COPD Flashcards
CXR findings - COPD
hyperlucency (trapped air)
barrel chest
vertically oriented heart
flattened diaphragm
Normal decrease in FEV1 for non-smokers
25-30 mL/yr after age 35
Decrease in FEV1 for smokers
> 60 mL/yr
What scale can determine prognosis of COPD progression?
BODE
BMI
Obstruction (degree of airflow limitation)
Dyspnea
Exercise capacity (6 min walk test)
Goal of therapy for COPD
(NO CURE)
- symptom control
- prevention of exacerbations
What is the BEST intervention for COPD?
Stop smoking!
Anticholinergic Agents - MOA
acts on enzyme guanylate cyclase -> increases cGMP -> -> -> bronchodilation
What is the biggest issue with Ipatropium (SAMA)?
QID
MDI - need spacer or proper # of steps (harder to use)
Tiotropium - counseling for technique
pill form for inhalation…not for PO!
Tiotropium - class and indication
Long acting anti-cholinergic (LAMA)
COPD
Ipratropium - class and indication?
short acting anti-cholinergic (SAMA)
asthma exacerbation and COPD
ICS for COPD - who?
more severe patients (b/c higher risk of death and pneumonia)
GOLD 3 and 4 (FEV1<2L)
Roflumilast (Dalisresp) - class and indication
PDE4-inhib severe COPD (GOLD 3 and 4)
PDE-4 Enzyme Inhibitor (Roflumilast) - MOA
inhibits phosphodiesterase 4 (PDE4) which results in accumulation of cAMP in lungs –> anti-inflammatory, mild bronchodilation, remodeling
Roflumilast - ADE
weight loss - 20% lose 5-10%, 7% lose > 10%
this is a problem b/c already thin
Are the decreases in exacerbation from Roflumilast clinically relevant?
No.
Not a first line…add to other drugs.
Who is a candidate? severe patient trying to keep out of hospital and can afford.
Are mucolytic agents recommended for COPD?
No
Doesn’t really help and has not been proven.
Vaccines for COPD patients
Pneumococcal and influenza
Supplemental home O2 - who can get?
PaO2 < 55 mm Hg (ABG) or SaO2 <88%
or
PaO2 56-59 mm Hg + (evidence of pulmonary hypertension or secondary erythrocytosis (Hct 55%) or right sided heart failure)
*Drugs to use with caution in COPD
Beta blockers Respiratory depressants (opiods, benzodiazepines)
*GOLD Guidelines: non-pharmacologic
A - smoking cessation + physical activity + vaccines
B - above + pulmonary rehab
*GOLD Guidelines: First Line
A - SAMA prn or SABA prn
B - LABA or LAMA
C/D - (ICS + LABA) or LAMA
Most common cause of COPD exacerbation
viral resp tract infection
*COPD Exacerbation - DOC
- Albuterol + Ipatropium
2. Systemic steroids (Prednisolone 30-40 mg qd x 10-14 days)
If a patient has fever, increased purulent sputum, dyspnea or mechanical ventilation, what should be added to the COPD regimen?
Antibiotics –>
Macrolide (azithro or clarithro)
3rd gen ceph
Resp FQ (Moxi, Levo)
Desired O2 sats during O2 therapy for COPD exacerbation
88-92% (because used to being low)
in high 02 sat, brain will have less drive to breathe and will retain more CO2
*Ipratropium - class?
SAMA (Anticholinergic)
*Aclidinium bromide (Tudorza Pressair) and Tiotropium bromide (Spiriva) - class?
LAMA (Anticholinergic)
Why are LAMAs associated with decreased COPD exacerbations compared to LABA?
Patients feel better probably because of easier technique for administration and more convenient dosing.
What medication used for COPD is a SAMA + SABA?
Ipratropium + albuterol (Combivent)
What PDE-4 Enzyme Inhibitor is used for severe COPD?
Roflumilast (Daliresp)
COPD - classifications
1 - Mild, FEV1>80%, with or without symptoms
2- Moderated, FEV1 50-80%, with or without symptoms
3- Severe, FEV1 30-50%, with our without symptoms
4- Very severe, FEV1 <70%
Can you give Ipatropium (SAMA) and Tiotropium (LAMA) together?
No because they have the same MOA…need to pick a short and long from two different classes.
Can you given Ipatropium (SAMA) and Salmetrol (LABA) together?
Yes because they have different MOA (different classes).
*Ipatropium vs Tiotropium dosing
Ipatropium 2 inhalations qid
Tiotropium 1 inhalation (cap) qd
Preferred admin of inhaled bronchodilator and ICS
MDI with spacer - slows down med/gets deeper but bulky.
