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FINAL - Respiratory symptom assessment readings > COPD class notes > Flashcards

COPD class notes Flashcards

1
Q

What is the prevalence of COPD?

A

10%

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2
Q

What is the most common reason for acute hospitalization in adults?

A

AECOPD, and is correlated with the highest total hospital cost of care

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3
Q

Watch the recommended COPD video from the notes!

A
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4
Q

What are 5 quick questions we can ask patients to assess for COPD?

A

The Canadian Lung Health test - If you are over 40 and smoke or used to smoke, you may be at risk of COPD. If you answer “Yes” to any of the following questions, please consider speaking to your doctor or nurse practitioner about spirometry testing

  1. Do you cough regularly?
  2. Do you cough up phlegm regularly?
  3. Do even simple chores make you short of breath?
  4. Do you wheeze when you exert yourself, or at night?
  5. Do you get frequent colds that persist longer than those of other people you?
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5
Q

How is COPD diagnosed?

A

SPIROMETRY - It confirms the diagnosis and helps define how severe the disease is

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6
Q

What is the diagnostic criteria for COPD?

A

A ratio of the FEV1/FVC of <0.70 or < the lower limit of normal (LLN) ratio (i.e., less than the lower fifth percentile of the reference value from a healthy population) is needed to confirm a diagnosis of COPD.
Spirometry will be done post- bronchodilator therapy.

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7
Q

Where in the lungs does COPD largely affect? The Large or small structure?

A

Mostly in the small, but some changes may be present in the large

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8
Q

What is more commonly seen in COPD vs. asthma?
a. Macrophages
b. Neutrophils
c. Eosinophils
d. A and B

A

D. Macrophages and neutrophils

HOWEVER, Eosinophils may be increased in SOME patients with COPD

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9
Q

What is the current definition of COPD?

A

“COPD is a heterogeneous lung condition characterized by chronic respiratory symptoms (dyspnea, cough, sputum production) due to abnormalities of the airways (bronchitis, bronchiolitis) and/or alveoli (emphysema) that cause persistent, often progressive, airflow obstruction”. 12

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10
Q

What is the definition of AECOPD?

A

An exacerbation of COPD (ECOPD) is defined as an event characterized by increased dyspnea and/or cough and sputum that worsens in <14 days which may be accompanied by tachypnea and/or tachycardia and is often associated with increased local and systemic inflammation caused by infection, pollution, or other insult to the airway

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11
Q

What is important information to gather about a pt with COPD?

A
  • self management education
  • Medication adherence,
  • comorbidities,
  • medications they are on,
  • Lab data (blood eosinophils)
  • and scales to assess disease severity
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12
Q

What self management information is important to collect from the patient?

A
  • What they know about the disease, how to use their inhaler, what physical activity should they engage in, how to recognize when an AECOPD is coming on
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13
Q

What are three potential inhaler device errors that can happen with respimats?

A
  • pt did not insert the cartrige
  • Pt. Did not insert the cartridge all the way
  • pt did not turn the device head all the way until they hear a click

CHECK THIS REFERENCEOUT FOR REVIEW
Makhinova T, Walker BL, Gukert M, Kalvi L, Guirguis LM. Checking Inhaler Technique in the Community Pharmacy: Predictors of Critical Errors. Pharmacy (Basel). 2020 Jan 7;8(1):6. doi: 10.3390/pharmacy8010006. PMID: 31935995; PMCID: PMC7151665.

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14
Q

What are the typical symptoms of COPD?

A
  • Cough
  • Sputum production
  • Dyspnea
  • Wheezing and chest tightness
  • Fatigue
  • Maybe Muscle wasting, weight loss, and anorexia - poor prognosis indicated if this occurs
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15
Q
A
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16
Q

Describe the following clinical presentation categories for COPD:
1. Symptoms (3 main ones)
2. Risk factors - 4
3. Physical examination - 4 items
4. Diagnostic tests - 4 to 5

A
  1. Symptom - Chronic cough, chronic sputum production, dyspnea
  2. Risk factors - Smoke, Indoor air pollution, occupational and environmental hazards, alpha1- antitrypsin deficienccy
  3. Physical examination - shallow breathing, increased resting respiratory rate, pursed lips during exhaltion, use of accessory respiratory muscles, cyanosis of mucosal membrane
  4. Diagnostic tests - spirometry, radiograph of chest (Maybe CT), Arterial blood gas (not routinely done, but maybe in decompensation)
  5. Lab abnormalities - pH<7.35 PaO2<80mm Hg, PaCO2 >50 mmHg, and bicarbonate >26 mEq
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17
Q

Describe the difference between GOLD 1, 2, 3, and 4

A
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18
Q

What are the various scoring systems used in COPD?

A

CAT (COPD assessment test)
Modified Medical research council dyspnea questionnair (mMRC), COPD Control questionnair (CCQ)

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19
Q

REVIEW THE DIFFERENT SCALES AND PRACTICE ASSESSING!

A
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20
Q

How are symptoms managed in COPD? How about reducing AECOPD risk?

A
  1. Symptoms are managed by - relieaving specific symptoms, improve their ability to exercise, and improve overalll health status
  2. Reducing AECOPD risk - Prevent disease progression, prevent and treat exacerbations, and reduc morbidity and mortality
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21
Q

Describe the process of COPD treatment?

A
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22
Q

Describe the comprehensive management of COPD chart

A
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23
Q

What is the most important facet/issue with COPD that needs to be dealth with? SOB, vaccinations, exercise tolerance?

A

Although there are many facets of COPD that need to be dealt with, shortness of breath with or without exertion is perhaps the most important one.
Shortness of breath affects a patient’s ability to exercise and engage in normal daily activities.

24
Q

What is the single more effective intervention in COPD that has the most impact on the natural history of COPD?

A

SMOKING CESSATION

Although smoking cessation is more effective at slowing the progression of COPD when it is done earlier, sustained or intermittent, smoking cessation should be advocated for all patients with COPD regardless of their disease severity of how long they have had COPD.7
Nicotine replacement therapy (nicotine gum, inhaler, nasal spray, transdermal patch, sublingual tablet, or lozenge) increases long-term smoking cessation rates and is significantly more effective than placebo.16,22-24
Regarding e-cigarettes, currently there is no evidence to support them as being effective or safe as a smoking cessation agent.16

25
Q

What is the most effective therapeutic strategy to improve shortness of breath, health status and exercise tolerance?

A

Pulmonary rehab

Pulmonary rehabilitation is appropriate for most people with COPD.
improved functional exercise capacity and health related quality of life have been demonstrated across all COPD severity, although the evidence is especially strong in patients with moderate to severe disease.
Even patients with chronic hypercapnic failure show benefit.27,28
Exercise training reduces a patient’s response to dyspnea, can help a patient deal with their anxiety and depression, reduces thoracic hyperinflation, and helps improve musculoskeletal deconditioning. 26

26
Q

What vaccines are important in COPD?

A

Immunizations are also important.
All patients with COPD should get the annual influenza vaccine plus the pneumococcal conjugate vaccine (PCV20 or PCV15) or the pneumococcal polysaccharide vaccine (PPSV23). 30
Currently, PCV15 followed by PPSV23 OR one dose PCV20 is recommended. Adults who only received PPSV23 may receive a PCV (either PCV20 or PCV15) if ≥ one year after their last PPSV23 dose.
In COPD, a booster 5 years later is also needed, probably regardless of age. Influenza and pneumococcal vaccines can be administered concomitantly.16

27
Q

Describe why education is important in COPD

A

Finally, it’s important for patients with COPD to understand their disease.
They need to know when they are feeling good and when they are feeling bad. This is patient specific and can vary with disease severity.
So, it is important for you to know your patients well. Explain to them what COPD is and what they can do to manage it.
Explain all the non-pharmacologic options available but also the pharmacologic ones. Inhaler technique and medication adherence is often poor in this population so this needs to be reinforced on a regular basis.

Lastly, do your best to get your patient and their family doctor to fill out a COPD action plan.
Unfortunately, it appears this is rarely done yet it is critical to make sure an exacerbation is caught early and dealt with quickly.
This link provides the CTS COPD Action Plan: https://cts-sct.ca/action-plans/
Please see the following link for numerous, patient friendly, COPD self-management resources. https://www.lung.ca/copd

28
Q

What are the main stay therapy in COPD?

A

Bronchodialators

They act by changing airway smooth muscle tone with improvements in expiratory flow reflect widening of the airways.31,32
Bronchodilators tend to reduce dynamic hyperinflation at rest and during exercise, and improve exercise performance

29
Q

What is the pharmacotherapy for group E, A and B patients

A
30
Q

How are modifications to therapy in COPD done?

A
31
Q

Continue on slide 51

A
32
Q
A
33
Q

If patients treated with LABA+LAMA+ICS (or those with eosinophils < 100 cells/μL) still having exacerbations, think about the following when would we:
1. Add Roflumilast
2. Add a macrolide
3. Withdraw ICS

A
  1. Add roflumilast - In patients with an FEV1
    < 50% predicted and chronic bronchitis,39 especially if they have had at least one exacerbation requiring hospitalization in the previous year
  2. Add macrolide - Especially in those who are not current smokers.42,43
    Attention to the development of resistant organisms should be considered before adding on azithromycin into decision-making.
  3. Withdrawal ICS - Can be considered if pneumonia or other considerable side-effects develop.
    If blood eosinophils are ≥ 300 cells/μL de-escalation is more likely to be associated with the development of exacerbations, so it is probably best not done.44,45
    Adverse effects related to high-dose ICS are more common at higher doses so consider carefully.16
34
Q

What should we do if patients are being treated with LABA/ICS and they:
1. Have no asthma features?

A

If the patient is well controlled, you can probably just leave them where they are, but if the patient continues to have:
Further exacerbations, treatment should be increased to LABA+LAMA+ICS if the blood eosinophil count is ≥ 100 cells/μL or switched to LABA+LAMA if it is < 100 cells/μL.
Major symptoms consider switching to LABA+LAMA.

35
Q

Describe the benefits of each of these agents from the trials:
1. Short acting beta2 agonists
2. Formorterol and salmeterol
3. Indacaterol
4. Oladaterol and Volanterol
5. Ipratropium
6. Long acting antimuscarinics

A
36
Q

Describe the benefits of the following agents from pivotal trials in COPD:
1. Combination bronchodilators
2. Combinations of SABAs and SAMAs
3. Formoterol and tiotropium in separate inhalers
4. Glycopyrrolate/formoterol
5. Umeclinidium/vilanterol

A
37
Q

Describe the pivotal trials for these agents benefits:
1. LABA+LAMA+ICS
2. Dupilumab

A
38
Q

What effect does formorterol and salmeterol have on mortality or rate of decline of lung function?

A

NO EFFECT!

does improve lung function, dyspnea, health status, exacerbations, and number of hospitalizations.

39
Q

What are the benefits of indacaterol?

A

Once daily LABA that improves breathlessness, health status and exacerbations

40
Q

What are the benefits of oladaterol and vilanterol?

A
  • Improve lung function symptoms
41
Q

What are some considerations when chosing inhaler devices for patients?

A

Complexity of steps to use.46
The time it takes to deliver a medication.47
Is cleaning required?
Inspiratory maneuvers to use the inhaler effectively48
The mores steps there are, the more likely an error will occur.49

42
Q

What are three important traits needed to successfully inhale drug particles from handheld devices into the lower respiratory tract

A

Inspiratory flow, speed of flow, and inhaled volume

Metered-dose inhalers (MDIs) and soft mist inhalers(SMIs) require a slow and deep inspiration. Dry powder inhalers (DPIs) require forceful inspiration.16

43
Q
A
44
Q

What portion of people make at least one error when using an inhaler?

A

2/3 people

45
Q

A patient who is able consciously inhale, but has sufficient inspiratory flow, and poor hand-breath coordination should use what type of device?

A

pMDI +holding chamber, or DPI, or SMI

46
Q

Patient can consciously inhale, but has insufficient inspiratory flow, and bad hand-breath coordination

A
  • PMDI +holding chamber, SMI, or Nebulizer
47
Q

What is a COPD patient is not able to consciously inhale medications

A
  1. pMDI + holding chamber
  2. Nebulizer
48
Q

What is the issue with adherence?

A

Unfortunately, non-adherence has been reported as with a range of 2% to 93%, with over half of the included studies reporting non-adherence in > 50% of subjects.102

49
Q

What types of symptoms are associated with AECOPD?

A
  • Airway inflammation
  • Increased mucus production
  • and significant gas trapping

The above three issues contributes to an increase in dyspnea which is the MAIN symptom of AECOPD

50
Q

What are other symptoms of AECOPD?

A
  • increased sputum purulence/volume, with increased cough and wheeze
51
Q

What is the main trigger of AECOPD?

A
  • viral infections, although bacterial infections can play a role

Other things might be : Ambient air pollution, excess heat

52
Q

What is the treatment for AECOPD (in a stepwise fashion)?

A
53
Q

When should antibiotics be prescribed in AECOPD?

A

If the patient has:
1. Three cardinal symptoms - dyspnea, sputum volume, and sputum purulence
2. OR have two of the cardinal symptoms if increased purulence of sputum is one of the two symptoms, or they require mechanical ventilation

54
Q

What are extrapulmonary complications of COPD related to SOB?

A

There can be extrapulmonary complications related to shortness of breath.
These can include anxiety, depression, cardiovascular disease, and musculoskeletal deconditioning.
Finally, shortness of breath is related to increased risk of exacerbation.

55
Q

What is the definition of Stable COPD?

A

Stable COPD: Patients are considered to have “stable COPD” in all clinical states other than during the period of an AECOPD. However, patients with “stable COPD” may have progressive symptoms and/or have experienced an exacerbation

56
Q

What treatments should be used if the patient has COPD and Asthma?

A

If patients with COPD have concomitant asthma they should be treated like patients with asthma.
Here the use of an ICS is mandatory, although in COPD, ICS are never used alone
Rescue short-acting bronchodilators should be prescribed to all patients for immediate symptom relief, regardless of short-acting nature of long-acting bronchodilators.

57
Q

What is the recommended therapy adjustment/assessment if:
1. Patient is responding well
2. If not responding well

A
  1. If the patient is responding well to initial therapy, keep it as it is.
  2. If not:
    Check to see if adherence is ideal, inhaler technique and if comorbidities are causing a lack of control

Consider the most prominent treatable characteristic to target (see on the next slide)

Use the exacerbation pathway if both symptoms and exacerbations need to be dealt with

Place the patient in the correct pathway/box and treat accordingly

Assess, adjust and review as in the previous slide

All of these recommendations to do require classification into the A,B and E groups.

FINAL - Respiratory symptom assessment readings (9 decks)

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