COPD Flashcards
True or false: COPD is chronic, progressive, and not reversible
True
The two principal COPD conditions are_______________________ and ______________ , which are referred to as phenotypes.
chronic bronchitis and emphysema
What are the COPD guidelines called?
GOLD
1) What defines chronic bronchitis?
2) Define emphysema
1) Excessive mucus secretion w. cough for at least 3 months of the year for at least two consecutive years
2) Permanent enlargement of the airspaces + destruction [of terminal bronchiole walls]
COPD affects ___________ million Americans
16-28
Describe the etiology of COPD
1) Cigarette smoking
2) Environmental factors (like tobacco smoke)
3) Genes
4) α1-antitrypsin (AAT): correlates w. development of emphysema and pulmonary dysfunction
-Accounts for < 1% of all COPD cases
1) Cigarette smoking is the most common risk factor of COPD and accounts for ___________ of cases of COPD in the United States
2) ______% of all smokers develop COPD
1) 85-90%
2) 50%
What is the pathophys of COPD?
Neutrophilic
Do glucorticosteroids work for COPD?
Variable effect (compared to asthma, where they inhibit inflammation)
Describe the effects COPD has on the lungs in mmHg
↓ PaO2 = 45-60 mm Hg
↑ PaCO2 = 50-60 mm Hg
What happens as COPD progresses?
1) pH balance will be maintained by kidneys
Patients at risk for respiratory acidosis
2) Development of pulmonary hypertension
Right ventricle hypertrophy > right-sided heart failure
3) Thoracic hyperinflation
4) Systemic effects incl: cachexia (ie, weight loss & muscle wasting)
What improves diagnostic accuracy for COPD? Describe
Spirometry combined with physical examination:
Reduction in FEV1/FVC ratio to less than 70% (0.70)
(specifically postbronchodilator spirometry)
COPD:
1) When should Sx assessment be measured? Using what?
2) What is group E and who is in it?
1) At baseline and then during routine visits using CAT or mMRC
2) Patients with at least two exacerbations in the last 12 months, or one exacerbation requiring hospitalization, are considered high risk for future exacerbations (group E)
Describe how to score the grades of COPD with the GOLD scale
1) Mild: >/=80%
2) Moderate: 50-80%
3) Severe: 30-50%
4) Very severe: <30%
How do you score a CAT?
<10 means less symptoms, >/= 10 means more symptoms
Describe the initial pharmacological COPD Tx: What are the criteria for groups A and B?
Group A: mMRC 0-1; CAT <10. Group B: mMRC >/=2, CAT >/=10.
Both: 0 or 1 moderate exacerbations (not leading to hospital admission).
Describe the initial pharmacological COPD Tx: What are the treatments for groups A and B?
Group A: Any bronchodilator
Group B: LABA + LAMA*
*pts also need emergency SABA
Describe the initial pharmacological COPD Tx: What are the criteria for group E? What is the Tx?
> /=2 moderate exacerbations or >/=1 leading to hospitalization
Tx: LABA + LAMA
*also emergency SABA
*consider adding ICS if blood eos >/=300
What are the 4 major aspects of COPD Tx?
Assess and monitor the condition, avoid or reduce exposure to risk factors, manage stable disease, and treat exacerbations
1) True or false: Most treatments for COPD have not been shown to improve survival or to slow the progressive decline in lung function.
2) What do many COPD therapies do?
1) True
2) Improve pulmonary function and quality of life as well as reduce the risk of COPD exacerbations and duration of hospitalization
What is the only COPD intervention proven to affect long-term decline in FEV1 and slow the progression?
Smoking cessation
What are the first line pharmacotherapies for smoking cessation?
1) Bupropion SR 150mg PO for up to 3 days, then BID for 12wks-6months
2) Nicotine gum up to 12wks
3) Nicotine patches up to 8wks
4) Chantix (varenicline) for 12wks
Nicotine cessation products:
1) Who should you avoid bupropion for?
2) Who is NRT contraindicated for?
3) What does varenicline do?
1) For patients with PMH of seizures or eating disorders
2) With recent (w/in 2 weeks) stroke or MI
3) Relieves physical withdrawal symptoms and reduces the rewarding properties of nicotine
Nicotine cessation products:
1) What is the MOA of varenicline?
2) What are the other options?
3) What is allowed for Tx in the UK but not US?
1) Partial agonist on nicotinic receptors
2) Tricyclic antidepressants, behavioral therapy and hypnosis
3) E-cigarettes; due to missing long-term safety data (UK is exception)
What are some non-pharmaceutical Txs for COPD?
1) Pulmonary rehabilitation
2) Oxygen 1 to 2 L/min (if <55mmHg)
List 5 vaccines that can prevent respiratory conditions
1) Influenza
2) Tdap
3) RSV
4) COVID-19
5) Pneumonia
Adult pneumonia vaccines (2025):
1) What are the recommendations for 19-49 yr/olds?
2) What abt for adults 50 years and older?
1) 19-49 years old w/ COPD; other indications have same recommendations (eg, smoking or heart failure)
2) One dose: Prevnar-15, Prevnar-20, or Capvaxive (PCV21)
List 2 categories of short acting bronchodilators
1) Short-acting beta agonist (SABA)
2) Short-acting anticholinergics (also known as antimuscarinics)
Short-acting beta agonists (SABA):
1) Give two examples and what each are
2) What are some adverse effects?
1) Albuterol (Ventolin, ProAir, Proventil): Racemic mixture of (R)-albuterol, which is responsible for the bronchodilator effect, and (S)-albuterol, which has no therapeutic effect
-Levalbuterol (Xopenex): Single-isomer formulation of (R)-albuterol
2) Tremors, palpitations, tachycardia, jitteriness
Short-acting anticholinergics (also known as antimuscarinics):
1) What is the MOA?
2) Give an example of a med in this category
3) What are some adverse effects?
1) M1 – 3 acetylcholine antagonist
2) Ipratropium (Atrovent)
-Less risk of causing skeletal muscle tremor and tachycardia
3) Dry mouth; may precipitate narrow-angle glaucoma symptoms
Long-acting bronchodilators:
1) Are they appropriate for acute COPD relief?
2) Is LABA monotherapy appropriate?
3) What do the 2023 guideline update recommendations say?
4) What 2 drugs in this category have the most outcome evidence to support use?
1) No
2) Not associated with increased mortality and is recommended as part of international guidelines
3) Combination therapy (LAMA + LABA) for group B + E
4) Salmeterol and formoterol
List 5 long-acting bronchodilators that are long-acting β2-agonists (LABAs) and how they’re used
1) Salmeterol (Serevent Diskus)
-dry powder inhaler (DPI)
2+3) Formoterol (Perfomist) + Arformoterol (Brovana)
-nebulized solutions
4) Indacaterol (Arcapta)
-DPI
5) Olodaterol (Striverdi)
-soft mist inhaler (SMI)
List 5 long-acting bronchodilators that are long-acting muscarine-agonists (LAMAs) and how they’re used
1) Tiotropium (Spiriva Respimat or Spiriva Handihaler)
-SMI and DPI
2) Aclidinium (Tudorza Pressair)
-DPI
3) Glycopyrrolate (Lonhala Magnair or Seebri Neohaler)
-Nebulized or DPI
4) Umeclidinium (Incruse Ellipta)
-DPI
5) Revefenacin (Yupelri)
-Nebulized
Corticosteroids:
1) True or false: ICS monotherapy for patients with COPD is not recommended
2) What should you counsel pts using these meds to do?
3) What is there a risk of?
1) True
2) Recommend adequate intake of calcium and vitamin D and consider periodic bone mineral density testing for patients at risk of osteopenia
-Wash mouth after use (oral candidiasis)
3) Pneumonia and mycobacterial pulmonary infections
Combination dual and triple therapy for COPD; is it effective?
Significant improvement compared with LABA or LAMA monotherapy
True or false: ICS/LABA dual Tx is not recommended for COPD pts, but is for asthma pts
True
When may triple therapy with ICS/LABA/LAMA may be considered instead of LAMA/LABA for COPD pts?
For pts w. blood eosinophil ≥ 300 cells/μL (0.3 x 109/L) or ≥ 100 cells/uL [and ≥ two moderate exacerbations or one exacerbation requiring hospitalization in the last year (high risk)]
Dupilumab (Dupixent, a biologic):
1) What is the MOA?
2) It decreases exacerbations and improves lung function for COPD patients with what?
3) What is the dose?
1) MAB directed at blocking interleukin-4 + 13 receptors
2) PMH of exacerbations + eosinophil count > = 300 cells / mcl and concurrent use of LAMA/LABA/ICD
3) 300 mg injection every other week
Dupilumab (Dupixent):
1) List 2 warnings for it
2) List some adverse rxns
1) Anaphylaxis, helminth infections,
2) Injection site reactions, increased risk of herpes + UTIs, arthralgias
Methylxanthines: List 2
Theophylline (PO) and aminophylline (IV)
Methylxanthines (Theophylline (PO) and aminophylline (IV)):
1) What is the MOA?
2) What may they do for pts with COPD?
3) What is the target amt to reduce seizure risk?
1) Inhibition of phosphodiesterase +inhibition of release of mediators from mast cells and leukocytes
2) May offer improvements in lung function and gas exchange
3) Target = troughs = 15 mcg/mL
1) Methylxanthines (theophylline (PO) and aminophylline (IV)) can cause what at > 20 mcg/mL?
2) Why?
1) Toxicities: arrhythmias and seizures (QT prolongation)
2) Narrow therapeutic index
Roflumilast (Daliresp) (a phosphodiesterase 4 (PDE4) inhibitor):
1) What is the MOA?
2) Who is it recommended for?
1) Relaxation of airway smooth muscle cells and decreased activity of inflammatory cells
2) Pts with recurrent exacerbations despite treatment with triple inhalation therapy (LAMA/LABA/ICS) or if eosinophil count (<100 cells/μL [0.1 x 109/L])
Theophylline should not be given with what? Why?
Roflumilast (Daliresp); similar MOA
Roflumilast (Daliresp) (a phosphodiesterase 4 (PDE4) inhibitor):
1) Adverse effects?
2) How do you dose?
1) Neuropsychiatric effects such as suicidal thoughts, insomnia, anxiety, and new or worsened depression
2) Start at 250 mcg PO Qday for 4 weeks, then increase to a maintenance dose of 500 mcg PO Qday
Ensifentrine (Ohtuvayre)(Phosphodiesterase 3 & 4 inhibitor; a new drug): What can it cause?
Psychiatric symptoms
Azithromycin (macrolide):
1) Who is this Tx of no benefit to?
2) How is it dosed?
3) What is there an increased risk of?
4) What is an adverse effect? List 2 drug interactions
1) Current smokers (avoid combination)
2) 250mg Qday or 250mg three times weekly; reassess after 12 months
3) Hearing loss for COPD cohort
4) QT-prolongation; Flecainide and fluconazole
α1-Antitrypsin Replacement Therapy: is there a lot of evidence for its use in COPD Tx?
Sparse evidence to recommend use + expensive
1) There’s a lack evidence for routine use of what OTC med in treating COPD pts?
2) When are opioids like morphine used in treating COPD?
1) Mucolytics – guaifenesin
2) End-stage dyspnea
Define an exacerbation
A change in the patient’s baseline symptoms (dyspnea, cough, or sputum production)
How can COPD exacerbations be treated?
1) O2 therapy
2) Noninvasive positive-pressure ventilation (NPPV)
(Patients with severe acidosis (pH <7.25), respiratory arrest, or cardiovascular instability should be not considered for NPPV)
3) Bronchodilators (avoid theophylline)
4) Systemic corticosteroids: Prednisone 40 mg PO daily (or equivalent) for 5 days
5) Antibiotics
List the types of COPD exacerbations
1) Type 1 = mild
2) Type 2 = moderate
-2 cardinal Sx
3) Type 3 = severe
-3 cardinal Sx
What do the treatments for all 3 types of acute COPD exacerbations have in common?
All should be treated with a short-acting bronchodilator
List the treatments for the 3 types of COPD acute exacerbations
1) Mild: short-acting bronchodilators only
2) Moderate: short-acting bronchodilators + antibiotics or systemic corticosteroids
3) Severe: all of the above + hospitalization/ ER visit
