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Primary care of adults 2 > COPD > Flashcards

COPD Flashcards

1
Q

What is the GOLD definition of COPD?

A
  • 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)

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2
Q

Is there a genetic predisposition to COPD?

A

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

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3
Q

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

A

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

HD, cancer, stroke and accidents on the decline

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4
Q

How does COPD affect large airways?

A

inflammation, mucus gland hypertrophy, smooth muscle hypertrophy, bronchoconstriction

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5
Q

How does COPD affect small airways?

A

inflammation, fibrosis, luminal obstruction, bronchoconstriction

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6
Q

How does COPD affect alveoli?

A

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

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7
Q

How did GOLD 2014 change assessment of COPD?

A
  • 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
      *
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8
Q

What are the GOLD 2014 goals

A
  1. Airflow obstruction –> slow FEV1 decline
  2. Symptom burden –> improve sx
  3. Functional limitations –> improve QoL
  4. Exacerbation frequency –> decrease exacerbations
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9
Q

Why did GOLD 2014 change their assessment model?

A

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

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10
Q

How is COPD classified according to GOLD 2014

A
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11
Q

What is the MMRC scale?

A
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12
Q

What is CAT?

A

COPD Assessment Tool

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13
Q

1st line for COPD, according to GOLD

A

Anticholinergics or B2 agonists

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14
Q

List of anticholinergics for COPD

A

Ipratropium bromide (MDI, SMI, neb)

Titropium (DPI, SMI)

Aclidinium (DPI)

Umeclidinium (DPI)

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15
Q

List of B2 agonists for COPD

A

Albuterol/Levalbuterol (MDI, neb)

Slmeterol, formoterol (MDI, DPI)

Indacaterol (DPI)

Vilanterol (DPI)

Aformoterol (neb)

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16
Q

Adjunct therapy for COPD (after 1st line)

A

ICS (MDI, DPI, neb)

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17
Q

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

A

Theophylline, Roflumilast, Macrolides

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18
Q

GOLD

What FEV1 would be classified as Stage 1 Mild

A

≥ 80% predicted

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19
Q

GOLD

What FEV1 would be classified as Stage 2 Moderate

A

50% to 79% predicted

20
Q

GOLD

What FEV1 would be classified as Stage 3 Severe

A

30% to 49% predicted

21
Q

GOLD

What FEV1 would be classified as Stage 4: Very Severe

A

FEV1 < 30% predicted

22
Q

Anticholinergic bronchodilators: MOA

A
  • 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
23
Q

Benefits of SAMAs and LAMAs

A
  • Synergy with beta-agonists
  • Benefit even if NO beta-agonist response on PFTs
  • Favorable side effect profile, limited systemic absorption
24
Q

SEs of SAMAs and LAMAs

A

Dry mouth, prostatism, glaucoma

25
Q

Benefits of Roflumilast (PDE-4 inhibitor)

A
  • more selective PDE inhibition than theophylline
  • anti-inflammatory; decreases breakdown of cAMP
  • Reduces frequence of exacerbations
26
Q

Side Effects of Roflumilast (PDE-4 inhibitor)

A

High frequency!

  • GI: N/V/D, decreased appetite, C/Id in liver dz
  • Wt loss: >10% in some cases
  • Neuropsych: insomnia, worsening depression, HAs
27
Q

Initial mgmt for COPD category A

A

1st line: SABA prn or SAMA prn

2nd line: LAMA or LABA or SABA + SAMA

alternative: theophylline

28
Q

Initial mgmt for COPD GOLD category B

A

1st line: LABA or LAMA

2nd line: LABA + LAMA

Alternative: SABA and/or SAMA, Theophylline

29
Q

Initial mgmt for COPD GOLD C

A

1st line: ICS + LABA or LAMA

2nd line: LABA + LAMA or LAMA + PDE-4 or LABA + PDE-4

Alternative: SABA +/- SAMA, Theophylline

30
Q

Initial mgmt for COPD GOLD D

A

First line: ICS + LABA +/- LAMA

Second line:

ICS + LABA + PDE-4, or

LABA + LAMA, or

LAMA + PDE-4

Alternative: carbocystein, SAMA +/- SABA, Theophylline

31
Q

Difference between Tx guidelines for COPD vs asthma

A

bronchodilator is first line/cornerstone in COPD (other Txs phenotype specific)

Don’t move progressively from A to D - may move around

32
Q

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

A

All benefit

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

33
Q

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

A
  • Who benefits: Those with Mod/sev obstruction OR uncontrolled sx
  • Work best: Combination LABA/LAMA and/or ICS >> individual effects; also ↓ AE
34
Q

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

A
  • Mod/sev obstruction OR frequent AE
  • Combo - Not monotherapy; infection risk concerns
35
Q

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

A

Severe dz + chronic bronchitis + freq Acute Exacerbations

Significant side effects

36
Q

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

A

Frequent Acute exacerbations despite LABA/LAMA/ICS

Cardiac warning; monitor EKG, LFT, NTM, audiography

37
Q

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

A

Refractory dyspnea

Side effects limit use; low dose effective

38
Q

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

A

All

Ask, Advise, Assess, Assist, Arrange

39
Q

COPD: what IZs are recommended and how often?

A

All COPD pts benefit

Flu: annual

Pvax: reboost after age 65y if >5yrs

40
Q

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

A

Who benefits: Likely all (insurance limited to mod/sev)

Effects: ↑ exercise tol, QoL, ↓ dyspnea, sx

41
Q

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

A

Who benefits: PaO2 <55mmHg or SaO2 <88 OR PAH, cor pul, polycythemia

Effects: LTOT improves survival; palliative advantages

42
Q

COPD: Nasal intermittent positive pressure ventilation (NIPPV)

who benefits and how?

A

Who: Overlap syndrome (OSA + COPD); ??

How: Acute benefits known; data on chronic use mixed

43
Q

COPD: LVRS (Lung Volume Reduction Surgery)/Bronchoscopic-LVRS

Who benefits and how?

A

Who: UL emphysema with ↓ exercise tolerance

How: Very subset-specific outcome advantages

44
Q

Characteristics of COPD exacerbations

A

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

45
Q

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

A
  • 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

Primary care of adults 2 (15 decks)

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