COPD Flashcards
define COPD
a respiratory disorder largely caused by smoking, and is characterized by progressive, partially reversible airway obstruction and lung hyperinflation, systemic manifestations, and increasing frequency and severity of exacerbations
emphysema
abnormal enlargement of the airspace distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis
chronic bronchitis
chronic cough for at least 3 months x 2 consecutive years
risk factors of COPD
exposure to particles
infections
socio-economic status
genetics
lung growth and development
airway hyper-responsiveness
what imbalance is noted in the lungs of patients with COPD?
protease-antiprotease
what may play an important role in amplifying the inflammatory process?
oxidative stress
what is a hallmark of COPD?
expiratory flow limitation due to increased resistance from mucosal inflammation, airway remodeling, fibrosis, and secretions
what causes lung hyperinflation?
obstruction of the small airways results in air-trapping
what do gas exchange abnormalities result in?
hypoxemia and hypercapnia
what is the result of mucous hypersecretion?
chronic productive cough
what happens during exacerbations?
there is an increase in hyperinflation and gas trapping, with decreased expiratory flow
what can lead to structural changes in late COPD?
pulmonary hypertension due to hypoxic vasoconstriction of small pulmonary arteries
what comorbidities are associated with COPD?
ischemic heart disease
congestive heart failure
arrhythmias
pulmonary hypertension
lung cancer
depression
metabolic disorders
what are the three cardinal symptoms of COPD?
shortness of breath
chronic cough
phlegm
end-stage symptoms of COPD
adopt positions that relieve dyspnea
use of accessory respiratory muscles
expiration through pursed lips
cyanosis
enlarged liver from right heart failure
how do patient initially present with COPD?
extremely sedentary lifestyle and presents with general fatigue
patient has complaints of dyspnea and chronic cough
episodes of cough, sputum, wheezing, fatigue and dyspnea
difference in age of onset in asthma vs. COPD
asthma usually < 40
COPD usually > 40
difference in smoking history in asthma vs. COPD
asthma - not causal, but worsens control
COPD - usually > 10 packs/year
difference in sputum production in asthma vs. COPD
asthma - infrequent
COPD - often
difference in allergies in asthma vs. COPD
asthma - often
COPD - infrequent
difference in clinical symptoms in asthma vs. COPD
asthma - intermittent and variable
COPD - persistent and progressive
difference in disease course in asthma vs. COPD
asthma - stable (with exacerbations)
COPD - progressive worsening (with exacerbations)
difference in spirometry in asthma vs. COPD
asthma - often normalizes
COPD - may improve but never normalizes
difference in airway inflammation in asthma vs. COPD
asthma - eosinophilic
COPD - neutrophilic
difference in response to ICS in asthma vs. COPD
asthma - essential for optimal control
COPD - helpful in patients with moderate to severe disease and frequent AECOPD
difference in role of bronchodilators in asthma vs. COPD
asthma - as needed use only
COPD - regular therapy usually necessary
difference in role of exercise training in asthma vs. COPD
asthma - rarely formally used
COPD - essential therapy
difference in end-of-life discussions in asthma vs. COPD
asthma - rarely necessary
COPD - often essential
what is required to make a diagnosis of COPD?
spirometry
- post bronchodilator FEV1/FVC ratio <0.7 confirms diagnosis
who should be screened for COPD?
patients with risk factors
- smokers/ex-smokers >40 who have:
- persistent cough or sputum production
- frequent respiratory tract infections
- progressive activity-related SOB
- evening wheeze
what results would be seen in a pulmonary function test of someone with COPD?
FEV1 < 80% and FEV1/FVC ratio <0.7
OR FEV1/FVC less than the lower limit of normal (more accurate)
how are total pack years calculated?
(# of cigarettes smoked/day / 20) x # years of smoking
grade 0 on mMRC dyspnea scale
breathless with strenuous exercise (lots of people)
grade 1 on mMRC dyspnea scale
MILD stage - SOB when hurrying on the level or walking up a slight hill
grade 2 on mMRC dyspnea scale
MODERATE stage - walks slower than people of the same age on the level or stops for breath while walking at own pace on the same level
grade 3 on mMRC dyspnea scale
MODERATE stage - stops for breath after walking 100 meters or after a few minutes on the same level
grade 4 on mMRC dyspnea scale
SEVERE stage - too breathless to leave the house, or breathlessness when dressing
what is the CAT test?
validated, short and simple patient completed questionnaire
how does the scoring work for a CAT test?
score ranges from 0-40
- 0-10 = low impact
- 11-20 = medium impact
- 21-30 = high impact
- >30 = very high impact
spirometry post bronchodilator for MILD COPD
FEV1 >80% of predicted
FEV1/FVC < 0.7
spirometry post bronchodilator for MODERATE COPD
FEV1 50-79% of predicted
FEV1/FVC < 0.7
spirometry post bronchodilator for SEVERE COPD
FEV1 30-49% of predicted
FEV1/FVC < 0.7
spirometry post bronchodilator for VERY SEVERE COPD
FEV1 < 30% of predicted
FEV1/FVC < 0.7
goals of therapy for COPD
prevent disease progression
prevent and treat exacerbations
alleviate breathlessness and other respiratory symptoms
improve exercise tolerance and daily activities
prevent and treat complications of the disease
improve health status
reduce mortality
treatment options for COPD
smoking cessation
eliminate exposures
patient education
avoid sedatives / narcotics
vaccines
pharmacological treatment
what is the only intervention shown to slow progression of COPD?
smoking cessation
what are the benefits of pulmonary rehabilitation?
reduced dyspnea
increased exercise endurance
improved quality of life
decreased fatigue
what vaccines are recommended for patients with COPD?
annual flu vaccine
pneumococcal vaccine
what is the main pharmacologic treatment for COPD?
bronchodilators
dosing of SABAs in COPD
QID prn
what is the short acting muscarinic antagonist (SAMA) and its dosing?
ipratropium QID prn
what is the combo SABA & SAMA and its dosing?
salbutamol + ipratropium (Combivent) QID prn
MOA od SAMAs and LAMAs
competitively inhibit cholinergic receptors in bronchial smooth muscle
SAMA effectiveness
less effective then B2 agonists in asthma
slower onset of action than SABAs
adverse effects of SAMA & LAMA
dry mouth
cough
constipation
urinary retention
headache
what is the dosing for the LABAs in COPD?
salmeterol and formoterol - BID
indacaterol and olodaterol - OD
what are the LAMAs and their dosing?
tiotropium - OD
aclindinium - BID
glycopyrronium - OD
umeclidinium - OD
what is the difference in LABAs and LAMAs?
both improve symptoms
Tiotropium (LAMA) may be superior in decreasing exacerbations
LAMAs may be better tolerated
should ICS be used in COPD?
should not be used as first line or as monotherapy
they do have some evidence for reducing exacerbations though
what kind of combo products are there in COPD?
LAMA/LABA
SAMA/SABA
ICS/LABA
LABA/LAMA/ICS
what is N-acetylcysteines role in COPD?
high dose, 600mg orally BID may reduce exacerbations in those who had 2 or more exacerbations in the previous 2 year period
what is roflumilast?
a phosphodiesterase IV inhibitor that improves FEV1 and can decrease exacerbations
what is the dosing for roflumilast?
500mcg tab OD added on to bronchodilator treatment
side effects of roflumilast
diarrhea
weight loss
nausea
headache
sleep disturbances
pros and cons of theophylline in COPD
pros - effective bronchodilator taken OD or BID
cons - serious drug toxicity may occur, and several potential drug interactions
low risk of exacerbations
1 or less moderate exacerbation in the last year
high risk of exacerbations
2 moderate or 1 severe exacerbation in the last year requiring hospital admissions/ED visit
drug treatment of mild COPD
SABA prn and LAMA or LABA
drug treatment for moderate and severe COPD with low risk AECOPD
SABA prn + LAMA/LABA combo
step up to LAMA/LABA/ICS if needed
drug treatment for moderate and severe COPD with high risk AECOPD
SABA prn + LAMA/LABA/ICS
can add on prophylactic macrolide/PDE-4 inhibitor/mucolytic agents if needed
what are some other serious therapies for COPD?
lung volume reduction surgery
lung transplantation
what is an acute exacerbation?
sustained worsening of dyspnea, cough or sputum production leading to an increase in the use of maintenance medications and/or supplementation with additional medications
what is the treatment of acute exacerbations?
bronchodilators - SAMA and SABA become scheduled
steroids (systemic) - restore lung function quicker. typically dosed prednisone 30-50mg daily x 5-14 days
antibiotics when sputum is yellow or green, increased sputum volume and increased dyspnea
which antibiotics could be used in COPD without risk factors?
amoxicillin
doxycycline
cotrimoxazole
(x5-7 days)
which antibiotics could be used in COPD with risk factors?
amoxi clav (5-10 days)
cefuroxime axetil (5-10 days)
levofloxacin (3-5 days)
