COPD Flashcards
what is different about the airflow limitation in COPD compared to asthma
it is not reversible in COPD
_____ is chronic/recurrent excessive mucus secretion
chronic bronchitis
____ is permanent enlargement of air spaces, leading to destruction of the lung’s smallest structures where gas exchange occurs
emphysema
avoidable risk factors for COPD
tobacco smoke, occupational dusts and chemicals, air pollution
non-modifiable risk factors for COPD
genetic predisposition (AAT deficiency), airway hyperresponsiveness, impaired lung growth
what does AAT normally do
coats the lungs and protects them from neutrophil elastase
what is neutrophil elastase
produced by white blood cells to break down harmful bacteria, potentially damaging to lungs if exposed
what happens with AAT deficiency
lungs lack the AAT coating, leaving them open to damage by neutrophil elastase. AAT trapped in the liver, causing liver damage
GOLD Grade 1
mild, FEV1 > 80% predicted
GOLD Grade 2
moderate, FEV1 50-80% predicted
GOLD Grade 3
severe, FEV1 30-50% predicted
GOLD Grade 4
very severe, FEV1 <30% predicted
CAT assessment
score 10 or more means symptoms not controlled
mMRC dyspnea scale
score 2 or more means symptoms not controlled
GOLD E
2 or more moderate exacerbations, or 1 or more leading to hospitalization
GOLD A
0 or 1 moderate exacerbations (not hospitalization), mMRC 0-1 and CAT <10
GOLD B
0 or 1 moderate exacerbations (not hospitalization), mMRC 2+, CAT 10+
PDE4 inhibitor
roflumilast
roflumilast place in therapy
only recommended after recurrent exacerbations despite triple inhaler therapy
roflumilast side effects
nausea, diarrhea, decreased appetite, weight loss, headache, neuropsychiatric effects
theophylline place in therapy
considered in acutely ill patient when other long-term treatment bronchodilators are unavailable or unaffordable. therapeutic range is trough of 8-15 mcg/mL. monitor concentrations 1-2x/yr
azithromycin place in therapy
chronic therapy reduced exacerbations and improved QOL over one year, but can lead to macrolide resistance among lung flora
mucolytics (NAC) place in therapy
commonly started during hospitalizations, reduction of exacerbations in patients with moderate disease over 1 year, breaks up mucoproteins and lowers viscosity so easier to cough up
therapy for group E
LABA + LAMA (consider + ICS if blood eos >300)
therapy for group A
a bronchodilator
therapy for group B
LABA + LAMA
symptoms of COPD exacerbation
increase in sputum volume, increase in sputum purulence, dyspnea
outpatient management for COPD mild-moderate exacerbations
SABA, prednisone 40 mg daily for 5 days, azithromycin or doxycycline for 5-7 days, supplemental O2
bupropion SR mechanism
enhances noradrenergic and dopamine release
varencicline mechanism
partial a4b2 nicotinic receptor agonist, blocks nicotine from receptor binding sites to reduce the reward effects
varenicline warnings
black box for neuropsychiatric symptoms removed in 2016. several renal impairment (adjust dose), pregnancy and breastfeeding, adolescents < 18, monitor patients with severe/unstable CV
varenicline adverse effects
nausea, sleep disturbance (insomnia, abnormal/vivid dreams), constipation, flatulence, vomiting
varenicline dosing
start 1 week prior to quit date. Days 1-3: 0.5 mg once daily with food or water for nausea. Days 4-7: 0.5 mg twice daily (take second dose with evening meal instead of HS if causing insomnia). Day 8-Week 12: 1 mg twice daily
varenicline duration
12 weeks, with an additional 12 weeks for successful quitters. (up to 12 months if needed/covered)
counseling for varenicline
report changes in mood, thinking, behavior (quitting smoking itself can change mood)
when is varenicline useful
when other agents have failed because it has a different MOA. can be used in combination with NRT agents and bupropion.
bupropion contraindications
seizures, eating disorders, MAOIs
bupropion boxed warning
neuropsychiatric symptoms: suicidal ideation, aggression, depression
bupropion precautions
concomitant medications that lower seizure threshold, hepatic impairment, pregnancy and breastfeeding, adolescents <18
bupropion side effects
insomnia, dry mouth
bupropion dosing
start 1-2 weeks before quit date. 150 mg daily for first 3 days. Then 150 mg BID dosed at least 8 hours apart.
bupropion duration of therapy
7-12 weeks, up to 6 months
when to consider bupropion
if depression is a comorbidity. may also blunt post-cessation weight gain
bupropion counseling
avoid bedtime dosing with insomnia risk (8a/4p)
NRT general contraindications
MI past 2 weeks, serious arrhythmias, unstable or worsening angina, pregnancy or breastfeeding, adolescents <18
additional contraindications for NRT patch
skin disorders
additional contraindications for NRT gum
temporomandibular joint disease
additional contraindications for nicotine inhaler
bronchospastic disease
additional contraindications for nicotine nasal spray
reactive airway disease or nasal conditions
NRT patch side effects
headache, sleep disturbance (insomnia, abnormal dream), skin irritation
dosing for NRT patch if >10 cigarettes/day
21 mg/day for 4-6 weeks. 14 mg/day for 2 weeks. 7 mg/day for 2 weeks.
dosing for NRT patch if <10 cigarettes/day
14 mg/day for 6 weeks. 7 mg/day for 2 weeks
NRT patch duration of therapy
8-10 weeks, has been extended to 6 months
NRT patch counseling
change patch daily upon awakening. recommend wearing for 24 hours to start, remove at bedtime if sleep disturbance. apply to clean, dry, hairless, minimal perspiration area. rotate daily
NRT gum side effects
mouth/jaw soreness, dyspepsia, hiccups, hypersalivation. if incorrect technique: lightheadedness, nausea, throat and mouth irritation, problematic with dental work
instructions for NRT gum
“chew and park” 1 piece of gum with urge to smoke up to 24 pieces/24 hours
when to use 2 mg gum dosage
<25 cigarettes/day or 1st cig >30 mins of waking
when to use 4 mg gum dosage
> 25 cigarettes/day or 1st cig <30 mins of waking
gum dosing weeks
weeks 1-6: chew 1 piece q1-2h, at least 9 pieces/day if monotherapy. weeks 7-9: chew 1 piece q2-4h. weeks 10-12: chew 1 piece q4-8h
NRT gum duration of therapy
12 weeks, some users extend beyond 3 months
NRT gum pros
oral tobacco substitute, can delay weight gain, titrate to manage symptoms while combining with other NRT
NRT gum counseling
no food/acidic beverage 15 min pre and post, rotate areas in mouth
NRT lozenge side effects
nausea, cough, headache, dyspepsia, hiccups, insomnia
when to use 4 mg NRT lozenge
smoke first cigarette <30 min of waking
when to use 2 mg NRT lozenge
smoke first cigarette >30 min of waking
NRT lozenge dosing weeks
weeks 1-6: one lozenge q1-2h. weeks 7-9: one lozenge q2-4h. weeks 10-12: one lozenge q4-8h. use at least 9 lozenges/day for the first 6 weeks if monotherapy, max 20 lozenges/day
NRT lozenge duration of therapy
12 weeks-6 months
NRT lozenge pros
oral tobacco substitute, can delay weight gain, titrate to manage symptoms while combining with other NRT
NRT lozenge counseling
allow to dissolve slowly (10 min minimum, 20-30 min standard). no food/beverage 15 min pre and post.
nicotine inhaler side effects
mouth/throat irritation, dyspepsia, hiccups, cough, rhinitis
nicotine inhaler instructions
6-16 cartridges per day, best with continuous active puffing for 20 minutes. inhale into back of throat or puff in short breaths, do not inhale like a cigarette. initial 1 cartridge q1-2h.
nicotine inhaler duration of therapy
3-6 months
pathologic changes in COPD
decreased ciliary motility, mucus hypersecretion, smooth muscle thickening, chronic inflammation: scarring and fibrosis
key cells in COPD versus asthma
COPD: neutrophils, large increase in macrophages, CD8
asthma: eosinophils, mast cells, CD4
response to ICS in COPD
variable
key differences in COPD vs asthma
COPD: later in life, cough and sputum, no allergic component, airflow limitation cannot be reversed
asthma: early in life, cough and wheeze, triad of allergic diseases, airflow limitation is reversible, FEV1 improves after SABA
what to prioritize if a patient has asthma and COPD
prioritize asthma treatment, smoking cessation, LAMA, pulmonary rehab, mucolytics
COPD symptoms
chronic cough, chronic sputum production, dyspnea progress over time
physical exam: COPD
shallow breathing, increased RR, barrel chest due to hyperinflation, pursed lip breathing on exhalation, use of accessory muscles, cachexia, central cyanosis
what is required for COPD diagnosis
spirometry: FEV1/FVC <0.7
what are some factors that can affect spirometry results
age, height/weight, sex, smoking status, patient effort and coordination, previous pulmonary disease, ethnicity
what is a mild COPD exacerbation treated with
SABDs
what is a moderate COPD exacerbation treated with
SABDs+ antibiotics and/or oral corticosteroids
SAMA MOA
blocks acetylcholine at muscarinic receptors–> decrease smooth muscle contraction
ipratropium onset
15-20 mins
ipratropium frequency
6 hrs
SAMA adverse
dry mouth, metallic taste
LAMA advantages over SAMA
better improvement in lung function and symptoms, more convenient dosing (once or twice daily), reduced exacerbations and hospitalization
LABA adverse
tachycardia and arrhythmias
ICS MOA
anti-inflammatory to decrease mucus, inhibit leukocytes and prostaglandins
role of ICS in COPD
no clear benefit for lung function but can reduce exacerbation frequency, never first line and always in combo with LABA due to lack of benefit. can cause pneumonia after long term use
what is roflumilast not recommended for
use with theophylline
vaccinations for COPD
Flu, COVID, pneumococcal, Tdap, zoster
pneumococcal recommendations for COPD
reduces incidence of CAP and exacerbations: one dose of PCV20. Or one dose of PCV15 followed by PPSV23
when to consider LABA + LAMA + ICS
if blood eosinophils >300
when to consider roflumilast
FEV1<50% and chronic bronchitis
when to consider azithromycin
former smokers
signs of severe exacerbation
sputum purulence, sputum volume, dyspnea or signs of respiratory failure: mental status changes, RR>30, hypoxemia with supplemental O2
on average, how many attempts are necessary for a patient to quit smoking successfully
7
how many cigarettes does a usual pack contain
20
5 A’s for smoking cessation program
ask, advise, assess, assist, arrange
stages of change for smoking cessation
precontemplation, contemplation, preparation, maintenance, relapse
