen to music, look at pictures, or recite a poem. Ask a friend or carer to sit with you and remember you can recover from breathlessness

6th ed. Box 15.2.2

Question 10

List four strategies for managing dyspnea during a dyspnea crisis (5TH ED)

Answer 10

◆ hand held fan and do pursed lip breathing
- recovery position

◆ Adjust O2 flow

◆ 2 puffs from SABA with aerochamber or nebulizer
◆ Take anti-anxiety medication
◆ If above ineffective fentanyl 12.5 mcg SL and repeat q10mins x 1

• if not settling call 911

Box 15.2.2 5th Ed.

Question 11

List two criteria of advanced COPD according CTS

Answer 11

From CTS 2019 Pharm COPD update:
◆ Mod & Severe COPD:
- COPD Assessment Test (CAT) greater than or = 10
- modified MRC breatlesssness scale (mMRC) greater than or = 2
———————-
Spirometry grades from COPD Foundation guide:
◆ FEV1<30%
◆ FEV1/FVC<70%
Note: old card/ 5th edition answer

Question 12

Name TWO adverse effects of Phosphodiesterase type 4 inhibitors.

Answer 12

◆ gastrointestinal effects
◆ Insomnia
◆ depressed mood
- used cautiously in patients with cachexia or depression

Question 13

Name FOUR classification groups for interstitial lung disease by etiology

Answer 13

◆ Known associations
- connective tissue, occupational exposure, drug tox, genetics

◆ Granulomatous
- sarcoid, hypersensitivity pneumonitis, infection

◆ Idiopathic interstitial pneumonia (includes idiopathic pulmonary fibrosis)

◆ Misc (histiocytosis X)

Fig 15.2.1

KGIM

Question 14

Which is the archetypal chronic progressive fibrotic ILD? What’s their prognosis?

Answer 14

Idiopathic pulmonary fibrosis (average survival from diagnosis 2-4 years)

Question 15

Name FIVE classification groups for interstitial lung disease by disease behaviour*

Answer 15

◆ Reversible & self limiting
◆ Reversible w/ risk of progression
◆ Stable w/ residual disease
◆ Progressive, irreversible dz w/ potential for stabilization
◆ Progressive, irreversible dz despite therapy

Question 16

Name THREE supportive treatments for idiopathic pulm fibrosis.

Answer 16

◆ oxygen
◆ pulm rehab
◆ lung transplantation

Question 17

When to consider lung transplant in patients with IPF?

Answer 17

At time of diagnosis regardless of severity (median survival post-transplant is 4.5 years)

Question 18

How to treat IPF exacerbation?

Answer 18

• Supportive care
• O2
• Broad sprectrum abx
• High dose steroids may be considered

Question 19

Role of opioids in managing breathlessness in COPD/IPF.

Answer 19

◆ A low dose should be initiated with up-titration weekly until efficacy is achieved
- e.g. LA morphine 5 mg daily or IR morphine 2.5 mg every 6 hours as required
- to a maximum of MEDD 30 mg/day.

Question 20

Name 3 non pharm treatments for cough in COPD/IPF

Answer 20

◆ Physiotherapy techniques

◆ Positive expiratory pressure devices are helpful for clearing secretions

◆ Cough suppression techniques:
- patient education
- laryngeal hygiene and hydration
- avoiding cough triggers
- cough control technique
- breathing exercises
- psycho-educational counselling

Question 21

Name THREE pharm treatments for cough in COPD/IPF (thick sputum)

Answer 21

◆ mucolytics
◆ nebulized sodium chloride (0.9%) solution
◆ short-term use of:
- nebulized lidocaine
- systemic codeine, methadone, morphine
- pregabalin

Question 22

Name ONE antifibrotic therapy for IPF and how it impacts disease.

Answer 22

◆ antifibrotic drugs:
- pirfenidone
- nintedanib

◆ significantly reduce disease progression over 12 months in mild to moderate IPF
◆ nintedanib also increases the time to first acute exacerbation
◆ new drugs do not reverse pulmonary fibrosis or improve exercise tolerance, symptoms, or quality of life