COPD Flashcards
What is the GOLD definition of COPD?
- 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)
Is there a genetic predisposition to COPD?
Yes - A1AT, but there also seems to be a predisposition that interacts w/environment
What distinguishes COPD from the other top 5 causes of death in the US?
It’s the only one on the rise - underdiagnosed / unrecognized until too far along!
HD, cancer, stroke and accidents on the decline
How does COPD affect large airways?
inflammation, mucus gland hypertrophy, smooth muscle hypertrophy, bronchoconstriction
How does COPD affect small airways?
inflammation, fibrosis, luminal obstruction, bronchoconstriction
How does COPD affect alveoli?
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
How did GOLD 2014 change assessment of COPD?
- 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
*
What are the GOLD 2014 goals
- Airflow obstruction –> slow FEV1 decline
- Symptom burden –> improve sx
- Functional limitations –> improve QoL
- Exacerbation frequency –> decrease exacerbations
Why did GOLD 2014 change their assessment model?
COPD is a heterogeneous disease and requires a multidimentional severity model beyond spirometry
How is COPD classified according to GOLD 2014
What is the MMRC scale?
What is CAT?
COPD Assessment Tool
1st line for COPD, according to GOLD
Anticholinergics or B2 agonists
List of anticholinergics for COPD
Ipratropium bromide (MDI, SMI, neb)
Titropium (DPI, SMI)
Aclidinium (DPI)
Umeclidinium (DPI)
List of B2 agonists for COPD
Albuterol/Levalbuterol (MDI, neb)
Slmeterol, formoterol (MDI, DPI)
Indacaterol (DPI)
Vilanterol (DPI)
Aformoterol (neb)
Adjunct therapy for COPD (after 1st line)
ICS (MDI, DPI, neb)
add-on Tx for COPD after 1st line and adjunct
Theophylline, Roflumilast, Macrolides
GOLD
What FEV1 would be classified as Stage 1 Mild
≥ 80% predicted
GOLD
What FEV1 would be classified as Stage 2 Moderate
50% to 79% predicted
GOLD
What FEV1 would be classified as Stage 3 Severe
30% to 49% predicted
GOLD
What FEV1 would be classified as Stage 4: Very Severe
FEV1 < 30% predicted
Anticholinergic bronchodilators: MOA
- 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
Benefits of SAMAs and LAMAs
- Synergy with beta-agonists
- Benefit even if NO beta-agonist response on PFTs
- Favorable side effect profile, limited systemic absorption
SEs of SAMAs and LAMAs
Dry mouth, prostatism, glaucoma
Benefits of Roflumilast (PDE-4 inhibitor)
- more selective PDE inhibition than theophylline
- anti-inflammatory; decreases breakdown of cAMP
- Reduces frequence of exacerbations
Side Effects of Roflumilast (PDE-4 inhibitor)
High frequency!
- GI: N/V/D, decreased appetite, C/Id in liver dz
- Wt loss: >10% in some cases
- Neuropsych: insomnia, worsening depression, HAs
Initial mgmt for COPD category A
1st line: SABA prn or SAMA prn
2nd line: LAMA or LABA or SABA + SAMA
alternative: theophylline
Initial mgmt for COPD GOLD category B
1st line: LABA or LAMA
2nd line: LABA + LAMA
Alternative: SABA and/or SAMA, Theophylline
Initial mgmt for COPD GOLD C
1st line: ICS + LABA or LAMA
2nd line: LABA + LAMA or LAMA + PDE-4 or LABA + PDE-4
Alternative: SABA +/- SAMA, Theophylline
Initial mgmt for COPD GOLD D
First line: ICS + LABA +/- LAMA
Second line:
ICS + LABA + PDE-4, or
LABA + LAMA, or
LAMA + PDE-4
Alternative: carbocystein, SAMA +/- SABA, Theophylline
Difference between Tx guidelines for COPD vs asthma
bronchodilator is first line/cornerstone in COPD (other Txs phenotype specific)
Don’t move progressively from A to D - may move around
COPD: who benefits from a SABA or SAMA and when should they be used?
All benefit
should be used as rescue tx in all but very mild dz
COPD: who benefits from a LABA or LAMA and how do they work best?
- Who benefits: Those with Mod/sev obstruction OR uncontrolled sx
- Work best: Combination LABA/LAMA and/or ICS >> individual effects; also ↓ AE
COPD: who benefits from a ICS and how is it recommended they be used?
- Mod/sev obstruction OR frequent AE
- Combo - Not monotherapy; infection risk concerns
COPD: who benefits from a PDE-4is and what is an important consideration?
Severe dz + chronic bronchitis + freq Acute Exacerbations
Significant side effects
COPD: who benefits from a macrolides and what is are important considerations?
Frequent Acute exacerbations despite LABA/LAMA/ICS
Cardiac warning; monitor EKG, LFT, NTM, audiography
COPD: who benefits from oral opiates and what is are important considerations?
Refractory dyspnea
Side effects limit use; low dose effective
COPD: who benefits from smoking cessation and what are the 5 As?
All
Ask, Advise, Assess, Assist, Arrange
COPD: what IZs are recommended and how often?
All COPD pts benefit
Flu: annual
Pvax: reboost after age 65y if >5yrs
COPD: who benefits from pulmonary rehabilitation and what are the effects?
Who benefits: Likely all (insurance limited to mod/sev)
Effects: ↑ exercise tol, QoL, ↓ dyspnea, sx
COPD: who benefits from O2, what are the benefits?
Who benefits: PaO2 <55mmHg or SaO2 <88 OR PAH, cor pul, polycythemia
Effects: LTOT improves survival; palliative advantages
COPD: Nasal intermittent positive pressure ventilation (NIPPV)
who benefits and how?
Who: Overlap syndrome (OSA + COPD); ??
How: Acute benefits known; data on chronic use mixed
COPD: LVRS (Lung Volume Reduction Surgery)/Bronchoscopic-LVRS
Who benefits and how?
Who: UL emphysema with ↓ exercise tolerance
How: Very subset-specific outcome advantages
Characteristics of COPD exacerbations
Increased dyspnea, cough
Severe: altered mental status, hypercarbia, hypoxemia
COPD exacerbatinos: what do you need to differentiate it from?
- 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
