respi: copd Flashcards
COPD is characterised by
qpersistent respiratory sx and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases
- chronic bronchitis
- emphysema
chronic bronchitis
- consists of persistent cough + sputum production
- for most days of 3 months in a year for at least 2 consec years
- independent disease entity, that may occur before or after the development of airflow limitation
emphysema
- abnormal permanent enlargement of the airspaces distal to terminal bronchioles
- accompanied by destruction of their walls +/- obvious fibrosis
risk factors for copd
- tobacco smoking
- indoor/outdoor air pollution
- occupational exposures
- genetic factors - severe hereditary alpha-1 antitrypsin deficiency: early onset of lung damage
- age and sex - aging and female sex incr risk
- lung growth and development
- socioeconomic status: inversely related
- asthma and airway hyper-reactivity
- chronic bronchitis: incr freq of exacerbations
- infections: hx of severe childhood infection
copd should be considered in any pt who has
dypsnea, chronic cough, sputum production, hx of exposure to risk factors
dyspnea that is
progressive over time, characteristically worse with exercise, persistent
chronic cough
may be intermittent and may be unproductive
- recurrent wheeze
- present throughout the day, seldom nocturnal only
GOLD 1
> = 80
GOLD 2
50-79
GOLD 3
30-49
GOLD 4
<30
mMRC grade 0
only breathless w strenuous exercise
mMRC grade 1
short of breath when hurrying on the level or walking up a slight hill
mMRC grade 2
walk slower than people of the same age on the level because of breathlessness, or have to stop for breath when walking on my own pace on the level
mMRC grade 3
stop for breath after walking about 100 meters or after a few mins on the level
mMRC grade 4
too breathless to leave the house or when dressing/undressing
CAT: <10
low impact on life
>= 10: consider regular treatment for sx
CAT: >30
high impact on life, can barely leave house
CAT: how many points change will suggest a clinically significant change in health status?
2
Spiriva
tiotropium
Incruse
umeclidinium
Onbrez
indacaterol
Relvar
vilanterol + fluticasone
Seretide
salmeterol + fluticasone
Symbicort
formoterol + budesonide
regular treatment with ICS
incr risk of pneumonia esp in those w severe disease
LTRA use in copd
not tested adequately
simvastatin use in copd
does not prevent exacerbation in copd pt at incr risk of exacerbations and without indications for statin therapy
- but observational studies suggest that statins may have pos effects on some outcomes in pts with copd who receive them for cv and metabolic indications
PDE4i in copd
in pt w chronic bronchitis, severe to moderate copd and a hx of exacerbation - can improve lung function and decr exacerbations
oral glucocorticoids use in copd
long term use has numerous side effects with no evidence of benefits
theophylline in copd
low dose reduce exacerbations but does not improve post-bronchodilator lung function
theophylline adr
- n/v, diarrhea
- incr urination
- incr hr, palpitations
- breathlessness
- insomnia
- can cause seizures in toxic levels (has narrow therapeutic window)
initial pharmacological treatment: group A
bronchodilator: SABA or SAMA
initial pharmacological treatment: group B
long-acting bronchodilator: LABA or LAMA
initial pharmacological treatment: group C
LAMA
initial pharmacological treatment: group D
LABA+LAMA or ICS+LABA
when deciding whether or not to initiate ICS therapy, consider these factors:
- freq of exacerbations
- hosp for an exacerbation
- blood eosinophil count
- hx of or concurrent asthma
- hx of repeated pneumonia
- hx of mycobacterial infection
azithromycin
may reduce exacerbation rate, esp in ex-smokers
- 250mg/d or 500mg 3x/wk for 1 year
azithromycin adr
stomach cramps, diarrhea
long term use, concern of ototoxicity eg. hearing impairment
PDE4i: roflumilast
- Reduce inflammation by inhibiting the breakdown of
intracellular cyclic AMP - Reduces moderate and severe exacerbations treated with
systemic steroids in patients with severe to very severe
COPD - Benefits greater in patients with a prior history of
hospitalisation for an acute exacerbation - Adverse effects: diarrhea, nausea, reduced appetite,
weight loss, abdominal pain, sleep disturbance,
headache, depression - Not registered in Singapore
vaccinations
influenza: all
PCV13 and PPSV23: >65yo, younger pt w significant comorbid conditions incl chronic heart or lung disease
covid-19: all
Tdap (dTaP/dTPa): adults who were not vaccinated in adolescence to protect against pertussis (whooping cough)
Long-term oxygen therapy (LTOT) is indicated for stable
patients who have:
- PaO2 at or below 7.3 kPa (55 mmHg) or SaO2 at or below 88%,
with or without hypercapnia confirmed twice over a three week
period; or - PaO2 between 7.3 kPa (55 mmHg) and 8.0 kPa (60 mmHg), or
SaO2 of 88%, if there is evidence of pulmonary hypertension,
peripheral edema suggesting congestive cardiac failure, or
polycythemia (hematocrit > 55%). - Shown to improve survival in patients with severe resting
hypoxemia
exacerbation of copd
an acute event
characterized by a worsening of the patient’s
respiratory symptoms that is beyond normal dayto-
day variations and leads to a change in
medication.”
exacerbations are classified as
mild, moderate, severe
mild exacerbation
treat w short-acting bronchodilators only
moderate exacerbation
treat with short-acting bronchodilators plus antibiotics and/or corticosteroids
severe exacerbation
pt requires hospitalisation or visits the emergency room. may be a/w acute respiratory failure
o2 therapy
maintain PaO2>60mmHg or SaO2 = 88-92%
corticosteroids
prednisolone PO 40mg OM x5d
- longer courses may be a/w incr risk of pneumonia and mortality
role of vit d in immune modulation
All patients hospitalised for exacerbations should be assessed
and investigated for severe deficiency (<10 ng/ml) and given
vitamin D supplementation if required
methylxanthines
(theophylline) not recommended due to incr side effect profile
indications for antibiotics
- Patients with 3 “cardinal symptoms” (i.e., worsening
dyspnea, increased sputum purulence and increased
sputum volume) - Patients with 2 “cardinal symptoms” if increased sputum
purulence is one of them - Severe exacerbations that require mechanical
ventilation (invasive or non-invasive) - Consider other indicators of infection
- Fever
- Increased WBC count
- CRP, procalcitonin
- Changes on chest X-ray
most common bacteria
- Haemophilus influenzae
- Streptococcus pneumoniae
- Moraxella catarrhalis
