COPD Flashcards
COPD
preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation usually caused by significant exposure to noxious particles or gases
Risk factors for COPD
-smoking
-occupational dust and chemicals
-indoor/outdoor pollution
-genes
-infections
-socio-economic status
-aging population
Clinical Presentation of COPD
-Dyspnea
-Cough (often first sx of COPD) - intermittent or persistent; productive or unproductive
-Chronic sputum production
-Wheezing
-Comorbidities
Diagnosis of COPD
-Spirometry: FEV1/FVC < 0.70
Bronchodilators
-Inc FEV1 or change other spirometric variables
-Widening of the airways
-Improve emptying of the lungs
Beta agonists
-relax airway smooth muscles by stimulating beta 2 adrenergic receptors, which inc cyclic AMP and antagonizes bronchoconstriction - bronchodialation
-AE: tremor, hypokalemia, tachycardia, tacyphylaxis
-SABA: albuterol, levalbuterol
-LABA: Salmeterol, Formoterol, Olodaterol, Aformoterol, Indacaterol
Muscarinic antagonists
-block bronchoconstrictor effects of acetylcholine on the M3 muscarinic receptors expressed in the airway smooth muscle
-SAMAs have slightly longer duration than SABAs
-poor systemic absorption
-AE: dry mouth (anticholinergic), tiotropium may cause metallic taste, cough, nausea, blurred vision, glaucoma
-SAMA: Ipratropium bromide
-LAMA: Tiotropium (Spiriva), Aclidinium, Umeclidinium (incruse ellipta)
short acting bronchodilator combos
-prn for symptoms or scheduled
-SABA + SAMA
-improve efficacy and equal or lesser SE
-Albuterol/Ipratropium MDI
-Albuterol/Ipratropium neb
Long acting bronchodilator combos
-Stiolto
-Anoro Ellipta
ICS/LABA combo
-Fluticasone furoate/vilanterol (Breo)
-Fluticasone propionate/salmeterol (Advair, Wixela)
-Budesonide/fomoterol (Symbicort)
-mometasone/formoterol (Dulera)
Triple therapy inhaler
-Fluticasone furoate/umeclidinium/vilanterol (Trelegy Ellipta)
-Budesonide/glycopyrrolate/formoterol (Breztri aerosphere)
Oral steroids
-used for exacerbations not for chronic management
Roflumilast (Daliresp)
-PDE4 inhibitors reduce inflammation by inhibiting the breakdown of intracellular cAMP
-AE: nausea, diarrhea, weight loss, sleep disturbances, HA, worsen depression
-do not use with Theophylline
Assessment of COPD (ABCD assessment tool)
-need spirometric value of < 0.7 (FEV1/FVC)
-then grade severity based on gold guidelines, then assess symptoms/risk of exacerbations by using A,B,C,D grouping
GOLD 1 (mild)
> /= 80%
GOLD 2 (moderate)
50-79%
GOLD 3 (severe)
30-49%
GOLD 4 (very severe)
< 30%
Group A
-mMRC 0-1
-CAT < 10
-0 or 1 exacerbation, not leading to hospital admission
Group B
-mMRC >/= 2
-CAT >/= 10
-0 or 1 exacerbation not leading to hospitalization
Group C
-mMRC 0-1
-CAT < 10
- >/= 2 or >/= 1 leading to hospitalization
Group D
-mMRC >/= 2
-CAT >/= 10
- >/= 2 or >/= 1 leading to hospitalization
mMRC
-measure of breathlessness
-scale 0-4
-predicts future mortality risk
CAT
comprehensive assessment of symptoms not just breathlessness
ICS
don’t want to use in COPD patients unless they have features of asthma or inc eosinophil count
Group A
-bronchodilator
-long acting (LAMA or LABA) are preferred unless patient has occasional dyspnea
Group B
long acting bronchodilator (LAMA or LABA)
Group C
LAMA
Group D
-LAMA or
-LAMA + LABA or (if highly symptomatic CAT >20)
-ICS + LABA (if eos >/= 300)
Adjusting therapy
-use follow up pharmacological treatment algorithm
-either dyspnea pathway or exacerbation pathway
Dyspnea
-LABA or LAMA -> LABA + LAMA
-if eos is >300 or eos >100 and > 2 moderate exacerbations/ 1 hospitalization switch to LABA + ICS or triple therapy
Exacerbations
-LABA or LAMA -> LABA + LAMA
-if eos is >300 or eos >100 and > 2 moderate exacerbations/ 1 hospitalization switch to LABA + ICS
-if eos > 100 switch to triple therapy
if eos < 100 switch to roflumilast or azithromycin (former smokers)
long term oxygen therapy
in patients with severe resting chronic hypoxemia, long term oxygen therapy (>15 hours per day) improves survival
Asthma-COPD Overlap
-Step 1: does the patient have chronic airway disease?
-Step 2: if the patient has over 3 features of either asthma or COPD then it is likely the right diagnosis
-Step 3: spirometry (< 0.7 ratio)
-Step 4: initial therapy (start treatment as for asthma with low or moderate ICS; usually add LABA &/or LAMA or continue if already prescribed
Acute COPD exacerbation
-sx: increased dyspnea, increased sputum purulence and volume increased cough and wheeze
-goal O2: 88-92%
-causes: main: viral; 2nd: bacterial and pollution; last: fungal
Acute exacerbation classification
-mild: Short acting bronchodilators only (ex. albuterol)
-moderate: Short acting bronchodilators + abx +/- steroids
-severe: hospitalization or ED visit +/- severe acute respiratory failure
Acute exacerbation nonpharm
-O2 < 90% saturation (target 88-92)
-ventilation (NIV for severe respiratory acidosis (pH < 7.35 and PaCO2 > 45), severe dyspnea, persistent hypoxemia
-Intubation and mechanical ventilation: life threatening hypoxemia, etc.
(Acute) bronchodilators
-albuterol or ipratropium
(Acute) steroids
-Prednisone 40 mg po daily
-treat for 5 days
-use oral unless pt cannot tolerate
-no taper required unless over 14 days
(Acute) abx
-treat for 5-7 days
-3 cardinal signs: increased dyspnea, increased sputum vol and purulence
-2 cardinal signs: one needs to be inc sputum purulence
-Augmentin 875 mg po or Unasyn 3 gm IV Q6h (renal dosing)
-Azithromycin 500 mg po daily x 3 days or 500 mg x 1 then 250 mg days 2-5
-doxycycline 100 mg po BID
-Risk for pseudomonas: Cefepime, Pop/tazo, levofloxacin, carbapenem
(Acute) monitoring
-steroids: WBC, glucose
-abx: WBC w/ neutrophils, temp, cultures, SCr, CrCl, eGFR (if renal elimination)
-bronchodilators: HR, frequency of use
