COPD

Question 1

COPD

Answer 1

Progressive respiratory disease characterized by airflow limitation that is not fully reversible.
Chronic bronchitis/emphysema
Preventable in most cases
3rd leading cause of death

Question 2

COPD risk factors

Answer 2

Smoking (85-90%)
Environmental smoke, occupational dusts and chemicals, air pollution
Genetic predisposition (alpha-1 antitrypsin deficiency), airway hyperresponsiveness, impaired lung growth, age

Question 3

COPD pathophysiology

Answer 3

Inhaled noxious particles leads to inflammation causing small airway disease and parenchymal destruction (all leading to airflow limitation)

Question 4

Clinical presentation

Answer 4

Dyspnea, chronic cough, chronic sputum production, physical exam findings more common in severe disease

Question 5

Diagnosis

Answer 5

Post-bronchodilatory FEV1/FVC

Question 6

Non-pharmacologic treatment

Answer 6

Minimize smoke exposure, occupational fumes, avoid outside when pollution is high, flu/pneumonia (>65) vaccine, regular physical activity, oxygen, pulmonary rehab

Question 7

Bronchodilators

Answer 7

FIRST line approach. Beta-2 agonists and anticholinergics.
Can do combination, and either short/long acting.
EVERYONE should have a SABAL

Question 8

Anticholingergics

Answer 8

“-ium”
Short: ipratropium bromide
Long: quite a few (glycopyrronium bromide doesnt end in “-ium”)

Question 9

LABA’s in COPD

Answer 9

Not for monotherapy or exacerbations.
For moderate to severe COPD with symptoms on a regular basis
Patient with short-acting therapy not experiencing adequate relief

Question 10

Salmeterol

Answer 10

LABA, slower onset of action 15-20 minutes. Most others are fast.

Question 11

Short-acting anticholinergics

Answer 11

Blocks action of ACH at parsympathetic sites in bronchial smooth muscle, causes bronchodilation.
Initial therapy for intermittent symptoms.

SE: dry mouth, nausea, metallic taste

Not good for PRN usage. Peak 1.5-2 hours, good for 4-6 hours.

Question 12

Atrovent (ipratropium bromide)

Answer 12

Short-acting anticholinergic

Question 13

Long-acting anticholinergics

Answer 13

Competitively and reversibly inhibit action of ACH at M3 receptors in bronchial smooth muscle, causing bronchodilation. Reduce cGMP.
Moderate to severe COPD with symptoms on a regular basis.

SE: dry mouth, blurred vision, urinary retention, precipitation of narrow-angle glaucoma symptoms

Question 14

Tiotropium

Answer 14

Long-acting anticholinergic. Onset within 30 minutes. Duration of action >24 hours. Counsel on appropriate inhaler technique given several different dosage forms.

Question 15

ICS/oral corticosteroids

Answer 15

Broad anti-inflammatory efficacy, mediated in part by inhibition of production of inflammatory cytokines. Oral generally not indicated for chronic use.

NOT for monotherapy or first line therapy. Add on for severe COPD with frequent exacerbations.

SE: thrush.

Question 16

Methylxanthines

Answer 16

Inhibit phosphodiesterase, calcium ion influx into smooth muscle, release of mediators from mast cells and leukocytes. Stimulate endogenous catecholamines.

For patients who cannot use inhaled medications or who remain symptomatic despite appropriate use of inhaled bronchodilators.

SE: GI, tachycardia, headache, dizzy

Question 17

Theophylline

Answer 17

Methylxanthines

Question 18

PDE-4 inhibitors

Answer 18

Reduce inflammation by inhibiting breakdown of intracellular cAMP

Gold3 and 4 patients with repeated exacerbations and chronic bronchitis treated with corticosteroids

SE: nausea, reduced appetite, diarrhea, sleep disturbance, headache

Question 19

Daliresp (Roflimulast)

Answer 19

PDE-4 inhibitor

Question 20

COPD exacerbations

Answer 20

Antibiotics, bronchodilators, corticosteroids, oxygen

Question 21

Antibiotic use

Answer 21

Use if at least two of the following: increased dyspnea, increased sputum purulence, increased sputum volume