COPD (Cut off for Exam 3) Flashcards
COPD Guidelines
- GOLD 2019
- Frequently updated
COPD + Death
- 3rd leading cause of death in US
- >15 million diagnosed (assumed to be underestimated)
COPD Definition
- Common, preventable, treatable
- Persistent respiratory symptoms
- Airflow limitation due to airway or aveolar abnormalities
- Caused by significant exposure to noxious particles or gases
Factors + Diagnosing COPD
- Medical History
- Physical exam
- Spirometry - required to establish diagnosis
Characteristics + Increased COPD
->40 y.o.
-Dyspnea
-Chronic cough
-Chronic sputum production
-Family history of COPD
-Recurrent lower respiratory tract infections
History of exposure to risk factors
NOT diagnostic, perform spirometry in any patients > 40 y.o. with any of the indicators
COPD - Dyspnea
- Cardinal symptoms
- Major cause of disability and anxiety
- Increased effort to breathe, heaviness, air hunger, gasping
- Chronic and progressive
COPD - Cough (chronic)
- Often the first symptom
- Often discounted by patients as a consequence of smoking or environmental exposures
- May start as intermittent but becomes chronic
- May or may not be productive
COPD - Other Presentations
- Sputum production
- Wheezing and chest tightness
- Fatigue
- Weight loss
- Anorexia
Spirometry + COPD
- Most reproducible and objective measurement of airflow limitation
- Most common pulmonary function test (PFT)
- Measures FEV1:FVC like in asthma (closer to 0.8 in health patients, lower in those with obstructive lung disease)
FEV1 + Severity
- Used to diagnose severity in those with FEV1:FVC < 70%
- GOLD 1: Mild, FEV1 >= 80%
- GOLD 2: Moderate, FEV1 50-79%
- GOLD 3: Severe, FEV1 30-49%
- GOLD 4: Very Severe, FEV1 <30%
Other Patient Factors to Consider….
- Current level of patient’s symptoms (CAT or mMRC questionnaire)
- Exacerbation risk
- Presence of co-morbidities
Exacerbations and level of symptoms used to place them in treatment groups, Groups A-D
COPD - Treatment Goals
- Relieve symptoms
- Improve exercise tolerance
- Improve health status
- Reduce exacerbations
- Prevent disease progression
- Reduce morality
COPD - Treatment Principles
- Treatment often cumulative
- Maintenance of regular treatment for long periods of time
- Individuals differ in response to treatment
COPD + Non-Pharm Therapy
- Smoking cessation
- Oxygen: O2 saturation < 88%, =88% with pulmonary HTN, heart failure, or polycythemia
- Pulmonary rehabilitation (Groups B-D) - exercise, nutrition, education, smoking cessation, behavioral health
Vaccinations + COPD
- Important part of preventative therapy
- Annual influenza vaccination
- Pneumococcal vaccination
MDI
- Metered dose inhaler
- Difficult to coordinate
- Valved holding chamber helpful
- Contains propellants
DPI
- Dry powder inhaler
- Requires forceful inhalation
SMI
- Soft Mist Inhaler
- Slow steady mist
- No skaing or spacer required
Nebulizer
- Not portable
- Expensive
- No coordination of breath required
- Continue only if symptomatic benefit clear
Bronchodilator Therapy Key Points
- Inhaled treatment preferred
- Long acting bronchodilators preferred (LABA and LAMA)
- Consider combinations of mechanisms
- Theophylline - not recommended unless other long-term treatment bronchodilators are unavailable or too expensive
Bronchodilators Benefits
- Improves FEV1: dose response is relatively flat, increasing dose may provide subjective benefit in acute episodes, not helpful in stable disease
- Toxicity is dose related
- Improve exercise performance, dyspnea, health status
- Reduce exacerbation rates, decrease hospitalizations
- Given as-needed or on a regular basis
Muscarinic Antagonists
- Frequently used in COPD
- Short-acting (SAMA) and LAMA
- Greater effect on exacerbation rates versus LABA
- Nebulization with mask over eyes may precipitate acute glaucoma
- Questionble evidence of CV events and mortality with ipratropium and Spiriva Respimat in COPD patients
Albuterol - MDI
- SABA
- Proventil, ProAir, Ventolin
- 2 puffs (90 mcg/puff)
- Every 4-6 hours PRN
Albuterol - Nebulizer
- SABA
- AccuNeb
- Nebulized solution
- 2.5 mg
- Every 4-6 hours PRN
Levalbuterol - MDI
- SABA
- Xopenex HFA
- 2 puffs (45 mcg/puff)
- Every 4-6 hours PRN
Levalbuterol - Nebulizer
- SABA
- Xopenex
- Nebulized solution
- 0.63 mg
- Every 6-8 hours PRN
Ipratropium - MDI
- SAMA
- Atrovent HFA
- 2 puffs (17 mcg)
- Four times daily, up to 12 puffs per day
Ipratropium - Nebulizer
- SAMA
- 0.5 mg
- Every 6-8 hours
Combivent
- Ipratropium + Albuterol
- SAMA + SABA
- Respimat (SMI)
- 1 inhalation (20/100 mcg)
- Four times daily, up to 6 inhalations per day
Duoneb
- Ipratropium + Albuterol
- SAMA + SABA
- Nebulizer Solution
- 0.5/2.5 mg
- Every 6 hours; up to every 4 hours
Serevent
- LABA
- Salmeterol
- Diskus (DPI)
- 1 inhalation (50 mcg)
- BID
Perforomist
- LABA
- Formoterol
- Nebulizer solution
- 20 mcg
- BID
Brovana
- LABA
- Arformoterol
- Nebulizer solution
- 15 mcg
- BID
Arcapta
- LABA
- Indacterol
- Neohaler (DPI)
- 1 inhalation (75 mcg cap)
- Once a day
Striverdi
- LABA
- Olodaterol
- Respimat (SMI)
- 2 inhalations (2.5 mcg)
- Once a day
Spiriva
- LAMA
- Tioptropium
- Handihaler (DPI) or Respimat (SMI)
- DPI: 1 inhalation (18 mcg)
- SMI: 2 inhalations (2.5 mcg)
- Once daily
Turdorza
- LAMA
- Aclidinium
- Pressair (DPI)
- 1 inhalation (400 mcg tab)
- BID
Incruse
- LAMA
- Umeclidinium
- Ellipta (DPI)
- 1 inhalation (62.5 mcg)
- Once a day
Seebri
- LAMA
- Glycopyrrolate
- Neohaler (DPI)
- 1 inhalation (15.6 mcg)
- BID
Yupelri
- LAMA
- Revefenacin
- Nebulizer solution
- 1 vial (175 mcg)
- Once a day
Anoro
- LABA + LAMA
- Vilanterol + Umeclidinium
- Ellipta (DPI)
- 1 inhalation (62.5/25 mcg)
- Once a day
Stiolto
- LAMA + LABA
- Olodaterol + Tiotropium
- Respimat (SMI)
- 2 inhalations (2.5/2.5 mcg)
- Once a day
Utibron
- LABA + LAMA
- Indacaterol + Glycopyrrolate
- Neohaler (DPI)
- 1 inhalation (27.5/15.6 mcg)
- BID
Bevespi
- LABA + LAMA
- Formoterol + Glycopyrrolate
- Aerosphere (MDI)
- 2 actuations (9/4.8 mcg)
- BID
Duaklir
- LABA + LAMA
- Aclidinium + Formoterol
- Pressair (DPI)
- 1 inhalation (400/12 mcg)
- BID
Theophylline
-Available but NOT frequently used for COPD
-Metabolized by P450 (drug interactions)
-Clearance declines with age
Adverse effects: toxicity is dosed related
-Arrhythmias, convulsions, headaches, insomnia, nausea
Anti-Inflammatory + Long-term ICS Monotherapy
- NOT recommended
- Increases risk of pneumonia, oral candidiasis, hoarse voice, skin bruising
Anti-Inflammatory + ICS/LABA
-More effective improving lung function, health status, and reducing exacerbation in moderate to very severe disease
Anti-Inflammatory + ICS/LAMA/LABA
- Improves lung function, symptoms, health status, and reduces exacerbations
- Compared to ICS+LABA, LABA+LAMA, or LAMA
Anti-Inflammatory + PDE4
-Severe to very severe COPD
AND
-History of exacerbations
Long-Term Azithromycin + Erythromycin
-Reduce exacerbations over 1 year
ICS Monotherapy
- NEVER used for COPD
- Long-term safety is unknown with COPD
- Withdrawal form use may cause exacerbations and increased symptoms
- Long term use also hasn’t been shown to reduce long-term decline
COPD + Pneumonia
- ICS use increases the risk
- Current smokers
- > = 55 y.o.
- BMI < 25 kg/m^2
- Poor mMRC dyspnea grade
- Severe airflow limitation
- Prior exacerbations or pneumonia
Advair
- LABA + ICS
- Used in COPD
- Fluticasone propionate + Salmeterol
- Diskus (DPI)
- 1 inhalation (250/50 mcg)
- BID
Symbicort
- LABA + ICS
- Used in COPD
- Budesonide + Formoterol
- MDI
- 2 puffs (160/4.5 mcg)
- BID
Breo
- LABA + ICS
- Used in COPD
- Fluticasone furoate + Vilanterol
- Ellipta (DPI)
- 1 inhalation (100/25 mcg)
- Once a day
Trelegy
- LABA + ICS
- Used in COPD
- Fluticasone furoate + Umeclidinium + Vilanterol
- Ellipta (DPI)
- 1 Inhalation (100/62.5/25 mcg)
- Once a day
Roflumilast
- Daliresp
- Used in COPD
- PDE4
- Inhibits inflammation by breakdown of cAMP, no direct bronchodilator effect
- Used in combination with at least 1 long lasting bronchodilator
- Reduces exacerbations in patients with severe COPD (FEV1 < 50%, chronic bronchitis, frequent exacerbations)
- AE: Nausea, reduced appetite, abdominal pain, diarrhea, sleep disturbances, headache (reduce over time)
- Monitor for weight loss and depression
Antibiotics + COPD
- Not for antimicrobial activity
- Reduce risk of exacerbations in those with increased risk of exaberations
- No data beyond one year
- Azithromycin: 250mg/day or 500 mg three times per week
- Increases incidence of bacterial resistance and impaired hearing tests
- Erythromycin: 500 mg BID
Other Medications for COPD
- Oral steroids: numerous SE, recommended only for short-term management of acute exacerbations
- Little evidence for mucolytics or leukotriene modifiers
- Antitussives have no conclusive evidence
Group A Initial Therapy
Bronchodilator
Group B Initial Therapy
- LABA
- LAMA
Group C Initial Therapy
-LAMA
Group D Initial Therapy
- LAMA
- LAMA + LABA
- ICS + LABA
Follow-Up Treatment
If response to initial therapy is appropriate, maintain it
- If not, consider predominent treatable trait to target (exacerbations, dyspnea, etc.)
- Exacerbation > dyspnea
- Place patient in box corresponding to current treatment and follow indications
- Recommendation not dependent on ABCD designation
Dyspnea Treatment
- Start with LABA or LAMA
- Then go to LABA + LAMA
- If still no response, consider switching inhaler device, molecules, or investigating/treating other causes of dyspnea
- If on ICS, get off if there is a lack of response, has pneumonia, or inappropriate original indication
Exacerbation Treatment
- Start on LABA or LAMA
- Go up to LABA + LAMA if blood levels or normal
- LABA + ICS is eosinophil >= 300, OR eos >= 100 AND >= 2 moderate exacerbations/1 hospitalization
- Get off of ICS if inappropriate (same reasons as dyspnea card)
- Can increase from LABA + LAMA to LABA + LAMA + ICS
- Can also alternatively add on roflumilast (FEV1 < 50% and chronic bronchitis) OR azithromycin (former smokers)
Monitor + Follow-up
- Lung function is expected to wrosen over time
- Use symptoms/objective measures of airflow limitation to determine to modify therapy
- Monitor symtoms, physical exam, smoking status, medication regimen every visit
- CAT/mMRC every 2-3 months
- Spirometry at least annually
COPD Comorbidities
- Heart failure, atrial fibrillation, and HTN should be treated
- In Afib, use of high doses of beta-agonists can make heart rate control more difficult
- Use beta-blockers if necessary
