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PHARM 311 Respiratory System > 9. COPD > Flashcards

9. COPD Flashcards

1
Q

COPD

A

A common, preventable & treatable disease that is characterised by persistent respiratory symptoms & airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles/gases

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2
Q

COPD pathophysiology - Emphysema & Chronic Bronchitis

A

Emphysema is a result of destroyed air sac walls, therefore the airway & its sacs lose their flexibility, making it harder for them to contract & expand
- Symptoms include wheezing, shortness of breath & chest tightness

Chronic bronchitis is the result of damaged airway liming being inflamed & producing mucus, thereby leading to the development of a persistent cough
- Symptoms include ongoing cough that produces a lot of mucus

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3
Q

COPD in Maori

A
  • Burden greater in Maori than other New Zealanders
  • Onset 15-20 years younger
  • Hospitilisation 3.5 times higher
  • Mortality 2.2 times higher
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4
Q

Bronchitis - areas affected & pathophysiology

A

Bronchiole - smallest airway that lead to alveoli, purpose is to deliver air to the alveoli

Smooth muscle - responsible for controlling airway calibre

Mucus - Known as airway surface liquid, is a thin layer of fluid covering the luminal surface of the airway to protect the lung through mucociliary clearance of foreign particles & chemicals

Inflammation -> smooth muscle contraction -> mucus hyper secretion

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5
Q

Emphysema - areas affected

A

Alveoli - tiny air sacs that are primary location of gas exchange

Elastic fibres - allow alveoli to expand & recoil back

Loss of elastic fibres -> decreased surface area -> collapsed alveoli

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6
Q

Diagnosing COPD

A

Risk factors:

  • Host factors
  • Tobacco
  • Occupation
  • Indoor/outdoor pollution

Symptoms:

  • Shortness of breath
  • Chronic cough
  • Sputum

Spirometry:
- Required to establish diagnosis

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7
Q

Spirometry & its key measures

A

Common test to assess lung function

Key measures include:

Forced expiratory volume (FEV1)
- Amount of air that can be forced from the lungs in 1 second

Forced vital capacity:
- Largest amount of air that can be forcefully exhumed in 1 breath

FEV1/FVC ratio:
- Calculated value that represents the percentage of your lung capacity you can expel in 1 breath

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8
Q

Role of spirometry

A

Diagnosis

Assessment of severity of airflow obstruction (for prognosis)

Follow up assessment:
- Therapeutic decisions + Pharmacological in selected circumstances e.g. discrepancy between spirometry & level of symptoms
+ Consider alternative diagnoses when symptoms are disproportionate to degree of airflow obstruction
+ Non-pharmacological (e.g. interventional procedures)
- Identification of rapid decline

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9
Q

Assessment - Goals

A

To determine the levels of airflow limitation & its impact on the patient’s health status

To achieve these goals, consider:

  • Presence & severity of spirometric abnormality
  • Current nature & magnitude of the patient’s symptoms
  • History of moderate & severe exacerbations & future risk
  • Presence of co-morbidities

Note: There is only a weak correlation between FEV1 symptoms & impairment of a patient’s health status - formal symptomatic assessment required

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10
Q

Classification of airflow limitation severity in COPD (based on post-bronchodilator FEV1)

A

In patients with FEV1/FVC < 0.70:

GOLD 1: Mild - FEV1 ≥ 80% predicted

GOLD 2: Moderate - 50% ≤ FEV1 < 80% predicted

GOLD 3: Severe - 30% ≤ FEV1 < 50% predicted

GOLD 4: Very severe - FEV1 < 30% predicted

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11
Q

Modified MRC dyspnea scale & CAT score

A

mMRC - grade 1 to 4 regarding patients breathlessness

CAT - questionnaire regarding what the patient thinks about their condition & severity of it

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12
Q

Refined ABCD assessment tool

A

Takes into account all aspects of COPD

Spirometry: FEV1/FVC < 0.7

Assessment of airflow limitation: GOLD 1-4

Assessment of symptoms/risk of exacerbations

  • 0 or 1 (not leading to hospital admission) [A or B]
  • ≥2 or ≥1 leafing to hospital admission [C or D]
  • mMRC 0-1, CAT <10 [A or C]
  • mMRC ≥2 CAT ≥10 [B or D]
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13
Q

COPD exacerbations

A
  • Defined as an acute worsening of respiratory symptoms that result in additional therapy
  • Best predictor of having frequent exacerbations (≥2 exacerbations per year) is a history of earlier events
  • Deterioration in airflow limitation is associated with an increasing prevalence of exacerbations, hospitalisations & death
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14
Q

Remember treat holistically - co-morbidities/risk factors

A
  • Smoking
  • Poor diet - adequate nutrition required
  • Cardiovascular disease - comorbidity
  • Metabolic syndrome - gas exchange
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15
Q

NZ COPD guidelines 2021 - severity

A

Mild:

  • Few symptoms
  • Breathlessness on moderate exertion
  • Little or no effect on daily activities
  • Cough & sputum production
  • FEV1 typically 60-80% predicted

Moderate:

  • Breathlessness walking on level ground
  • Increased limitation of daily activities
  • Recurrent chest infections
  • Exacerbations requiring oral corticosteroids and/or antibiotics
  • FEV1 typically 40-59% predicted

Severe:

  • Breathless on minimal exertion
  • Daily activities severly restricted
  • Exacerbations of increasing frequency & severity
  • FEV1 typically < 40% predicted
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16
Q

NZ COPD guidelines 2021 - Medicine management

A

CHECK device technique & adherence at each visit

Step 1: START with a SABA for PRN use e.g. salbutamol, terbutaline, ipratropium or combination salbutamol + irpatropium

Step 2: ADD a LAMA e..g tiotropium, glycopyrronium or umeclidinium, or a LABA, e.g. salmeterol,, indacaterol or formoterol as an alternative

Step 2A: Consider the need for a combination LABA/LAMA e.g. indacaterol/glycopyrronoum, vilanterol/umeclidinium, olodaterol/tiotropium depending on patients symptoms. Patients with an eosinophilic pattern of disease may benefit from ICS/LABA instead of LAMA/LAMA

Step 3: CONSIDER adding an ICS e.g. fluticasone or budesonide: Triple therapy may be appropriate for patients with ≥ 1 exacerbation requiring hospitalisation or ≥ 2 moderate exacerbations in the last 12 months, AND signifiant symptoms despite LABA/LAMA or ICS/LABA treatment. Patients with a blood eosinophil count ≥ 0.3 x 10^9/L are most likely to benefit from ICS treatment

17
Q

Treatment goals

A

Reduce symptoms:

  • Relieve symptoms
  • Increase exercise tolerance
  • Improve health status

Reduce risk:

  • Prevent disease progression
  • Prevent & treat exacerbations
  • Reduce mortality
18
Q

Smoking cessation

A

Greatest benefit in COPD

  • Nicotine replacement therapy
  • Varenicline
  • Bupropion
  • Nortriptyline
19
Q

Vaccinations

A

Influenza vaccine:

  • Reduces serious illness & death in COPD patients
  • Should be actively promoted
  • Subsidised in NZ for those with COPD

Pneumococcal vaccine:

  • Recommend for all patients ≥ 65 years or younger patients with significant comorbidities to reduce the incidence of pneumonia & reduce exacerbations
  • Evidence conflicting & not subsidised in NZ for those with COPD
20
Q

Bronchodilators

A
  • Inhaled bronchodilators are central to symptom management
  • Regular & as-needed use of SABA & SAMA improves FEV1 & symptoms
  • Combination SABA + SAMA are superior to either alone
  • LABAs & LAMAs significantly improve lung function, shortness of breath, health status & reduce exacerbation rates
  • LAMAs reduce exacerbations & decrease hospitalisations greater than LABAs
  • Combination LABA + LAMA reduce exacerbations compared to either alone
21
Q

Bronchodilators cont’d

A

LABAs & LAMAs are preferred over short-acting agents except in those with only occasional shortness of breath & when immediate relief of symptoms required

  • Patients may be started on single long-acting bronchodilator or dual-long acting bronchodilator therapy (under SA)
  • If a single long-acting bronchodilator is ineffective in reducing symptoms of shortness of breath add another of a different class
22
Q

Pharmacological treatment groups

A

Group A: Bronchodilator

Group B: Long acting bronchodilator (LABA or LAMA)

Group C: LAMA

Group D: LAMA or LAMA + LABA or ICS + LABA

23
Q

Antimuscarinic drugs

A
  • Block the bronchoconstrictor effects of acetylcholine on M3 muscarinic receptors expressed in airway smooth muscle
  • Very safe as poorly absorbed when given via inhaled route however watch for dry mouth, urinary symptoms, bitter or metallic taste
24
Q

Inhaled corticosteroids

A

Regular ICS increases the risk of pneumonia especially in those with severe disease

25
Q

Key messages about drugs in COPD

A
  • Inhaler technique, device suitability & adherence should be reviewed regularly
  • SABA +/- SAMA for symptom relief
  • LAMA bronchodilator class of choice
  • Escalate to LABA + LAMA combination if LAMA does not control breathlessness/exacerbations
  • ICS to reduce exacerbations in addition to LABA + LAMA combination ‘triple therapy’
  • ICS + LABA if raised eosinophils or asthma/COPD overlap
26
Q

Inhaled route

A
  • Choice of inhaler device should be individually tailored & take into account the patient’s ability to use the device & their preference
  • Inhaler techniques should be demonstrated when starting on the device & regularly while patients are on therapy
27
Q

Soft mist inhalers

A

“Turn, Open, Press”

Pros:

  • Very fine mist particles
  • Excellent lung deposition
  • Once daily dosing
  • Little medication deposited into the oropharynx

Cons:

  • Requires good coordination & dexterity to use
  • Requires loading of device
  • Must be able to hold breath to ensure dose it not exhaled
28
Q

Breezehaler & Handihaler

A

Requires capsule to be inserted into device & contents inhaled

Pros:

  • Can inhale multiple times to receive dose
  • Breezhaler capsules clear so can visibly check if dose is completely inhaled

Cons:

  • Capsule should not be swallowed
  • Good dexterity required to load & manipulate capsules & device
29
Q

Ellipta devices

A

Flip open cover, revealing the mouthpiece until it click

Pros:

  • Easy to use
  • Large font dose indicator

Cons:
- Can cause cough & taste disturbances

30
Q

Other anti-inflammatories

A
  • Long term use of oral glucocorticoids (prednisone) are not recommended due tp numerous side effects & lack of benefit however beneficial in exacerbations
  • Antibiotics (macrolides e.g. azithromycin/erythromycin) reduce exacerbation rate over a year
31
Q

Pulmonary rehabilitation

A
  • Education & exercise programme to help patients’ self-management of their chronic breathing problems to make behavioural changes improving symptom control & their quality of life
  • Programme often up to 8 weeks
  • Multidisciplinary team approach
  • May reduce readmissions & mortality rate
32
Q

Surgical options

A
  • Lung volume reduction surgery
  • Bullectomy
  • Transplantation
  • Bronchoscopic interventions such as end-bronchial valves, lung coils, vapour ablation
33
Q

End stage COPD

A
  • Opiates (e.g. Morphine)
  • Oxygen in those with resting hypoxia
  • Nutritional supplementation in malnourished
  • Ventilation in those with hypercapnia

PHARM 311 Respiratory System (10 decks)

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