COPD Flashcards
(138 cards)
1
Q
what is the GOLD 2017 definition of COPD?
A
COPD is a common, preventable and treatable disease that is characterized by <b>persistent respiratory symptoms and airflow limitation</b> that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases
2
Q
what is the hallmark symptom of COPD?
A
dyspnea
-persistent, progressive, worse with exercise/activity
3
Q
what are symptoms/indicators of COPD?
A
dyspnea, chronic cough (intermittent & unproductive), chronic sputum production
4
Q
what’s the difference b/w COPD sx’s and asthma symptoms?
A
COPD sx’s are persistent
5
Q
what is the #1 exposure that leads to COPD?
A
tobacco smoke
6
Q
why are sx’s persistent with COPD?
A
b/c damage airway and once damage airway, can’t reverse the damage
7
Q
what is the difference b/w COPD and asthma in terms of airway inflammation?
A
COPD has neutrophilic inflammation (vs asthma as Eosinophilic inflammation)
-neutrophilic inflammation doesn’t respond as well to ICS so beta agnostic or antimuscarinics (bronchodilators) are the staple txt of COPD
8
Q
what is the staple treatment of COPD?
A
beta agonist or antimuscarinics (bronchodilators)
9
Q
what do you see on chest x-ray for COPD?
A
hyperinflation
vs asthma is usually normal
10
Q
what are the COPD phenotypes?
A
Chronic bronchitis & Emphysema
11
Q
what is Chronic bronchitis?
A
Chronic productive cough for 3 months in each of 2 successive years when other causes of chronic cough have been excluded
12
Q
what is emphysema?
A
Abnormal permanent enlargement of airspaces distal to the terminal bronchioles
13
Q
what is asthma-COPD overlap? what meds do you use?
A
3 elements of asthma and 3 elements or more of COPD
Use ICS b/c asthma will respond to ICS
14
Q
what is the gold standard/required for dx of COPD?
A
spirometry (PFT)
15
Q
what does underuse of using spirometry to dx COPD lead to?
A
inaccurate COPD dx
16
Q
what 2 main areas does spirometry measure?
A
he amount of air exhaled (i.e. “volume”) – FVC (forced vital capacity) – total volume able to move out of lungs
The speed in which air is exhaled (i.e. “flow”) – FEV1
17
Q
what is FEV1?
A
Forced Expiratory Volume in 1 second:
-Volume of air expired in the 1st second of the maneuver
18
Q
what is FVC?
A
Forced Vital Capacity:
-The total volume of air forcibly exhaled in one breath
19
Q
what is the FEV1/FVC ratio?
A
The fraction of air exhaled in the 1st second relative to the total volume exhaled
20
Q
what does the FEV1/FVC tell you?
A
doesn’t say COPD or asthma specifically, but it tells you it’s an obstructive disorder
21
Q
If FEV1/FVC ratio improves after give SABA, what does that tell you?
A
If improvement of >200ml or 12% increase = asthma
22
Q
If FEV1/FVC ratio doesn’t improve after give SABA, what does that tell you?
A
that it’s COPD
23
Q
what is Gold 1?
A
mild COPD
FEV1 ≥80% predicted
24
Q
what is GOLD 2?
A
moderate COPD
FEV1 ≥50%-80% predicted
25
what is GOLD 3?
severe COPD
FEV1 ≥30%-50% predicted
26
what is GOLD 4?
very severe COPD
FEV1 <30% predicted
27
what is the health related quality of life & gold spirometric classification questionnaire?
Questionnaire that measures quality of life and symptom burden
-The higher the score the worse the symptom burden is
28
pts with hyperinflation, see increase in what?
increase in FRC (functional residual capacity) and IC (inspiratory capacity) goes down
use bronchodilator here
-won't improve lung fxn but will improve amount of hyperinflation
29
what does increased FRC and decreased IC mean?
hyperinflation
30
what are the goals of treating COPD?
Decrease symptoms
- relieve symptoms
- improve exercise tolerance
- improve health status
Decrease risk
- prevent progression
- prevent & treat exacerbations
- reduce mortality
31
what is the GOLD definition of EXACERBATION?
An acute worsening of respiratory symptoms that results in additional therapy
32
how do you manage a mild exacerbation?
short acting bronchodilator only
33
how do you manage a moderate exacerbation?
short acting bronchodilators PLUS antibiotics and/or oral corticosteroids
34
how do you manage a severe exacerbation?
requires hospitalization or visits the ED, may also be associated with respiratory failure
35
how do you treat exacerbations?
oxygen >90% or PaO2 >60
initiate bronchodilator txt (SABA or combo therapy of beta-2agonists + anticholinergics)
Add oral or IV corticosteroids
Consider abx therapy and provide supportive therapy
36
if pt is hospitalized for COPD exacerbation and you give them O2, what must you obtain?
obtain ABG after 30-60 mins to ensure oxygenation without CO2 retention and/or acidosis
37
what combo therapy is good for exacerbations?
beta2-agonists + anticholinergics
-albuterol + ipratropium (Atrovent)
38
what does the oral or IV corticosteroids do to help COPD exacerbations?
- Shorten recovery time
- Improve lung function (FEV1) and hypoxemia (PaO2)
- Reduce relapse and treatment failure
-Shorter courses of ICS – 5 days for most exacerbations is good for mild to moderate exacerbations
39
what are the mMRC or CAT scores?
indicate symptom burden
Low symptom burden is mMRC 0-1 or CAT <10
High symptom burden is mMRC ≥ 2 or CAT ≥ 10
40
what is group A for COPD risk groups? what do you use for treatment?
Group A = Less symptoms, Low exacerbation risk
- mMRC 0-1 or CAT < 10
- 0-1 exacerbations & 0 hospitalizations
Treatment:
Preferred = short or long acting bronchodilator
-evaluate its effects and continue, stop, or try alternative bronchodilator
41
what is group B for COPD risk groups? what do you use for treatment?
Group B = More symptoms, Low exacerbation risk
- mMRC ≥ 2 or CAT ≥ 10
- 0-1 exacerbations & 0 hospitalizations
Treatment:
Preferred = LAMA or LABA
-if persistent symptoms, then LAMA+LABA
42
what is group C for COPD risk groups? what do you use for treatment?
Group C = Less Symptoms, High Exacerbation Risk
- mMRC 0-1 or CAT <10
- ≥2 exacerbations or ≥1 hospitalizations
Treatment:
Preferred = LAMA
-if further exacerbations... LAMA+LABA (preferred) or LABA+ICS
43
what is group D for COPD risk groups? what do you use for treatment?
Group D = More symptoms, High exacerbation risk
- mMRC ≥ 2 or CAT ≥ 10
- ≥2 exacerbations or ≥ hospitalizations
Treatment:
Preferred = LAMA+LABA (can also use LABA+ICS but not preferred)
-persistent symptoms/further exacerbations...LAMA+LABA+ICS
-if further exacerbations: consider Roflumilast if FEV1 <50% & consider macrolide (former smokers)
44
what is the brand/generic name of short-acting antimuscarinic (SAMA)?
ipratropium (Atrovent)
45
what type of drug is salmeterol?
LABA (serevent)
46
what type of drug is Serevent?
LABA
47
what type of drug is formoterol?
LABA
48
what type of drug is Perforomist?
LABA
49
what type of drug is arformoterol?
LABA
50
what type of drug is Brovana?
LABA
51
what type of drug is indacaterol?
LABA
52
what type of drug is Arcapta?
LABA
53
what type of drug is olodaterol?
LABA
54
what type of drug is Striverdi?
LABA
55
what type of drug is aclidinium?
LAMA
56
what type of drug is Tudorza?
LAMA
57
what type of drug is glycopyrrolate?
LAMA
58
what type of drug is Seebri?
LAMA
59
what type of drug is umeclidinium?
LAMA
60
what type of drug is Incruse?
LAMA
61
what does regular and pro use of a SABA or SAMA improve?
FEV1 and symptoms
62
what do LABAs and LAMAs significantly improve?
FEV1, dyspnea, health status, & decrease exacerbation rates
63
combination txt is superior to what?
Combination treatment is superior to either class alone at improving FEV1 & symptoms
64
LAMAs have a greater effect on what compared with LABAs?
LAMAs have a greater effect on exacerbation reduction compared with LABAs
65
what meds are recommended initial bronchodilators to treat an acute exacerbation?
SABA +/- SAMA
66
SAMA may be preferred over what for mono therapy?
SAMA may be preferred over SABAs when used as monotherapy in preventing acute mild-moderate exacerbations in patients with moderate-severe COPD
67
what is a SAMA?
Ipratropium (Atrovent HFA)
68
what type of drug is Atrovent HFA?
SAMA
69
what type of drug is ipratropium?
SAMA
70
what is the indication of ipratropium (Atrovent HFA), availability, and features?
Indication: Maintenance txt of bronchospasm associated with COPD
Availability:
- nebulized solution
- MDI
Features:
- Dose counter
- Solution – no shaking required!
- Priming and cleaning required!
71
what is the short acting bronchodilator combo product? what is the dose? what is the indication?
```
Combivent Respimat (ipratropium + albuterol)
-SAMA + SABA
```
Dose: one puff
Indication: COPD uncontrolled on a regular aerosol bronchodilator and require a second
*(DuoNeb = nebulizer formulation)
72
are long-acting formulation bronchodilators preferred over short-acting formulations for COPD?
YES!!!
For both beta2-agonists and anticholinergics [antimuscarinics], long-acting formulations are preferred over short-acting formulations
73
when should maintenance therapy with long-acting bronchodilator be initiated for COPD?
as soon as possible before hospital discharge
74
when do Respimat products expire?
after 90 days
75
what is the onset of Arcapta & Striverdi?
5min and last 24 hours
```
Arcapta = indacaterol
Striverdi = olodaterol
```
76
what are the long-acting beta agonist for nebulization?
Brovana (Arformoterol)
Perforomist (Formoterol Fumarate)
77
what muscarinic receptor do you want to block in the airways?
want to block Ach effects at the M3 receptor on airway smooth muscle
-results in bronchodilation
-antimuscarinics block M3 receptor
78
when do all Ellipta devices expire?
in 6 weeks
79
what is Anoro Ellipta?
LAMA + LABA
80
what is umeclidinium/vilanterol?
LAMA + LABA
81
what is Stiolto Respimat?
LAMA+LABA
82
what is tiptropium/olodaterol?
LAMA+LABA
83
what is Utibron Neohaler?
LAMA+LABA
84
what is glycopyrrolate/indacaterol?
LAMA+LABA
85
what is Bevespi Aerosphere?
LAMA+LABA
86
what is glycopyrrolate/formoterol?
LAMA+LABA
87
what is an ICS+LABA more effective at?
An ICS + LABA is more effective than the individual components in improving lung function and health status and reducing exacerbations in patients with exacerbations and moderate to very severe COPD
88
regular treatment with ICS increases the risk of what?
pneumonia especially intros w/severe disease
89
Triple ICS/LAMA/LABA improved what compared to ICS/LABa or LAMA monotherapy?
Triple ICS/LAMA/LABA improved lung function, symptoms, and health status and reduces exacerbations compared to ICS/LABA or LAMA monotherapy
90
if patient is not responding to LAMA/LABA consider what?
triple therapy with ICS (ICS/LAMA/LABA)
*Otherwise, unless there is an asthma component, leading towards LABA/LAMA
91
for COPD, what do you not use alone where in asthma you do?
For COPD – do not use ICS alone (vs asthma you do)
-ICS becomes the add-on for COPD
SABA is the staple of COPD so give combo of SABA and ICS
92
what is Breo Ellipta? strength approved for COPD? dose? features?
ICS/LABA
-only lower strength (100mcg/25mcg) is approved for COPD
Dose: one inhalation/day
Features:
- no cleaning, no priming, no shaking
- vilanterol component - bronchodilation approx 5 min
93
what is Trelegy Ellipta? dose? indication?
ICS/LABA/LAMA
Dose: one inhalation/day
Indication: Long-term, once-daily, maintenance treatment of patients with COPD, including chronic bronchitis and/or emphysema, who are on a fixed-dose combination of fluticasone furoate and vilanterol for airflow obstruction and reducing exacerbations in whom additional treatment of airflow obstruction is desired or for patients who are already receiving umeclidinium and a fixed-dose combination of fluticasone furoate and vilanterol
94
what is a selective phosphodiesterase 4 (PDE4) inhibitor?
Roflumilast (Daliresp)
95
what is Roflumilast (Daliresp)? dose? Pro's/cons? similar to?
PDE4 inhibitor
Once daily “add-on option” in patients not controlled on a bronchodilator (for Group D patients)
Pro’s:
-Oral capsule, Weight loss, May decrease exacerbation frequency
Con’s:
- Psychiatric disturbances?? – dream disturbances
- Metabolized mostly via CYP3A4 and CYP1A2
- Nausea is the most common adverse effect
Similar to theophylline, but has less DDIs and don’t have to monitor levels
96
what is roflumilast?
PDE4 inhibitor
97
what is Daliresp?
PDE4 inhibitor
98
when do you consider abx therapy for COPD?
Consider antibiotic therapy if the patient exhibits:
- Signs of lower respiratory tract infection
- Severe exacerbation requiring mechanical ventilation
99
what are the 3 cardinal signs of infection when considering abx therapy for COPD?
3 cardinal symptoms of an infection:
- increased dyspnea
- increased sputum production
- increased purulence
100
what sign of infection may you start abx if only 2 cardinal symptoms of infection present?
May start antibiotics if only 2 cardinal symptoms are present if one of the symptoms is increased sputum purulence
101
what do you give in combo with abx?
oral steroid
102
what course of abx is recommended?
shorter course
103
do any of the non-bronchodilator therapies for COPD add benefits?
NO!!!
104
what are the non-bronchodilator therapies for COPD?
- mucolytics (e.g. N-acetylcystein, carbocysteine)
- antitussives
- Leukotriene modifiers (Zyflo, Singulair, Accolate)
- Anti-TNF alpha antibody (infliximab)
- vitamin D
105
what is pulmonary rehab?
Multidisciplinary program of care – addresses all the components to help the patient
- Exercise training
- Education
- Psychological counseling
- Nutritional counseling
Patients at any stage of COPD can benefit – particularly Groups B, C, and D
Usually 6-10 weeks, more than that may not be a benefit
106
what should you follow-up with for COPD patients?
Medication adherence and Inhalation technique are most important
107
what vaccine should asthma/COPD patients get?
flu & pneumococcal
19-64 y/o give one time dose of PCV23 for asthma & COPD
after 65, give series, start with PCV13, wait a year and give PCV23
108
what is salmeterol?
Serevent (LABA)
109
what is serevent?
salmeterol (LABA)
110
what is ipratropium?
atrovent (SAMA)
111
what is atrovent?
ipratropium (SAMA)
112
what is formoterol?
perforomist (LABA)
113
what is arformoterol?
Brovana (LABA)
114
what is brovana?
arformoterol (LABA)
115
what is arcapta?
indacaterol (LABA)
116
what is indacaterol?
arcapta (LABA)
117
what is striverdi?
olodaterol (LABA)
118
what is olodaterol?
striverdi (LABA)
119
what aclidinium?
Tudorza (LAMA)
120
what is Tudorza?
aclidinium (LAMA)
121
what is Seebri?
glycopyrrolate (LAMA)
122
what is glycopyrrolate?
Seebri (LAMA)
123
what is umeclidinium?
Incruse (LAMA)
124
what is Incruse?
umeclidinium (LAMA)
125
what is Combivent Respimat?
Ipratropium + albuterol (SAMA + SABA)
126
what is DuoNeb?
Ipratropium + albuterol (SAMA + SABA) - Neublizer formation
127
what is Ipratropium + albuterol?
Combivent Respimat or DuoNeb
| SAMA + SABA
128
what is Foradil?
formoterol
129
what is formoterol?
Foradil
130
what is Anoro ellipta?
umeclidinium/vilanterol (LAMA + LABA)
131
what is umeclidinium/vilanterol?
Anoro Ellipta (LAMA + LABA)
132
what is Stiolto Respimat?
tiotropium/olodaterol (LAMA + LABA)
133
what is tiotropium/olodaterol?
Stiolto Respimat (LAMA + LABA)
134
what is Utibron Neohaler?
glycopyrrolate/indacaterol (LAMA + LABA)
135
what is glycopyrrolate/indacaterol?
Utibron Neohaler (LAMA + LABA)
-dpi
136
what is Bevespi Aerosphere?
Glycopyrrolate/formoterol (LAMA + LABA)
it's a MDI
137
what is Trelegy Ellipta?
fluticasone furoate/vilanterol/umeclidinium
| ICS/LABA/LAMA
138
what is fluticasone furoate/vilanterol/umeclidinium?
Trelegy Ellipta
| ICS/LABA/LAMA
