COPD Flashcards
What is COPD?
Inflammation affecting small airways:
- predominance of neutrophils, macrophages and cytotoxic T lymphocytes
- progressive narrowing
- fibrosis, destruction of lung parenchyma, destruction of alveolar walls (emphysema)
COPD results in…
airway closure on expiration
air trapping and hyperinflation
COPD includes:
emphysema and chronic bronchitis
they are treated the same
Sxs of COPD?
Include: wheezing, pursed lip breathing, chronic cough, barrel chest, dyspnea, easily fatigued, freq. respiratory infections, use of accessory muscles to breath
Risk factors for development of COPD?
tobacco smoker, occupational dusts/chemicals, air pollution, genetic (alpha 1 antitrypsin), airway hyper responsiveness, impaired lung growth
Goals of COPD tx?
prevent disease progression, relieve sxs, improve exercise tolerance, improve overall health status, prevent exacerbation, prevent/tx comp. Reduce morbidity and mortality.
GOLD COPD classifications based on postbronchodilator FEV1:
1: mild= FEV1 80%
2: moderate= FEV1 50%-80%
3: severe FEV1 30%-50%
4: very severe FEV1 less than 30%
What are the COPD assessment questionnaires?
CAT
mMRC (modified medical research council dyspnea questionnaire)
CCQ
the mMRC assessment tool only assess..
breathlessness
Class A COPD? Tx?
0-1 exacerbations (not leading to admission)
mMRC 0-1
CAT <10
Tx: bronchodilator
Class B COPD? Tx?
0-1 exacerbations (not leading to admission)
mMRC >2
CAT >10
Tx: LABA or LAMA if persistent sxs–> LAMA + LABA
Class C COPD? Tx?
> 2 exacerbations or 1 or more leading to admission
mMRC 0-1
CAT <10
LAMA if still not better –> LAMA +LABA or LABA + ICS
Class D COPD? Tx?
> 2 exacerbations or 1 or more leading to admission
mMRC >2
CAT >10
Tx: LAMA –>
LAMA + LABA ot LABA + ICS –>
LABA + LAMA + ICS
What should be considered in class D COPD pts who are former smokers?
A Macrolide
Effect of albuterol in COPD pts?
response generally less than that is seen in asthma
only small improvement in FEV1
may improve respiratory sxs and exercise tolerance
ADEs of beta agonist?
sinus tachycardia, rhythm disturbances, skeletal muscle tremors can occur initially
Effect of long acting beta agonists and antimuscarinic
superior outcomes in lung func. (spirometry)
sxs including dyspnea
reduce in exacerbation freq.
improved QOL
Name 2 antimuscarinic (bronchodilators)
Ipratropium (short acting)
Tiotropium (long acting)
Ipratropium MOA?
bronchodilation by competitively inhibiting cholinergic receptors in bronchial smooth muscle
ADEs of Antimuscarinic
dry mouth, nausea, occasional metallic taste
What are the anti-inflammatory mechanisms of corticosteroids?
reduction in capillary permeability to decrease mucus
inhibition of release of proteolytic enzymes from leukocytes
inhibition of prostaglandins
ADEs of corticosteroids
osteoporosis, muscular atrophy, thinning of the skin, development of cataracts, adrenal suppression with insufficiency
What are some examples of LABA & ICS?
salmeterol + fluticasone
Budesonide + Formoterol
Mometasone + Formoterol
What drug class is Trelegy Ellipta?
Combination of an inhaled corticosteroid (ICS), a LAMA and a LABA
delivered once in dry powder inhaler
What is Phosphodiesterase 4?
the major phosphodiesterase found in airway smooth muscle cells and inflammatory cells and is responsible for degrading cAMP
Name a phosphodiesterase 4 Inhibitor. Indication?
Roflumilast (Daliresp)
adjunct to bronchodilator therapy in class C and D COPD pts and are not controlled by inhaled bronchodilators
Roflumilast MOA?
selectively inhibit phosphodiesterase-4
anti-inflammatory effects
Both….and Roflumilast have similar MOA through inhibition of phosphodiesterases
Theophylline
ADEs of Phosphodiesterase 4 inhibitors
HA, dizziness, insomnia, diarrhea, weight loss,, nausea, decreased appetite, back pain
Contraindication for phosphodiesterase 4 inhibitors?
hepatic impairment
phosphodiesterase 4 inhibitors drug interactions?
Cimetidine and Ciprofloxacin both increase the concentration of Roflumilast
Roflumilast make increase the effect of immunosuppressants
Indication of Alpha 1 antitrypsin replacement therapy
inherited AAT deficiency associated emphysema
tx is focused on reduction of risk factors such as smoking and sxs tx with bronchodilators
weekly infusions of pooled human AAT
What is included in the 5 step strategy for smoking cessation program?
5As
Ask, Advise, Assess, Assist, Arrange
First line Pharmacotherapies for smoking cessation?
Bupropion SR, Nicotine gum, Nicotine inhaler, Varenicline (Chantix)
Common complaints associated with pharmacotherapies for smoking cessation?
Bupropion: insomnia, dry mouth
Nicotine (gum, inhaler, nasal spray, patches): sore mouth, nasal irritation, skin rxn, insomnia
Varenicline: nausea, sleep disturbances
Cardinal sxs of acute COPD?
worsening dyspnea, increase in sputum volume, increase in sputum purulence
upper respiratory tract infection
Staging of acute exacerbations of COPD
Mild (1): 1 cardinal sxs plus at least one of following:URI within 5 days, fever w/out explantation, increased wheezing, increased cough, increased RR or HR >20%
Moderate (2): 2 cardinal sxs
Severe (3): 3 cardinal sxs
When can you give abx for acute COPD exacerbation?
if 2 or more:
- increased dyspnea
- increased sputum production
- increased sputum purulence
Therapeutic options for acute exacerbations of COPD?
Abx, corticosteroids, bronchodilators, controlled oxygen therapy, noninvasive mechanical ventilation
When is Noninvasive mechanical ventilation not recommended for acute COPD exacerbations?
in pts with AMS, severe acidosis, respiratory arrest or cardiovascular instability
Recommended abx therapy for uncomplicated COPD exacerbation in pt with less than 4 exacerbations per yr, no comorbid illness and >50% FEV1? `
likely pathogens: s. pneumoniae, H. influenzae, M. matarrhalis, H. parainfluenzae
Macrolide, 2 or 3 gen cephalosporin, Doxycycline
Recommended abx therapy for complicated COPD exacerbation?
Likely pathogen: same as uncomplicated + drug resistant pneumococci, Beta lactamase-producing H. influenzae and M. catarrhalis
Amoxicillin/Clavulanate, Fluoroquinolone w/ enhanced pneumococcal activity
Tx for complicated COPD exacerbation w/ risk of p. aeruginosa?
fluoroquinolone w/ enhanced pneumococcal and P. aeruginosa activity (levofloxacin)
What puts someone at risk for p. aeruginosa infection?
chronic bronchial sepsis, need for chronic corticosteroid, resident at nursing home w/ > 4 exacerbations/yr
Who should be given long term Oxygen therapy?
in pts with severe resting chronic hypoxemia
Vaccinations recommended for COPD pts?
flu
pneumococcal
