COPD

Question 1

What is the GOLD definition of COPD?

Answer 1

• Common, treatable, preventable* (not reversible)
• Characterized by persistent airflow limitation; usually progressive; associated with enhanced chronic inflammatory response in airways/lungs to noxious particles or gases

*except in alpha-1 antitrypsin deficiency (<1% COPD)

Question 2

Is there a genetic predisposition to COPD?

Answer 2

Yes - A1AT, but there also seems to be a predisposition that interacts w/environment

Question 3

What distinguishes COPD from the other top 5 causes of death in the US?

Answer 3

It’s the only one on the rise - underdiagnosed / unrecognized until too far along!

HD, cancer, stroke and accidents on the decline

Question 4

How does COPD affect large airways?

Answer 4

inflammation, mucus gland hypertrophy, smooth muscle hypertrophy, bronchoconstriction

Question 5

How does COPD affect small airways?

Answer 5

inflammation, fibrosis, luminal obstruction, bronchoconstriction

Question 6

How does COPD affect alveoli?

Answer 6

loss of alveolar/capillary units, airway untethering, loss of recoil, dynamic upper airway collapse

copd has that asthmatics don’t – alveolar level. Loss of surface level. Organ is supposed to be spongy and becomes instead floppy

Question 7

How did GOLD 2014 change assessment of COPD?

Answer 7

• Severity/impairment not well described by FEV1
• Moved away from the prior stepwise rx model - did not account for heterogeneity of population
• New appreciation for:
  
  • Emphasis on phenotypic heterogeneity
  • Need for multidimensional disease characterization
  • Role for tailored medication regimens
  • Earlier symptom/goal directed management
• Aided by:
  
  • Simple symptom measurement tools (CAT, MMRC)
  • Advances in phenotype specific therapy
    *

Question 8

What are the GOLD 2014 goals

Answer 8

1. Airflow obstruction –> slow FEV1 decline
2. Symptom burden –> improve sx
3. Functional limitations –> improve QoL
4. Exacerbation frequency –> decrease exacerbations

Question 9

Why did GOLD 2014 change their assessment model?

Answer 9

COPD is a heterogeneous disease and requires a multidimentional severity model beyond spirometry

Question 10

How is COPD classified according to GOLD 2014

Answer 10

Question 11

What is the MMRC scale?

Answer 11

Question 12

What is CAT?

Answer 12

COPD Assessment Tool

Question 13

1st line for COPD, according to GOLD

Answer 13

Anticholinergics or B2 agonists

Question 14

List of anticholinergics for COPD

Answer 14

Ipratropium bromide (MDI, SMI, neb)

Titropium (DPI, SMI)

Aclidinium (DPI)

Umeclidinium (DPI)

Question 15

List of B2 agonists for COPD

Answer 15

Albuterol/Levalbuterol (MDI, neb)

Slmeterol, formoterol (MDI, DPI)

Indacaterol (DPI)

Vilanterol (DPI)

Aformoterol (neb)

Question 16

Adjunct therapy for COPD (after 1st line)

Answer 16

ICS (MDI, DPI, neb)

Question 17

add-on Tx for COPD after 1st line and adjunct

Answer 17

Theophylline, Roflumilast, Macrolides

Question 18

GOLD

What FEV1 would be classified as Stage 1 Mild

Answer 18

≥ 80% predicted

Question 19

GOLD

What FEV1 would be classified as Stage 2 Moderate

Answer 19

50% to 79% predicted

Question 20

GOLD

What FEV1 would be classified as Stage 3 Severe

Answer 20

30% to 49% predicted

Question 21

GOLD

What FEV1 would be classified as Stage 4: Very Severe

Answer 21

FEV1 < 30% predicted

Question 22

Anticholinergic bronchodilators: MOA

Answer 22

• Blockade of muscarinic acetylcholine receptors
  
  • SAMA: M2/M3
  • LAMA: M1/M3
  • M1 → parasympathetic ganglia
  • M2 → presynaptic autoreceptors that TERMINATE constriction
  • M3 → airway and submucosal glands

Question 23

Benefits of SAMAs and LAMAs

Answer 23

• Synergy with beta-agonists
• Benefit even if NO beta-agonist response on PFTs
• Favorable side effect profile, limited systemic absorption

Question 24

SEs of SAMAs and LAMAs

Answer 24

Dry mouth, prostatism, glaucoma

Question 25

Benefits of Roflumilast (PDE-4 inhibitor)

Answer 25

* more selective PDE inhibition than theophylline * anti-inflammatory; decreases breakdown of cAMP * Reduces frequence of exacerbations

Question 26

Side Effects of Roflumilast (PDE-4 inhibitor)

Answer 26

High frequency! * GI: N/V/D, decreased appetite, C/Id in liver dz * Wt loss: \>10% in some cases * Neuropsych: insomnia, worsening depression, HAs

Question 27

Initial mgmt for COPD category A

Answer 27

1st line: SABA prn or SAMA prn 2nd line: LAMA or LABA or SABA + SAMA alternative: theophylline

Question 28

Initial mgmt for COPD GOLD category B

Answer 28

1st line: LABA or LAMA 2nd line: LABA + LAMA Alternative: SABA and/or SAMA, Theophylline

Question 29

Initial mgmt for COPD GOLD C

Answer 29

1st line: ICS + LABA or LAMA 2nd line: LABA + LAMA or LAMA + PDE-4 or LABA + PDE-4 Alternative: SABA +/- SAMA, Theophylline

Question 30

Initial mgmt for COPD GOLD D

Answer 30

First line: ICS + LABA +/- LAMA Second line: ICS + LABA + PDE-4, or LABA + LAMA, or LAMA + PDE-4 Alternative: carbocystein, SAMA +/- SABA, Theophylline

Question 31

Difference between Tx guidelines for COPD vs asthma

Answer 31

bronchodilator is first line/cornerstone in COPD (other Txs phenotype specific) Don't move progressively from A to D - may move around

Question 32

COPD: who benefits from a SABA or SAMA and when should they be used?

Answer 32

All benefit should be used as rescue tx in all but very mild dz

Question 33

COPD: who benefits from a LABA or LAMA and how do they work best?

Answer 33

* Who benefits: Those with Mod/sev obstruction OR uncontrolled sx * Work best: Combination LABA/LAMA and/or ICS \>\> individual effects; also ↓ AE

Question 34

COPD: who benefits from a ICS and how is it recommended they be used?

Answer 34

* Mod/sev obstruction OR frequent AE * Combo - Not monotherapy; infection risk concerns

Question 35

COPD: who benefits from a PDE-4is and what is an important consideration?

Answer 35

Severe dz + chronic bronchitis + freq Acute Exacerbations Significant side effects

Question 36

COPD: who benefits from a macrolides and what is are important considerations?

Answer 36

Frequent Acute exacerbations despite LABA/LAMA/ICS Cardiac warning; monitor EKG, LFT, NTM, audiography

Question 37

COPD: who benefits from oral opiates and what is are important considerations?

Answer 37

Refractory dyspnea Side effects limit use; low dose effective

Question 38

COPD: who benefits from smoking cessation and what are the 5 As?

Answer 38

All Ask, Advise, Assess, Assist, Arrange

Question 39

COPD: what IZs are recommended and how often?

Answer 39

All COPD pts benefit Flu: annual Pvax: reboost after age 65y if \>5yrs

Question 40

COPD: who benefits from pulmonary rehabilitation and what are the effects?

Answer 40

Who benefits: Likely all (insurance limited to mod/sev) Effects: ↑ exercise tol, QoL, ↓ dyspnea, sx

Question 41

COPD: who benefits from O2, what are the benefits?

Answer 41

Who benefits: PaO2 \<55mmHg or SaO2 \<88 OR PAH, cor pul, polycythemia Effects: LTOT improves survival; palliative advantages

Question 42

COPD: Nasal intermittent positive pressure ventilation (NIPPV) who benefits and how?

Answer 42

Who: Overlap syndrome (OSA + COPD); ?? How: Acute benefits known; data on chronic use mixed

Question 43

COPD: LVRS (Lung Volume Reduction Surgery)/Bronchoscopic-LVRS Who benefits and how?

Answer 43

Who: UL emphysema with ↓ exercise tolerance How: Very subset-specific outcome advantages

Question 44

Characteristics of COPD exacerbations

Answer 44

Increased dyspnea, cough Severe: altered mental status, hypercarbia, hypoxemia

Question 45

COPD exacerbatinos: what do you need to differentiate it from?

Answer 45

* Differentiate from dyspnea crisis *– get pattern of anxiety, etc., that leads to acute crisis which can be helped by noninvasive ventilation, breathing exercises. COPD exacerbation progresses over days.* * BEWARE masqueraders: *many hospitalized for COPD exacerbations when it’s something else, OR is both. Need to treat the right cause.* * CHF * Pneumonia * PE * Multifactorial