L3: COPD Flashcards
progressive lung disease charaacterized by airflow limitation that is not fully reverrsible as compared to asthma
COPD
is COPD curable?
no. but it is treatable
t or f: copd can be managed by bronchodilators to improve brething and normalize lung function
f. lung function is not the same anymore
copd is characterized by ____
chronic airway inflammation has swelling of airway and mucus hypersecretion
2 types of COPD
chronic bronchitis and emphysema
also called aas blue bloaters due to inflamed airways
chronic bronchitis
also called as pink puffers s px who have this breathe through their mouth
emphysema
damaged alveoli or air sacs found aat the end of bronchioles, wrapped with capllaries, and this is where oxygen exchange occurs
emphysema
chronic or recurrent excessive mucus secretion into the bronchiaal tree with cough that may or maay not have phlegm
chronic bronchitis
cough is present on ost days for atleast 3 monnths of the year for atleast 2 consecuive years in a px with other causes of chronc cough have been excluded
chronic bronchitis
lost of elasticity of alveoli, air sacs become hyperinflated. This causes normal gaas exchange to be disrupt, causing high carbon dioxide level and air trapping in lungs. This results in chest enlargement
emphysema
genetic markers in COPD
matrix metalloproteinase 12 and a1 antitrypsin deficiency
A1AT is made here and is released into the bloodstream where it travels to the lungs
liver
AAT is a protective antiprotease enzyme that protects ceells against ___
elastases
elastases targets ___ which is a major comonent of the alveoli
elastin
copd or asthma
neutrophils
COPD
copd or asthma
large increase in macrophages
COPD
copd or asthma
inccrease in CD4+ T lymphocytes
asthma
copd or asthma
increase in CD8+ T lymphocytes
COPD
copd or asthma
activation of mast cells
asthma
copd or asthma
IL-8
COPD
copd or asthma
TNF-a
COPD
copd or asthma
squamous metaplasia of epithelium
COPD
copd or asthma
fragile epithelium
asthma
copd or asthma
parenchymaal destruction
copd
copd or asthma
thickening of basement membrane
asthma
copd or asthma
glucocorticoids have variable effect
copd
is the primary cause of COPD allergens?
no. asthma yun
symptoms of COPD (3)
chronic intermittent unproductive cough persistent for 3 months in a yr
chronic sputum production
dyspnea
standard for diagnosing and monitoring of COPD
spirometry
Used to confirm the presence of airflow limitation
and determine the severity of obstruction
spirometry
FEV1/FVC ratio < 0.70
→ COPD (but still
needs confirmatory test →
Postbronchodilator FEV1/FVC)
test that is not recommended for copd
PEF
FEV1 of mild moderate sevre and very severe GOLD
mild - more than or EQUAL TO 80%
moderate - 50% to 80%
severe - 30% to 50%
very severe - LESS THAN 30%
in spirometry for COPD, bronchodilators can be given by either _ or _
MDI or nebulizatipm
dose and amount of time to wait before measuring again
- SABA
- short acting anticholinergic
- 400mcg and 10-15 min
- 160mcg and 30-45 min
Used when there is suspected infection such as
pneumonia or influenza.
chest radiograph
assesment tests
- CAT
- mMRC
- CCQ
less vs more symptoms in
1. CAT
2. mMRC
3. CCQ
- CAT
- <10 less symp
- >= 10 more symptoms - mMRC
- <2 less symp
- >= 2 more symp - CCQ
- <1 less symp
- >= more symp
less symptoms, low risk (not
hospitalized)
cat A
more symptoms, low risk
cat B
less/more symptoms, high risk
(may or may NOT be hospitalized)
cat E
measures amount of O2 or CO2 in the
arterial blood.
ABG
partial measure of oxygen
PaO2
partial measure of carbon dioxide
PaCO2
partial o2 and co2 in severe copd
o ↓PaO2 → 45-60 mmHg → Hypoxemia
o ↑PaCO2→ Hypercapnia
If acute respiratory distress develops (e.g., due
to pneumonia or a COPD exacerbation) the
PaCO2 may rise sharply leading to?
→ uncompensated
respiratory acidosis
exercise training along with smoking
cessation
pulmonary rehabilitation
Indicated if either of the 2 conditions is
observed and documented 2x in a 3-
week period:
▪ Resting PaO2 <55 mmHg (7.3
kPa) or SaO2 <88% (0.88) w/
or w/o hypercapnia
▪ Resting PaO2 >55 but <60
mmHg (7.3 and 8.0 kPa) or
SaO2 <88% (0.88) with
evidence of right-sided heart
failure, polycythemia, or
pulmonary HTN.
long-term oxygen therapy
partial o2 and SaO2
Goal is to increase PaO2 in equal to or
more than 60% and SaO2 in equal to or
more than 90%.
long term oxygen therapy is not reccomended if px is still not __
immunized
Help ↓ likelihood of respiratory
infections → COPD
immunization
immunizations
- Annual inactivated IM influenza vaccine
- 23-valent pneumococcal polysaccharide vaccine (PPSV23)
- 13-valent conjugated pneumococcal vaccine (PCV13)
- Tdap (dTaP) vaccine
≥ 65 yrs. old
if the 1st vaccination was > 5
years earlier and the patient
was younger than age 65.
revaccination
DO NOT reduce the frequency and severity of
exacerbations
short acting bronchodilators
Effective rescue medication or as needed therapy to manage symptoms
short acting bronchodilators
Stimulate adenylyl cyclase → ↑cAMP →
bronchial SM relaxation and improve
mucociliary clearance.
short acting beta 2 agonist
short acting beta 2 agonist drugs
r albuoterol
levalbuterol
SE of short acting beta 2 agpnist
Palpitation
• Hypokalemia
• Skeletal muscle tremor
• “Jittery feelings”
• Sinus tachycardia (rare)
• Arrhythmia (rare)
Competitively inhibit M1, M2, and M3→
blocking ACh→ ↓cGMP → Bronchodilation
and ↓ mucus secretion
short acting anticholinergic
has prolonged bronchodilation compared to albuterol
ipratropium
roa of short acting anticholi
inhalation and nebulization
another short acting anticholi other than ipra
oxitropium
SE of short acting anticholi
• Dry mouth
• Nausea
• Occasional metallic taste (gargle every use)
Reduce frequency symptoms and
exacerbation frequency
lonf acting bronchodilators
improves lung fx
long acting bronchodialtor
Indication:
o Frequent and persistent symptoms
o High risk of exacerbation
LABA
LABA drigs
arfomoterol
formoterol
indacaterol
olodaterol (5mon onset)
salmeterok (15-20min onset)
1st line monotherapy for patients at high risk
of exacerbations
tiotropium
COPD can recommend monotherapy of
____ (more recommended) or ____
LAMA
LABA
Greater reduction in exacerbation frequency
compared to LABA
tiotropium
long actong anticholi
aclidinium
glycopyrrolate
umeclidinium
tiotropium
Allows the lowest possible effective dose to be
used → reduce potential adverse effect from
individual agents
COMBINATION ANTICHOLINERGICS AND
B2-AGONIST (DUAL BRONCHODILATORS)
methylxanthnes roa
iv or oral
NO INHALATION
Inhibition Ca2+ influx into SM
methylxanthines
Inhibition of
release of mediators from mast cells and
leukocytes
methylxanthines
Indication:
• Patient intolerant or unable to use inhaled
bronchodilator.
methylxanthines
- since no inhalational
- iv or oral lamg siya
appropriate for long-term management of COPD
SR theophylline
requires monitoring of serum concentration 1 to 2x/yr
sr theophylline
dosing requires 200mg BID amd titrated upward every 3 to 5 days to the target dose
theophylline
SE of methylxanthines
dyspepsia
• NV
• Diarrhea
• Headache
• Dizziness
• Tachycardia
Seizure and death for severe effects
Inhibition of release of proteolytic enzymes from
leukocytes
• Inhibition of PG
corticosteroids
↓Capillary permeability → ↓mucus
corticosteroids
Indication:
• Inhalational therapy for chronic stable COPD
(category E)
• Short-term systemic use for acute
exacerbations
corticosteroids
Recommended if there is high eosinophilic
count >300 count
Recommended : LAMA + LABA + ICS
given when the patient has asthma and COPD unless the px has pneumonia, tb, immunosupressant, and low esoinophil counts
corticosteroids
SIDE EFFECTS:
• ↑risk of pneumonia and mycobacterial pulmonary infections in patients with COPD (long-term use)
• Hoarseness of voice
• Sore throat
• Oral candidiasis (gargle)
• Skin bruising
inhaled corticosteroids
severe ADRs of inhaled corticosteroids
SEVERE ADR:
• Osteoporosis
• Adrenal suppression
• Cataract
PDE4 inhibition → ↑cAMP →
Bronchodilation and ↓activity of
inflammatory cells and mediators (TNF-α
and IL-8)
PDE4 inhibitor (roflumilast)
main effect of pde4 inhib
anti inflammatory
roflumilast roa
oral
Indication:
o Recurrent exacerbations despite
treatment with triple inhalation
therapy
roflumilast
o Escalation therapy for patients with
recurrent exacerbations on
LAMA/LABA who are not
candidates for ICS.
roflumilast
dose of roflumilast
Starting dose: 250 mcg PO for 4
weeks → increase to a
maintenance dose of 500 mcg PO
OD
di of roflumilast
Theophylline! Both PDE-4 inhibitor
SE of roflumilast
o Diarrhea
o Nausea
o ↓appetite
o Weight loss
o Headache
o Neuropsychiatric effects (suicidal thoughts, insomnia, anxiety, and new or worsened depression)
Intended to maintain serum concentrations
above the protective threshold
A1-ANTITRYPSIN REPLACEMENT THERAPY
(AAT)
indication
- Patients with inherited AAT deficiency-
associated emphysema
A1-ANTITRYPSIN REPLACEMENT THERAPY
(AAT)
used for COPD as
expectorant
guaifensin
formulations of guaifensin with __ or ___ should not be used for COPD maintenance therapy
dextromethorphan
pseudoephedrine
antimicrobial therapy is recommended if all 3 lf the cardinal symptoms are present:
- inc dyspnea
- inc sputum prod
- inc sputum purulence
Biomarker to assist with decisions
regarding the use of antimicrobial
therapy for COPD exacerbations
C-reactive protein (CRP)
Common organisms for acute
exacerbations of COPD:
o Haemophilus influenzae
o Moraxella catarrhalis
o Streptococcus pneumoniae
o Haemophilus parainfluenzae
Right-sided heart failure secondary to pulmonary
hypertension
COR PULMONALE
tx for cor pulmonale
TREATMENT:
o Long-term oxygen therapy
o Increasing PaO2 above 60 mm Hg
(8.0 kPa)
o Diuretics
o Selective B1-blocker
Increase in amount of RBC
Polycythemia
polycythemia tx
TREATMENT:
• Continuous oxygen therapy
• Periodic phlebotomy if oxygen therapy alone is
not sufficient.
o Hct >55%-60% (0.55 to 0.60) and the
patient is experiencing CNS effects
suggestive of sludging from high blood
viscosity.
Surgical removal of bullae (dilated air
spaces in lungs)
bullectomy
Removes sections of lung to reduce
hyperinflation and may improve survival
in selected patients.
Lung volume reduction surgery (LVRS)
Replacing diseased lungs with healthy
lungs.
Lung transplantation
