COPD Flashcards
What is COPD?
- A progressive resp. disease characterized by airflow limitation that is not fully reversible.
- Abnormal inflamm. response in the airway and lungs to noxious particles or gases.
- Chronic inflamm. disease with systemic manifestatons
- chronic bronchitis and or emphysema
- Preventable in most cases!!!!
Epidemiology
- 3rd leading cause of death
- Major cause of morbidity, mortality, and disability.
Causes/Risk factors
- Cigarette smoke (responsible for 85-90%)
- Air pollution, occupational dusts & chemicals
- Genetic predisposition
- Airway hyperresponsiveness
- Impaired lung growth
- Age
Pathophysiology review
Inhaled noxious particles or gases–> inflammation–> small airway dx or parenchymal destruction–> airflow limitation
Small airway dx- airway inflammation/airway remodeling
Parenchymal destruction- loss of alveolar attachments/ Decrease of elastic recoil
clinical presentation
Dyspnea (persistent, worse with exercise, progressive), chronic cough(intermittent/unproductive), chronic sputum production, physical exam findings (more common in severe dx)
Diagnosis
- Spirometry
- Post-bronchodilatory FEV1/FVC
Considerations for diagnosis:
Family hx of COPD
Exposure to risk factors
Age 40 or older with 3 hallmark symptoms of progressive dyspnea, chronic cough, & productive sputum.
Stage I mild classification
FEV1 >80%
Chronic cough, sputum production
Stage II Moderate classification
50-80% FEV1
SOB on exertion
cough and sputum production
Stage III Severe classification
30-50% FEV1
Reduce exercise capacity, great SOB and fatigue, Repeated exacerbations
Stage IV Very Severe
FEV1 <30%
Severe airflow limitation
Resp. failure
Cor Pulmonale
Treatment goals
- Reduce symptoms
- Reduce risk
Reducing symptoms
Relieve symptoms, improve exercise tolerance, improve health status
Reduce risk
Prevent disease progression, prevent and treat exacerbations, reduce mortality
Non-pharmacologic treatment
Preventive care (minimize smoke & pollution), smoking cessation, vaccinations, regular physical activity, oxygen, pulm. rehab.
5A’s for smoking cessation
Ask, advise, assess, assist, arrange
Beta-2 agonists meds
Short-acting: albuterol & levalbuterol
Long acting: formoterol, arformoterol, indacaterol, salmeterol, olodaterol
Anticholinergics meds
short acting: ipratropium bromide
long-acting: aclidinium bromide, glycopyrronium bromide, tiotropium, umeclidinium.
Combination beta-agonist/anticholinergic meds
Short-acting: albuterol/ipratropium
Long-acting: vilanterol/umeclidinium, formoterol fumarate/glycopyrrolate, indacaterol/glycopyrrolate, olodaterol/tiotropium bromide.
Short-acting Beta 1 agonists (SABA) MOA
relax airway smooth muscle (bronchodilator)
Stimulate adenylyl cyclase to increase the formation of cAMP.
Short-acting Beta 1 agonists indication
Relief of bronchospasm during exacerbation.
Short-acting Beta 1 agonists adverse effects
Tachycardia, tremor, palpitations, dizziness, and headaches.
Increasing frequency of use indicates ________
inadequate control!
All patients should have a SABA readily available.
SABA pharmokinetics
Oral and parenteral agents discouraged in COPD, higher incidence of systemic adverse effects
Quick onset <5 mins
Duration of action is 4-6 hrs
Long-Acting Beta 2- Agonists (LABA) MOA
Relax smooth muscle with longer duration of action (bronchodilator)
LABA indication
- NOT for acute exacerbations ormonotherapy
- Moderate to severe COPD patients who experience symptoms on a regular and consistent basis
- Patient with short-acting therapy who are not experiencing adequate relief.
LABA adverse effects
Tachycardia, skeletal muscle tremor, hypokalemia
Short-acting anticholinergics MOA
Blocks the action of acetylcholine at parasympathetic sites in bronchial smooth muscle causing bronchodilation
Albuterol
short-acting beta 2 agonist
Levalbuterol
short acting beta 2 agonist
Formoterol
Long acting beta 2 agonist
Arformoterol
long acting beta 2 agonist
Indacaterol
long acting beta 2 agonist
Salmeterol
long acting beta 2 agonist
Olodaterol
Long acting beta 2 agonist
Ipatropium bromide
short acting Anticholinergic
Aclidinium bromide
long acting anticholinergic
Glycopyrronium bromide
long acting anticholinergic
tiotropium
long acting anticholinergic
umeclidinium
long acting anticholinergic
Albuterol/Ipratropium
Combination beta-agonist/anticholinergic
Vilanterol/umeclidinium
Combination beta-agonist/ anticholinergic
Formoterol fumarate/glycopyrrolate
combination beta agonist/anticholinergic
Indacterol/glycopyrrolate
combination beta agonist/anticholinergic
Olodaterol tiotropium bromide
combination beta agonist/anticholinergic
Short-acting anticholinergic indication
Initial therapy for patients with intermittent symptoms
Short acting anticholinergic adverse effects
Dry mouth (common), nausea, metallic taste.
Short acting anticholinergics
Peak of 1.5 to 2 hours
Duration of action 4-6 hours
Usually not as effective for as needed use
Ipratropum recommended use
2 puffs 4x a day
dose can often be titrated upward often to 24 puffs a day.
Long-Acting anticholinergics MOA
Competitevely & reversibly inhibit the action of acetylcholine at type 3 muscarinic (m3) receptors in bronchial smooth muscle, causing bronchodilation
Reduction in cyclic guanosine monophosphate (cGMP)
Long-Acting anticholinergics indication
Moderate to severe COPD with symptoms on a regular basis
Long acting anticholinergics adverse effects
Dry mouth (common), blurred vision, urinary retention (less common), precipitation of narrow-angle glaucoma symptoms
Tiotropium pharmokinetics
Tiotropium
Onset within 30 mins, with a peak effect in 3 hours
Duration of action > 24 hours
counsel on appropriate inhaler technique given several different dosage forms
Corticosteroids (Inhaled/Oral) MOA
Broad anti inflammatory efficacy, mediated in part by inhibition of production of inflamm. cytokines
Reduce bronchial hyperreactivity and reduces the frequency of exacerbations if taken regularly
Corticosteroids indication
ICSs should NOT be used as monotherapy or first-line therapy
Add on for severe COPD with frequent exacerbations
Oral corticosteroids are generally not indicated for chronic use.
Corticosteroid adverse effects
Thrush
ensure patients rinse mouth after each use!!!
Qvar (Beclomethasone)
Inhaled corticosteroids
Pulmicort (Budesonide)
Inhaled corticosteroids
Flovent Arnuity Ellipta (Fluticasone)
Inhaled corticosteroids
Deltasone (Prednisone)
Systemic corticosteroids
Medrol (Methylprednisolone)
Systemic corticosteroids
Symibicort (budesonide/formoterol)
combination short-acting beta 2 agonist plus ICS in one inhaler
Dulera (mometasone/formoterol)
combination short-acting beta 2 agonist plus ICS in one inhaler
Advair (fluticasone/salmeterol)
combination short acting beta 2 agonist plus ICS
Breo Ellipta (fluticasone/vilanterol)
combination short acting beta 2 agonist plus ICS
Methylxanthines MOA
Inhibition of phosphodiesterase, calcium ion influx into smooth muscle, release of mediators from mast cells and leukocytes
Stimulation of endogenous catecholamines
Methylxanthines indication
Reserve for patients who cannot use inhaled medications or who remain symptomatic despite appropriate use of inhaled bronchodilators
Methylxanthines adverse effects
GI (dyspepsia, N/V/D)
CV (tachycardia)
CNS (headache, dizziness)
Methylxanthines pharmokinetics
Therapeutic range of theophylline is 10-20 mcg/ml , more conservative range of 5-15.
Multiple drug to drug interactions
Inhaled bronchodilators preferred
PDE-4 Inhibitors MOA
Reduce inflammation by inhibiting breakdown of intracellular cAMP.
PDE-4 Inhibitors Indication
GOLD3 and GOLD4 patients with repeated exacerbations and chronic bronchitis treated with corticosteroids
PDE-4 Inhibitors Adverse effects
Nausea, reduced appetite, diarrhea, sleep disturbances, headache
Daliresp (roflimulast)
PDE-4 inhibitor
antimicrobial therapy should be used if the patient exhibits at least two of the following signs or symptoms:
Increased dyspnea, increased sputum purulence, increased sputum volume.
COPD exacerbations need for hospitalization:
- Marked increase in intensity of sx
- Severe underlying COPD
- Onset of new physical sx
- Failure of an exacerbation to respond to initial medical management
- Presence of serious comorbidities
- Frequent exacerbations
- Older age
- Insufficient home support
Elderly special considerations
Consider dexterity and ability to use devices
Consider anticholinergic side effects
Pediatrics special considerations
Consider use of a spacer to improve drug delivery
Specialist referral
- Concurrent cardiac dx, suspected asthma, or other pulm. dx
- Alpha-1 antitrypsin deficiency
- sx do not respond to optimal therapy or are out of proportion to obstructive dings
- severe or frequent exacerbations or pna complicating management
- ICU hospitalization or mechanical ventilation required.
COPD quality measures
- Spirometry
- FEV1/FVC ,70%
- bronchodilator medication
- influenza vaccine
- tobacco used documented
- current tobacco user
- tobacco counseling documented
COPD clinical pearls
- Smoking cessation!!
- Bronchodilators!!
- step-up approach
- add inhaled corticosteroids in severe patients if repeated exacerbations
- reverse antibiotics for pts with appropriate symptoms.
Inhaler Use- rescue inhaler
Used as needed for quick relief of coughing, wheezing, chest tightness, and SOB
Short-acting beta 2 agonist
Short-acting anticholinergic
Inhaler use- controller inhaler
Used daily to prevent/control resp. symptoms
- Inhaled corticosteroid
- Long-acting beta- 2 agonist
- Long-acting anticholinergic
Counsel pts on the indication of their inhaler and difference between inhalers
Inhaler types
Dry powder inhalers (DPIs), Ellipta, Metered dose inhalers (MDIs), Respimat
Dry powder inhalers
contain no propellants
quick and deep breath**
All have dose counters
Ellipta
Quick and deep breath**
Metered dose inhalers (MDIs)
Contains hydroflouroalkane (HFA) as a chemical propellant
- Slow and deep breath**
- Can be used with a spacer or spacer with mask
Respimat
Slow and deep breath
Spacer
- Remove need for coordination between actuation and inhalation
- Only used for MDIs
- Clean once a month; replace every 6-12 months
- Useful for pediatric or elderly populations
- Spacer mask available for young pediatrics
Inhaler patient education
- Indication/type of inhaler
- Priming
- Step-by-step instructions for use
- Preparing the dose
- breathing technique for taking the dose
- refilling
- cleaning
- review patient technique
- rinse mouth for steroid-containing
