Asthma/COPD Flashcards
What are 2 types of stimuli that can trigger asthma?
- Endogenous Stimuli
- Those stimuli generated inside the body
- e.g. stress, gastroesophageal reflux disease (GERD), rhinitis - Exogenous Stimuli
- Those stimuli generated outside the body
- e.g. exercise, allergens, irritants
What are 4 key factors for asthma diagnosis?
- Patient history
- Symptoms & severity, history
- Precipitating factors
- Very important for characterizing the disease - Physical Exam
- Poor indicator of the degree of airflow obstruction
- May be normal unless the patient is symptomatic - Pulmonary Function Tests
- Necessary to establish diagnosis, assess severity and treatment response
- FEV1/FVC < 75-80% predicted - Other laboratory Tests
What are the pulmonary function criteria to diagnose asthma in children (6+)? (2)
- Reduced FEV1/FVC = (<0.8-0.9)
- Increase in FEV1 after a bronchodilator or after course of controller therapy 12%+
What are the pulmonary function criteria to diagnose asthma in adults? (2)
- Reduced FEV1/FVC = (<0.75-0.8)
- Increase in FEV1 after a bronchodilator or after course of controller therapy 12%+ (and a minimum of 200+mL)
Asthma medications are traditionally divided into two main categories. What are they?
Controller and Reliever
Salbutamol is an example of a?
SABA
Terbutaline is an example of a?
SABA
What effect do SABAs provide the patient?
Temporary relief of asthma symptoms, no effect on inflammation
What are some side effects of SABAs (and LABAs)? (8)
- Tremors (shakiness)
- Palpitations (usually rapid but occasionally irregular heartbeats)
- Nervousness
- Irritability
- Insomnia
- Headache
- Blood pressure changes
- Hypokalemia
Regular, frequent use of SABAs is associated with what?
Increased tolerance, airway sensitivity and possible morbidity and mortality from asthma
ICS medications have what root word in it?
-son
ICS’s are the most ______ and _________ type of controller. Requires _____ use
common; effective; daily
Onset of effect of ICS’s is how long?
Days-weeks (maximal months); no effect on acute symptom relief
What are the side effects of ICS’s? (4)
- Thrush
- Voice changes (reversible)
- May be associated with mild reduction in linear growth in kids (primarily during the first year). With mod doses, children attain predicted height.
- Systemic side effects more common with high dose ICS
Should know the ICS steroid effect vs. side effect as doses increase graph?
Can see that at the low dose, we have a lot of effect with few side effects. As we increase to moderate doses, curves taper off for both effects and ADEs. In the high doses can see mostly plateau effect and a lot more ADEs. Will still use high dose if needed, but prefer not to if can be prevented.
What are 4 examples of LABAs?
- Formoterol
- Salmetrol
- Vilanterol (indicated for asthma only in combo with fluticasone furoate)
- Indacaterol (indicated in asthma in combo with mometasone)
LABAs are never to be used when?
Alone without an ICS
Which LABA is approved for rescue therapy (in combination with another drug)?
Formoterol in combination with budesonide (Symbicort)
What class of drug is montelukast?
Leukotriene receptor antagonist (LTRA)
What are 4 LAMA drugs?
- Tiotropium
- Glycopyrronium
- Umeclidinium
- Aclindinium (only BID one here)
What are some side effects of montelukast? (5)
- Headache
- Heartburn
- Nausea
- Rash
- Neuropsychiatric effects?
What are some side effects of LAMAs? (7)
- Drug mouth
- Blurred vision (if comes in contact with eyes)
- Tremors
- Tachycardia or palpitation
- Urinary retention in elderly men
- May cause increased intraocular pressure
- Glaucoma
Oral corticosteroids are given in asthma primarily when?
For flares
What are some short-term side effects of oral corticosteroids? (5)
- Insomnia
- Increased activity
- Mood changes
- Water retention
- Hyperactivity in children
What are some long-term side effects of oral corticosteroids? (6)
- Increased appetite
- Weight gain
- Stomach irritation
- Cataracts
- Osteoporosis
- HPA axis suppression
What are 3 biologics that might be used in asthma?
- Omalizumab
- Benralizumab
- Dupliumab
Why don’t patients take asthma medications as prescribed? (4)
- Most do not want to take daily medications when they feel well and have no asthma symptoms
- Many believe they know when they need to take their asthma medications
- Most use SABAs because these work quickly
- Many do not know or believe that poor current asthma control results in future risks
What % of patients have actually controlled asthma?
47% (compared to the 97% who THINK they were well controlled)
What’s the big deal about SABA overuse? (2)
- Over-reliance on SABA at the expense of ICS controller therapy associated with an increased risk of asthma-related death
- Episodes of high reliever use (>6 inhalations/day on at least 1 day) were predictive of an increased risk of exacerbations
What is considered a low dose ICS?
<250 mcg/day
What is considered a medium dose ICS?
200-500ish mcg/day
What is considered a high dose ICS?
> 400 or >500 mcg/day
Should know the 2021 asthma management continuum (6)
From the bottom:
1. Confirm diagnosis
2. Environmental control, education, and written action plan
3. SABA or bud/form as needed
4. ICS (second-line LTRA)
5. 1-11 yrs, increase ICS; >12 add LABA
6. 6-11 yrs, add LABA or LTRA; >12 add LTRA and/or tiotropium
How many daytime symptoms to be considered controlled asthma?
<= 2 days/week
How many nighttime symptoms to be considered controlled asthma?
<1 night/week AND mild
How many times per week can a reliever be used to be considered controlled asthma?
<= 2 doses/week
A higher risk for an asthma exacerbation is defined by any of the following: (4)
- History of a previous severe asthma exacerbation
- Poorly-controlled asthma as per CTS criteria
- Overuse of SABA (defined as use of more than 2 inhalers of SABA in a year)
- Current smoker
A severe asthma exacerbation has any one of these things: (3)
- Requires systemic steroids
- An ED visit
- Hospitalization
Mild exacerbation of asthma is defined as?
An increase in asthma symptoms from baseline that does not require systemic steroids, ED visit or hospitalization
What are some nonpharmacologic therapies for asthma? (3+5)
- Identify and avoid factors such as environmental allergens and occupational irritants
- Animals
- Mold/fungus
- Dust mites
- Outdoor – pollen, grass, ragweed, pollution etc
- Fumes - Smoking cessation!
- Problematic foods, additives or medication
What is the actual importance of environmental control in asthma? (4)
Reducing or eliminating exposure to triggers in the home/daycare, workplace, and school environment
- May reduce the need for pharmacotherapy
- Can reduce asthma symptoms
- Continued exposure = worsening airway inflammation and deterioration in asthma control
What are the general principles of environmental control in asthma? (4)
- Triggers need to be re-evaluated over time.
- Recommendations for implementing environmental control measures should be given with care
- Single strategy interventions specific to the individual’s sensitivity have not resulted in measurable asthma control benefits
- Multi-faceted interventions are the most effective
Should know the criteria for when to start an ICS in the following situation:
<12 years and if on PRN SABA well-controlled asthma at lower risk for exacerbation
Continue PRN SABA or switch to daily ICS + PRN SABA (based on patient preference)
Should know the criteria for when to start an ICS in the following situation:
<12 years and if on PRN SABA well-controlled asthma at higher risk for exacerbation
Switch to daily ICS + PRN SABA
Should know the criteria for when to start an ICS in the following situation:
12 years+ and if on PRN SABA well-controlled asthma at lower risk for exacerbation (2)
- Continue PRN SABA or switch to either daily ICS + PRN SABA
- Or alternative: PRN bud/ form (based on patient preference)
Should know the criteria for when to start an ICS in the following situation:
12 years+ and if on PRN SABA well-controlled asthma at higher risk for exacerbation (2)
- Switch to either daily ICS + PRN SABA
- Or alternative: PRN bud/ form (based on patient preference)
Should know the criteria for when to start an ICS in the following situation:
<12 years and NOT well controlled asthma
Switch to daily ICS + PRN SABA
Should know the criteria for when to start an ICS in the following situation:
12 years+ and NOT well controlled asthma (2)
- Switch to either daily ICS + PRN SABA
- Or alternative: PRN bud/form
- In individuals with poor adherence to daily medication despite substantial asthma education and support, we recommend PRN bud/ form over daily ICS + PRN SABA.
Asthma severity classification:
Very mild asthma is well controlled on: (1)
PRN SABA only
Asthma severity classification:
Mild asthma is well controlled on: (2)
- Low dose ICS (or LTRA) + PRN SABA OR
- PRN bud/form
Asthma severity classification:
Moderate asthma is well controlled on: (3)
- Low dose ICS + second controller + PRN SABA OR
- Moderate doses of ICS +/- second controller medication and PRN SABA OR
- Low-moderate dose bud/form + PRN bud/form
Asthma severity classification:
Severe asthma is well controlled on: (1)
High doses of ICS + second controller for the previous year or
systemic steroids for 50% of the previous year to prevent it from
becoming uncontrolled, or is uncontrolled despite this therapy
What are the symptoms of asthma exacerbation? (10)
- Prolonged, severe episode of asthma unresponsive to usual treatment, develops over hours to days
- Tachycardia
- Tachypnea
- Diaphoresis
- Severe dyspnea, ± wheeze
- Hyperinflated chest with accessory muscle use
- Anxiety
- Altered level of consciousness
- Paradoxical pulse
- Nasal flaring
What group of meds need to be avoided during an asthma exacerbation?
Sedatives/hypnotics
What are the treatment options for asthma exacerbation? (5)
- Short Acting Beta-2 Agonist + Short Acting Anticholinergic
- Corticosteroids – oral or IV
- Oxygen to correct hypoxemia – maintain oxygen saturation ≥ 90%
- Magnesium IV
- Mechanical Ventilation/Intubation
How does asthma and COPD differ in terms of age of onset?
Asthma: usually <40 years
COPD: usually >40 years
How does asthma and COPD differ in terms of smoking history
Asthma: Not causal, but worsens control
COPD: Usually >10 pack-years
How does asthma and COPD differ in terms of sputum production?
Asthma: Infrequent
COPD: Often
How does asthma and COPD differ in terms of allergies?
Asthma: Often
COPD: Infrequent
How does asthma and COPD differ in terms of clinical symptoms
Asthma: Intermittent and variable
COPD: Persistent and progressive
How does asthma and COPD differ in terms of disease course?
Asthma: Stable (with exacerbations)
COPD: Progressive worsening (with exacerbations)
How does asthma and COPD differ in terms of importance of co-morbid illnesses?
Asthma: Often important
COPD: Often improtant
How does asthma and COPD differ in terms of spirometry?
Asthma: Often normalizes
COPD: May improve but never normalizes
How does asthma and COPD differ in terms of airway inflammation?
Asthma: Eosinophilic
COPD: Neutrophilic
How does asthma and COPD differ in terms of response to inhaled corticosteroids?
Asthma: Essential for optimal control
COPD: Helpful in pts with moderate to severe disease and frequent AECOPD
How does asthma and COPD differ in terms of role of bronchodilators?
Asthma: As needed use only
COPD: Regular therapy usually necessary
How does asthma and COPD differ in terms of role of exercise training?
Asthma: Rarely formally used
COPD: Essential therapy
How does asthma and COPD differ in terms of end-of-life discussions?
Asthma: Rarely necessary
COPD: Often essential
What are 3 cardinal symptoms of COPD?
- Shortness of breath
- Chronic cough
- Phlegm
What are some other symptoms of COPD? (5)
- Frequent lung infections
- Reduced ability to go about daily activities
- Barrel-shaped chest
- Fatigue
- Unexplained weight loss
A clinical diagnosis of COPD should be considered in any patient who has: (4)
- Dyspnea
- Chronic Cough
- Sputum Production
- History of exposure to risk
Spirometry is required to make the diagnosis of COPD. What is the FEV1/FVC ratio?
<0.7
Who should be screened for COPD? (5)
Smokers/ex-smokers ≥40 who have:
- Persistent cough or sputum production
- Frequent respiratory tract infections
- Progressive activity-related SOB
- Evening wheeze
Go through the clinical evaluation steps for COPD (7)
1) Pulmonary Function Testing
* Must determine degree of reversibility
* FEV1 <80% and FEV1/FVC ratio <0.7
2) Quantification of tobacco consumption:
* “Total pack years” = (# of cigarettes smoked/d ÷20) x # years of smoking
Also record environmental exposures
3) Assessment of severity of breathlessness using the mMRC dyspnea scale or CAT test
4) Assessment of the frequency and severity of exacerbations
5) Assessment of symptoms that could point to complications
6) Assessment of symptoms that suggest comorbidities
7) Assessment of medications
GOLD 1 = CTS Mild stage of COPD. What is the FEV1 and FEV1/FVC ratio in this stage?
FEV1 80% predicted
FEV1/FVC < 0.7
GOLD 2 = CTS Moderate stage of COPD. What is the FEV1 and FEV1/FVC ratio in this stage?
FEV1 50-79% predicted
FEV1/FVC < 0.7
GOLD 3 = CTS Severe stage of COPD. What is the FEV1 and FEV1/FVC ratio in this stage?
FEV1 30-49% predicted
FEV1/FVC < 0.7
GOLD 4 = CTS Very severe stage of COPD. What is the FEV1 and FEV1/FVC ratio in this stage?
Very severe: FEV1 < 30% predicted,
FEV1/FVC <0.7
What are the symptoms of mMRC level 0 COPD?
Breathless with strenuous exercise
What are the symptoms of mMRC level 1 COPD?
SOB when hurrying on the level or walking up a slight hill
What are the symptoms of mMRC level 2 COPD?
Walks slower than people of the same age on the level or stops for breath while walking at own pace on the same level
What are the symptoms of mMRC level 3 COPD?
Stops for breath after walking 100 meters or after a few minutes on the same level
What are the symptoms of mMRC level 4 COPD?
Too breathless to leave the house, or breathlessness when dressing
What is the CAT test for COPD?
Reliable measure of the impact of COPD on a patient’s health status
CAT score ranges from 0-40:
What does 0-10 tell you?
11-20?
21-30?
>30?
0-10 = low impact
11-20 = medium impact
21-30 = high impact
>30 = very high impact
Should know the 9 very general treatments for COPD?
- Smoking Cessation
- Eliminate occupational & environmental exposures
- Comprehensive patient / family education/ self management strategies
- Vaccines
- Rehabilitation programs (Pulmonary Rehabilitation)
- Long-term oxygen therapy
- Avoid sedatives / narcotics in severe disease
- Pharmacologic treatment
- Treatment of acute exacerbations
What vaccines should COPD pts be getting? (2)
- Annual flu vaccine
- Pneumococcal
What to know about short acting bronchodilators in COPD?
- PRN use of short acting bronchodilators is recommended in all stages of disease
- Higher doses = more bronchodilation
- May increase beyond recommended dose in severe disease
- They may be prescribed scheduled in initial stages of disease - SABA + SAMA used during asthma exacerbation or
initial COPD treatment
Compare LABAs vs. LAMAs in COPD (5)
- Both improve symptoms
- LAMA (tiotropium) may be superior in decreasing exacerbations
- LAMAs may be better tolerated (decreased withdrawal
in RCTs) - Side effect profiles vary
- LAMA: dry mouth, constipation
- LABA: headache, dose dependent CV effects - Cost? similar
What are 5 LAMA/LABA combinations and what device do they come in?
- Aclidinium/formoterol = genuair
- Glycopyrronium/formoterol = MDI
- Glycopyrronium/indacaterol = breezehaler
- Tiotropium/olodaterol = respimat
- Umeclidinium/vilanterol = ellipta
What to know about ICS’s in COPD? (4)
- Inhaled corticosteroids should not be used as first-line medication.
- ICS should not be used as monotherapy
- ICS have evidence for reducing exacerbations, but inconsistent evidence for symptom improvement
- Patients with a higher eosinophil count may respond better
What are the ICS/LABA combinations and what device do they come in? (3)
Budesonide/formoterol (Symbicort®) = turbuhaler
Fluticasone/salmeterol = MDI and diskus
Fluticasone/vilanterol = ellipta
What are 2 ICS/LABA/LAMA combination drugs and what device do they come in?
- Fluticasone/umeclidinium/vilanterol (Trelegy) = ellipta
- Glycopyrronium/formoterol/budesonide = aerosphere
Goals of therapy for COPD include? (4)
- Alleviate dyspnea
- Improve health status
- Prevent AECOPD
- Reduce mortality
Define AECOPD mild exacerbation
Worsening or new respiratory symptoms without a change in prescribed medications
Define AECOPD moderate exacerbation
Prescribed antibiotic and/or oral corticosteroids
Define AECOPD severe exacerbation
Requiring a hospital admission or ED visit
Define low-risk of exacerbation of AECOPD
If they had 1 or less moderate exacerbation in the last year and did not require an ED visit or hospitalization
Define high-risk of exacerbation of AECOPD
If they had at least 2 moderate or 1 severe exacerbation in the last year requiring a hospital admissions/ED visit
Low symptom burden - what is COPD treatment?
LAMA or LABA
Low AECOPD risk - what is COPD treatment steps (2)?
- LAMA/LABA
- LAMA/LABA/ICS
High AECOPD risk - which is COPD treatment steps? (2)
- LAMA/LAMA/ICS
- LAMA/LABA/ICS + prophylactic macrolide/PDE-4 inhibitor/mucolytic agents
What is treatment for COPD exacerbation? (3)
- SAMA and SABA scheduled
- Corticosteroids
- Antibiotics for:
- Patients requiring mechanical ventilation
- Patients with at least 2/3 of the cardinal symptoms:
I. sputum purulence (change in phlegm color to
yellow or green)
II. increased sputum volume
III. increased dypsnea
What is first-choice antibiotics for simple COPD exacerbation without risk factors? (3)
- Amoxicillin
- Doxycycline
- Cotrimoxazole
x5-7 days
What is first-choice antibiotics for complicated COPD exacerbation with risk factors? (3)
- Amoxicillin / clavulanate (x 5-10 days)
- Cefuroxime axetil (x 5-10 days)
- Levofloxacin (x 3 days)
What are some “other” add on therapies for COPD treatment/management? (4)
- Prophylactic azithromycin
- Low dose add on - N-acetylcysteine
- Mucolytic
- Oral solution administered daily - Roflumilast
- PDE-4 inhibitor - Potential surgeries
- Lung volume reduction surgery
- Transplant
