3-COPD Flashcards
COPD is inflammation of the small airways due to
Narrowing
Fibrosis (chronic bronchitis)
Destruction of parenchyma
Destruction of alveolar walls (Emphysema)
COPD has a predominance of what types of cells
Neutrophils
Macrophages
TC1 cells (cytotoxic T)
COPD results in
Airway closure on expiration
Air trapping/hyperinflation
SOB and exercise limitation
How does GOLD reach categorization COPD
Spirometry confirmed diagnosis (FEV1:FVC <0.7)
Assessment of airflow limitation
Assessment of symptoms and risk of exacerbations
What are the GOLD COPD groups
1: FEV1 *)+
2: FEV1 50-79
3. FEV1 30-49
4: FEV1 <30
What are the GOLD COPD ABCD groups
A: 0-1 exacerbations, no hospital. mMRC 0-1, CAT <10
B: 0-1 exacerbations, no hospital, mMRC 2+, CAT 10+
C: 2+ exacerbation or 1+ hospital, mMRC 0-1, CAT <10
D: 2+ exacerbation or 1+ hospital, mMRC 2+, CAT 10+
How do you treat the different groups
A: Bronchodilator
B: LAMA or LABA- if Sx persist, LAMA+LABA
C: LAMA- if Sx persist, LAMA+LABA
D: LAMA+LABA, if Sx persist LAMA+LABA+ICS (can add Macrolide if ex-smoker)
Are SABA great COPD drugs?
not really, only small improvement in FEV1 (per spirometry)
response is usually less than seen in asthma
BUT, can improve respiratory Sx and exercise tolerance
Side Effects of Bronchodilators
Tachycardia, Tremors, Rhythm disturbance
Are LABA’s good COPD drugs?
Yes; Relieve dyspnea improve QoL improve lung function reduce exacerbation frequency
How do anti-muscarinics work
Competitively block cholinergic receptors in bronchial smooth muscle= Bronchodilation
What are the different anticholinergics
SAMA: Ipratropium. Slower onset but more prolonged effect vs albuterol
LAMA: Tiotropium, umeclidinium. Improve lung fun significantly, comparable to LABA. Decrease exacerbations, lower mortality risk
Side effects of anticholinergics are
Dry mouth
Nausea
Metallic taste
How do corticosteroids affect COPD (anti-inflammatory MOA)
Reduce capillary permeability (decrease mucus)
Inhibit LT enzyme release
Inhibit prostaglandins (PLA2, COX2)
When are systemic corticosteroids used
In chronic management, to slow disease progression
Side effects of Systemic corticosteroids are
Osteoporosis Muscular atrophy Thinning skin Cataracts (Adrenal suppression/insufficiency)
How do you treat Alpha Anti-Trypsin deficiency associated Emphysema
AAT infusion
Bronchodilators prn
What is a LABA+ICS
Salmeterol+Fluticasone
Formoterol+Budesonide
-Better at improving FEV1 and decreasing exacerbations
What did the FDA approve for COPD therapy in 2017
Triple therapy all in one inhaler QD, Trelegy Ellipta (Fluticasone+Umeclidinium+Vilanterol)
ICS+LAMA+LABA
Five step strategy for smoking cessation is
Ask Advise Assess Assist Arrange
What agents are first line smoking cessation meds
Bupropion SR (oral)
Nicotine gum, inhaler, nasal spray, patch
Varenicline/Chantix (oral)
When should you use oxygen therapy
Severe resting chronic hypoxemia, to improve survival
When shouldn’t you use oxygen therapy
Stable COPD and resting or exercise induced moderate desaturation
When should you use Non-invasive ventilation
Severe chronic hypercapnia
Hx ARF
What are the “cardinal symptoms” of COPD
Increasing Dyspnea, Sputum volume, Sputum purulence
What are the stages of acute COPD exacerbations
Mild: 1 cardinal Sx + 1 (URI w/in 5 days, fever, wheezing, cough, HR/RR increase >20% baseline)
Moderate: 2 cardinal Sx
Severe: 3 cardinal Sx
What therapies can be used in acute COPD exacerbations
Antibiotics Corticosteroids Bronchodilators Oxygen therapy Non-Invasive mechanical ventilation
What therapy is recommended in anyone with moderate or severe exacerbation
Antibiotics
What is the caveat to corticosteroid use
if longer than 14 days, taper down to avoid HPA axis suppression
Bronchodilators can be used in what form
Moderate dose inhaler or Dry powder inhaler (just as efficacious as nebulizers)
What bronchodilators would you use
Beta agonists (also increase mucociliary clearance) LAMA and LABA not for acute relief
How should oxygen therapy be administered
Titrate O2 to >90%
monitor ABG for hypercapnia
When should you NOT use Non-invasive mechanical ventilation
AMS
Severe acidosis
Respiratory arrest
Cardiovascular instability
What vaccines should COPD patients get
Flu vaccine yearly
Pneumococcal vaccine
Who gets the pneumococcal vaccines
PCV13: 65+, 19-64 with low immunity
PPSV23: 65+, 19-64 or <2 y/o smoker, chronic illness, cochlear implant or CSF leak, low immunity
What Abx should you use if pt has Uncomplicated exacerbation (<4 exacerbations x year and FEV1 >50%)
Azithromycin, Clarithromycin (Macrolide)
2-3 gen Cephalosporin
Doxycycline
What abx should you NOT use if pt has uncomplicated exacerbation (<4 exacerbations and FEV1 >50%)
Bactrim
Amoxicillin
1 gen cephalosporin
Erythromycin
What abx should you use if patient has a complicated exacerbation (65+, >4 exacerbations, FEV1 35-50%)
Augmenting
Levo/Moxi/Gemifloxacin (Fluoroquinolone anti-pneumo)
What abx should you use if patient has complicated exacerbation with P. Aureginosa RF (nursing home w/ 4+ exacerbations, FEV1 <35%, chronic corticosteroid use, chronic bronchial sepsis)
Levofloxacin (anti-pneumo and anti-pseudo Fluoroquinolone)
+/- IV therapy
