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Pulmonology > COPD > Flashcards

COPD Flashcards

1
Q

what is different about the airflow limitation in COPD compared to asthma

A

it is not reversible in COPD

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2
Q

_____ is chronic/recurrent excessive mucus secretion

A

chronic bronchitis

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3
Q

____ is permanent enlargement of air spaces, leading to destruction of the lung’s smallest structures where gas exchange occurs

A

emphysema

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4
Q

avoidable risk factors for COPD

A

tobacco smoke, occupational dusts and chemicals, air pollution

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5
Q

non-modifiable risk factors for COPD

A

genetic predisposition (AAT deficiency), airway hyperresponsiveness, impaired lung growth

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6
Q

what does AAT normally do

A

coats the lungs and protects them from neutrophil elastase

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7
Q

what is neutrophil elastase

A

produced by white blood cells to break down harmful bacteria, potentially damaging to lungs if exposed

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8
Q

what happens with AAT deficiency

A

lungs lack the AAT coating, leaving them open to damage by neutrophil elastase. AAT trapped in the liver, causing liver damage

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9
Q

GOLD Grade 1

A

mild, FEV1 > 80% predicted

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10
Q

GOLD Grade 2

A

moderate, FEV1 50-80% predicted

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11
Q

GOLD Grade 3

A

severe, FEV1 30-50% predicted

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12
Q

GOLD Grade 4

A

very severe, FEV1 <30% predicted

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13
Q

CAT assessment

A

score 10 or more means symptoms not controlled

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14
Q

mMRC dyspnea scale

A

score 2 or more means symptoms not controlled

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15
Q

GOLD E

A

2 or more moderate exacerbations, or 1 or more leading to hospitalization

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16
Q

GOLD A

A

0 or 1 moderate exacerbations (not hospitalization), mMRC 0-1 and CAT <10

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17
Q

GOLD B

A

0 or 1 moderate exacerbations (not hospitalization), mMRC 2+, CAT 10+

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18
Q

PDE4 inhibitor

A

roflumilast

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19
Q

roflumilast place in therapy

A

only recommended after recurrent exacerbations despite triple inhaler therapy

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20
Q

roflumilast side effects

A

nausea, diarrhea, decreased appetite, weight loss, headache, neuropsychiatric effects

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21
Q

theophylline place in therapy

A

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

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22
Q

azithromycin place in therapy

A

chronic therapy reduced exacerbations and improved QOL over one year, but can lead to macrolide resistance among lung flora

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23
Q

mucolytics (NAC) place in therapy

A

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

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24
Q

therapy for group E

A

LABA + LAMA (consider + ICS if blood eos >300)

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25
Q

therapy for group A

A

a bronchodilator

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26
Q

therapy for group B

A

LABA + LAMA

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27
Q

symptoms of COPD exacerbation

A

increase in sputum volume, increase in sputum purulence, dyspnea

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28
Q

outpatient management for COPD mild-moderate exacerbations

A

SABA, prednisone 40 mg daily for 5 days, azithromycin or doxycycline for 5-7 days, supplemental O2

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29
Q

bupropion SR mechanism

A

enhances noradrenergic and dopamine release

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30
Q

varencicline mechanism

A

partial a4b2 nicotinic receptor agonist, blocks nicotine from receptor binding sites to reduce the reward effects

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31
Q

varenicline warnings

A

black box for neuropsychiatric symptoms removed in 2016. several renal impairment (adjust dose), pregnancy and breastfeeding, adolescents < 18, monitor patients with severe/unstable CV

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32
Q

varenicline adverse effects

A

nausea, sleep disturbance (insomnia, abnormal/vivid dreams), constipation, flatulence, vomiting

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33
Q

varenicline dosing

A

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

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34
Q

varenicline duration

A

12 weeks, with an additional 12 weeks for successful quitters. (up to 12 months if needed/covered)

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35
Q

counseling for varenicline

A

report changes in mood, thinking, behavior (quitting smoking itself can change mood)

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36
Q

when is varenicline useful

A

when other agents have failed because it has a different MOA. can be used in combination with NRT agents and bupropion.

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37
Q

bupropion contraindications

A

seizures, eating disorders, MAOIs

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38
Q

bupropion boxed warning

A

neuropsychiatric symptoms: suicidal ideation, aggression, depression

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39
Q

bupropion precautions

A

concomitant medications that lower seizure threshold, hepatic impairment, pregnancy and breastfeeding, adolescents <18

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40
Q

bupropion side effects

A

insomnia, dry mouth

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41
Q

bupropion dosing

A

start 1-2 weeks before quit date. 150 mg daily for first 3 days. Then 150 mg BID dosed at least 8 hours apart.

42
Q

bupropion duration of therapy

A

7-12 weeks, up to 6 months

43
Q

when to consider bupropion

A

if depression is a comorbidity. may also blunt post-cessation weight gain

44
Q

bupropion counseling

A

avoid bedtime dosing with insomnia risk (8a/4p)

45
Q

NRT general contraindications

A

MI past 2 weeks, serious arrhythmias, unstable or worsening angina, pregnancy or breastfeeding, adolescents <18

46
Q

additional contraindications for NRT patch

A

skin disorders

47
Q

additional contraindications for NRT gum

A

temporomandibular joint disease

48
Q

additional contraindications for nicotine inhaler

A

bronchospastic disease

49
Q

additional contraindications for nicotine nasal spray

A

reactive airway disease or nasal conditions

50
Q

NRT patch side effects

A

headache, sleep disturbance (insomnia, abnormal dream), skin irritation

51
Q

dosing for NRT patch if >10 cigarettes/day

A

21 mg/day for 4-6 weeks. 14 mg/day for 2 weeks. 7 mg/day for 2 weeks.

52
Q

dosing for NRT patch if <10 cigarettes/day

A

14 mg/day for 6 weeks. 7 mg/day for 2 weeks

53
Q

NRT patch duration of therapy

A

8-10 weeks, has been extended to 6 months

54
Q

NRT patch counseling

A

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

55
Q

NRT gum side effects

A

mouth/jaw soreness, dyspepsia, hiccups, hypersalivation. if incorrect technique: lightheadedness, nausea, throat and mouth irritation, problematic with dental work

56
Q

instructions for NRT gum

A

“chew and park” 1 piece of gum with urge to smoke up to 24 pieces/24 hours

57
Q

when to use 2 mg gum dosage

A

<25 cigarettes/day or 1st cig >30 mins of waking

58
Q

when to use 4 mg gum dosage

A

> 25 cigarettes/day or 1st cig <30 mins of waking

59
Q

gum dosing weeks

A

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

60
Q

NRT gum duration of therapy

A

12 weeks, some users extend beyond 3 months

61
Q

NRT gum pros

A

oral tobacco substitute, can delay weight gain, titrate to manage symptoms while combining with other NRT

62
Q

NRT gum counseling

A

no food/acidic beverage 15 min pre and post, rotate areas in mouth

63
Q

NRT lozenge side effects

A

nausea, cough, headache, dyspepsia, hiccups, insomnia

64
Q

when to use 4 mg NRT lozenge

A

smoke first cigarette <30 min of waking

65
Q

when to use 2 mg NRT lozenge

A

smoke first cigarette >30 min of waking

66
Q

NRT lozenge dosing weeks

A

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

67
Q

NRT lozenge duration of therapy

A

12 weeks-6 months

68
Q

NRT lozenge pros

A

oral tobacco substitute, can delay weight gain, titrate to manage symptoms while combining with other NRT

69
Q

NRT lozenge counseling

A

allow to dissolve slowly (10 min minimum, 20-30 min standard). no food/beverage 15 min pre and post.

70
Q

nicotine inhaler side effects

A

mouth/throat irritation, dyspepsia, hiccups, cough, rhinitis

71
Q

nicotine inhaler instructions

A

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.

72
Q

nicotine inhaler duration of therapy

A

3-6 months

73
Q

pathologic changes in COPD

A

decreased ciliary motility, mucus hypersecretion, smooth muscle thickening, chronic inflammation: scarring and fibrosis

74
Q

key cells in COPD versus asthma

A

COPD: neutrophils, large increase in macrophages, CD8
asthma: eosinophils, mast cells, CD4

75
Q

response to ICS in COPD

A

variable

76
Q

key differences in COPD vs asthma

A

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

77
Q

what to prioritize if a patient has asthma and COPD

A

prioritize asthma treatment, smoking cessation, LAMA, pulmonary rehab, mucolytics

78
Q

COPD symptoms

A

chronic cough, chronic sputum production, dyspnea progress over time

79
Q

physical exam: COPD

A

shallow breathing, increased RR, barrel chest due to hyperinflation, pursed lip breathing on exhalation, use of accessory muscles, cachexia, central cyanosis

80
Q

what is required for COPD diagnosis

A

spirometry: FEV1/FVC <0.7

81
Q

what are some factors that can affect spirometry results

A

age, height/weight, sex, smoking status, patient effort and coordination, previous pulmonary disease, ethnicity

82
Q

what is a mild COPD exacerbation treated with

A

SABDs

83
Q

what is a moderate COPD exacerbation treated with

A

SABDs+ antibiotics and/or oral corticosteroids

84
Q

SAMA MOA

A

blocks acetylcholine at muscarinic receptors–> decrease smooth muscle contraction

85
Q

ipratropium onset

A

15-20 mins

86
Q

ipratropium frequency

A

6 hrs

87
Q

SAMA adverse

A

dry mouth, metallic taste

88
Q

LAMA advantages over SAMA

A

better improvement in lung function and symptoms, more convenient dosing (once or twice daily), reduced exacerbations and hospitalization

89
Q

LABA adverse

A

tachycardia and arrhythmias

90
Q

ICS MOA

A

anti-inflammatory to decrease mucus, inhibit leukocytes and prostaglandins

91
Q

role of ICS in COPD

A

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

92
Q

what is roflumilast not recommended for

A

use with theophylline

93
Q

vaccinations for COPD

A

Flu, COVID, pneumococcal, Tdap, zoster

94
Q

pneumococcal recommendations for COPD

A

reduces incidence of CAP and exacerbations: one dose of PCV20. Or one dose of PCV15 followed by PPSV23

95
Q

when to consider LABA + LAMA + ICS

A

if blood eosinophils >300

96
Q

when to consider roflumilast

A

FEV1<50% and chronic bronchitis

97
Q

when to consider azithromycin

A

former smokers

98
Q

signs of severe exacerbation

A

sputum purulence, sputum volume, dyspnea or signs of respiratory failure: mental status changes, RR>30, hypoxemia with supplemental O2

99
Q

on average, how many attempts are necessary for a patient to quit smoking successfully

A

7

100
Q

how many cigarettes does a usual pack contain

A

20

101
Q

5 A’s for smoking cessation program

A

ask, advise, assess, assist, arrange

102
Q

stages of change for smoking cessation

A

precontemplation, contemplation, preparation, maintenance, relapse

Pulmonology (2 decks)

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