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820 > COPD (Cut off for Exam 3) > Flashcards

COPD (Cut off for Exam 3) Flashcards

1
Q

COPD Guidelines

A
  • GOLD 2019

- Frequently updated

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2
Q

COPD + Death

A
  • 3rd leading cause of death in US

- >15 million diagnosed (assumed to be underestimated)

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3
Q

COPD Definition

A
  • Common, preventable, treatable
  • Persistent respiratory symptoms
  • Airflow limitation due to airway or aveolar abnormalities
  • Caused by significant exposure to noxious particles or gases
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4
Q

Factors + Diagnosing COPD

A
  • Medical History
  • Physical exam
  • Spirometry - required to establish diagnosis
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5
Q

Characteristics + Increased COPD

A

->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

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6
Q

COPD - Dyspnea

A
  • Cardinal symptoms
  • Major cause of disability and anxiety
  • Increased effort to breathe, heaviness, air hunger, gasping
  • Chronic and progressive
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7
Q

COPD - Cough (chronic)

A
  • 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
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8
Q

COPD - Other Presentations

A
  • Sputum production
  • Wheezing and chest tightness
  • Fatigue
  • Weight loss
  • Anorexia
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9
Q

Spirometry + COPD

A
  • 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)
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10
Q

FEV1 + Severity

A
  • 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%
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11
Q

Other Patient Factors to Consider….

A
  • 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

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12
Q

COPD - Treatment Goals

A
  • Relieve symptoms
  • Improve exercise tolerance
  • Improve health status
  • Reduce exacerbations
  • Prevent disease progression
  • Reduce morality
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13
Q

COPD - Treatment Principles

A
  • Treatment often cumulative
  • Maintenance of regular treatment for long periods of time
  • Individuals differ in response to treatment
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14
Q

COPD + Non-Pharm Therapy

A
  • 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
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15
Q

Vaccinations + COPD

A
  • Important part of preventative therapy
  • Annual influenza vaccination
  • Pneumococcal vaccination
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16
Q

MDI

A
  • Metered dose inhaler
  • Difficult to coordinate
  • Valved holding chamber helpful
  • Contains propellants
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17
Q

DPI

A
  • Dry powder inhaler

- Requires forceful inhalation

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18
Q

SMI

A
  • Soft Mist Inhaler
  • Slow steady mist
  • No skaing or spacer required
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19
Q

Nebulizer

A
  • Not portable
  • Expensive
  • No coordination of breath required
  • Continue only if symptomatic benefit clear
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20
Q

Bronchodilator Therapy Key Points

A
  • 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
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21
Q

Bronchodilators Benefits

A
  • 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
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22
Q

Muscarinic Antagonists

A
  • 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
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23
Q

Albuterol - MDI

A
  • SABA
  • Proventil, ProAir, Ventolin
  • 2 puffs (90 mcg/puff)
  • Every 4-6 hours PRN
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24
Q

Albuterol - Nebulizer

A
  • SABA
  • AccuNeb
  • Nebulized solution
  • 2.5 mg
  • Every 4-6 hours PRN
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25
Q

Levalbuterol - MDI

A
  • SABA
  • Xopenex HFA
  • 2 puffs (45 mcg/puff)
  • Every 4-6 hours PRN
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26
Q

Levalbuterol - Nebulizer

A
  • SABA
  • Xopenex
  • Nebulized solution
  • 0.63 mg
  • Every 6-8 hours PRN
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27
Q

Ipratropium - MDI

A
  • SAMA
  • Atrovent HFA
  • 2 puffs (17 mcg)
  • Four times daily, up to 12 puffs per day
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28
Q

Ipratropium - Nebulizer

A
  • SAMA
  • 0.5 mg
  • Every 6-8 hours
29
Q

Combivent

A
  • Ipratropium + Albuterol
  • SAMA + SABA
  • Respimat (SMI)
  • 1 inhalation (20/100 mcg)
  • Four times daily, up to 6 inhalations per day
30
Q

Duoneb

A
  • Ipratropium + Albuterol
  • SAMA + SABA
  • Nebulizer Solution
  • 0.5/2.5 mg
  • Every 6 hours; up to every 4 hours
31
Q

Serevent

A
  • LABA
  • Salmeterol
  • Diskus (DPI)
  • 1 inhalation (50 mcg)
  • BID
32
Q

Perforomist

A
  • LABA
  • Formoterol
  • Nebulizer solution
  • 20 mcg
  • BID
33
Q

Brovana

A
  • LABA
  • Arformoterol
  • Nebulizer solution
  • 15 mcg
  • BID
34
Q

Arcapta

A
  • LABA
  • Indacterol
  • Neohaler (DPI)
  • 1 inhalation (75 mcg cap)
  • Once a day
35
Q

Striverdi

A
  • LABA
  • Olodaterol
  • Respimat (SMI)
  • 2 inhalations (2.5 mcg)
  • Once a day
36
Q

Spiriva

A
  • LAMA
  • Tioptropium
  • Handihaler (DPI) or Respimat (SMI)
  • DPI: 1 inhalation (18 mcg)
  • SMI: 2 inhalations (2.5 mcg)
  • Once daily
37
Q

Turdorza

A
  • LAMA
  • Aclidinium
  • Pressair (DPI)
  • 1 inhalation (400 mcg tab)
  • BID
38
Q

Incruse

A
  • LAMA
  • Umeclidinium
  • Ellipta (DPI)
  • 1 inhalation (62.5 mcg)
  • Once a day
39
Q

Seebri

A
  • LAMA
  • Glycopyrrolate
  • Neohaler (DPI)
  • 1 inhalation (15.6 mcg)
  • BID
40
Q

Yupelri

A
  • LAMA
  • Revefenacin
  • Nebulizer solution
  • 1 vial (175 mcg)
  • Once a day
41
Q

Anoro

A
  • LABA + LAMA
  • Vilanterol + Umeclidinium
  • Ellipta (DPI)
  • 1 inhalation (62.5/25 mcg)
  • Once a day
42
Q

Stiolto

A
  • LAMA + LABA
  • Olodaterol + Tiotropium
  • Respimat (SMI)
  • 2 inhalations (2.5/2.5 mcg)
  • Once a day
43
Q

Utibron

A
  • LABA + LAMA
  • Indacaterol + Glycopyrrolate
  • Neohaler (DPI)
  • 1 inhalation (27.5/15.6 mcg)
  • BID
44
Q

Bevespi

A
  • LABA + LAMA
  • Formoterol + Glycopyrrolate
  • Aerosphere (MDI)
  • 2 actuations (9/4.8 mcg)
  • BID
45
Q

Duaklir

A
  • LABA + LAMA
  • Aclidinium + Formoterol
  • Pressair (DPI)
  • 1 inhalation (400/12 mcg)
  • BID
46
Q

Theophylline

A

-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

47
Q

Anti-Inflammatory + Long-term ICS Monotherapy

A
  • NOT recommended

- Increases risk of pneumonia, oral candidiasis, hoarse voice, skin bruising

48
Q

Anti-Inflammatory + ICS/LABA

A

-More effective improving lung function, health status, and reducing exacerbation in moderate to very severe disease

49
Q

Anti-Inflammatory + ICS/LAMA/LABA

A
  • Improves lung function, symptoms, health status, and reduces exacerbations
  • Compared to ICS+LABA, LABA+LAMA, or LAMA
50
Q

Anti-Inflammatory + PDE4

A

-Severe to very severe COPD

AND

-History of exacerbations

51
Q

Long-Term Azithromycin + Erythromycin

A

-Reduce exacerbations over 1 year

52
Q

ICS Monotherapy

A
  • 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
53
Q

COPD + Pneumonia

A
  • 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
54
Q

Advair

A
  • LABA + ICS
  • Used in COPD
  • Fluticasone propionate + Salmeterol
  • Diskus (DPI)
  • 1 inhalation (250/50 mcg)
  • BID
55
Q

Symbicort

A
  • LABA + ICS
  • Used in COPD
  • Budesonide + Formoterol
  • MDI
  • 2 puffs (160/4.5 mcg)
  • BID
56
Q

Breo

A
  • LABA + ICS
  • Used in COPD
  • Fluticasone furoate + Vilanterol
  • Ellipta (DPI)
  • 1 inhalation (100/25 mcg)
  • Once a day
57
Q

Trelegy

A
  • LABA + ICS
  • Used in COPD
  • Fluticasone furoate + Umeclidinium + Vilanterol
  • Ellipta (DPI)
  • 1 Inhalation (100/62.5/25 mcg)
  • Once a day
58
Q

Roflumilast

A
  • 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
59
Q

Antibiotics + COPD

A
  • 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
60
Q

Other Medications for COPD

A
  • 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
61
Q

Group A Initial Therapy

A

Bronchodilator

62
Q

Group B Initial Therapy

A
  • LABA

- LAMA

63
Q

Group C Initial Therapy

A

-LAMA

64
Q

Group D Initial Therapy

A
  • LAMA
  • LAMA + LABA
  • ICS + LABA
65
Q

Follow-Up Treatment

A

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
66
Q

Dyspnea Treatment

A
  • 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
67
Q

Exacerbation Treatment

A
  • 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)
68
Q

Monitor + Follow-up

A
  • 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
69
Q

COPD Comorbidities

A
  • 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

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