Respiratory: COPD Flashcards
Gas Exchange
Ability to transfer oxygen and carbon dioxide across alveoli membrane that is impaired in some cases of COPD
Alpha-1 Antitrypsin
An enzyme that regulates the breakdown of lung tissue
Emphysema
abnormal permanent enlargement of the airspaces distal to the terminal bronchioles accompanied by destruction of their walls yet without obvious fibrosis
Chronic Bronchitis
chronic or recurrent excessive mucus secretion into the bronchial tree with cough that is present on most days for at least 3 months of the year for at least 2 consecutive years in a patient in whom other causes of chronic cough have been excluded
COPD
a common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gasses
COPD Risk factors
Exposure to particles (tobacco, ait pollution, dust/chemicals)
Genetic (a1 antitrypsin deficiency) Age - elderly Gender Lung growth/development Socioeconomic status Asthma Bronchial Hyper-reactivity Chronic bronchitis Infections
COPD Pathophysiology
inflammation due to Neutrophils*** macrophages, CD8 T cell (doesn’t respond well to ICS)
perpetual process of inflammation leading to damage and repair = associated w/ older age
2 aspects of COPD
Small airway disease
&
Parenchymal destruction
Air trapping means that you’ll have….
more volume left in lungs after breath
Somethings seen with COPD
Air trapping
Gas exchange abnormalities
Mucus hypersecretion
Systemic manifestations
“barrel lung” and flattening of diaphragm due to air trapping
COPD Presentation
Dyspnea Cough Sputum production Wheezing and chest tightness * often have for years preceding diagnosis*
Pts >40 yrs old with at least one of these should be assessed for COPD
Dyspnea Chronic Cough Chronic Sputum Production Recurrent lower respiratory tract infection History of exposure to risk factors FH of COPD and/or childhood factors
Spirometry value for COPD diagnosis
post-bronchodilator FEV1/FVC <70%
Gold 1
Mild
FEV >80% predicted
Gold 2
Moderate
FEV 50-80% predicted
Gold 3
Severe
FEV 30-50% predicted
Gold 4
Very Severe
FEV 30% predicted
Objective measure of COPD
FEV1/FVC <70%
FEV1 predicted to determine Gold 1-4
Other objective measures of COPD
Imaging (CXR, CT)
Lung volumes and diffusing capacity
Oximetry and arterial blood gas
Exercise testing and assessment of physical activity
Low risk of exacerbations
< 1 exacerbations per year, and no hospitalization for exacerbation
High risk of exacerbations
> 2 exacerbations per year, or > 1 hospitalization
1st line therapy for COPD
Bronchodilator due to COPD being different kind of therapy
Anti-inflammatory agents are ____ to COPD
Add ons, usually to bronchodilators
ex.
Corticosteroids
PDE 4 Inhib
Macrolides
Goals of COPD Management?
Reduce Symtoms (receive symptoms, improve exercise tolerance & health status)
Reduce risk (prevent progression, exacerbations, reduce mortality)
Bronchodilator meds for COPD
B2 agonist
Anticholinergic
Methylxanthines
Anti inflammatory Medications for COPD
PDE4 inhib
Corticosteroids
Macrolides
Combo Therapies for COPD
Anticholinergic + B2 agonist
ICS/LABA
ICA/LABA/LAMA
SABA for COPD
Albuterol & Levalbuterol
PRN for SOB, can see combo with ipratropium for maintenance therapy
Tiotropium V Salmeterol
Tiotropium = more effective than salmeterol in preventing exacerbations.
Used daily, longer time to 1st exacerbation
Tiotropium v ICS/LABA
no difference in exacerbation rate between both groups
Clinical benefits of LAMA (Tiotropium)
Improvements in Health status, symptoms, FEV1, Effectiveness of pulmonary rehabilitation**, improved exercise performance
Improvements in exacerbation risk (better than LABA) and hospitalization rates
Methylxanthines (Theophylline) for COPD
less effective and no preffered
used as alternative treatment option
Key points for Bronchodilators COPD
- Inhaled bronchodilators are backbone of COPD therapy
- LAMAs> LABAs for exacerbation/hospitalization rate reduction
- Theophylline not recommended unless other bronchodilator unavailable or too much $$
- LA>SA and Inhaled>PO therapy
- Combo therapy better than mono
- pts can start on 1/2 bronchodilators or escalate from 1 to 2
When to not use ICS with COPD
Repeated pneumonia events
Blood eosinophils <100 cells/mcL
History of mycobacterial infection
When to consider use of ICS with COPD
1 moderate exacerbation of COPD per year
Blood eosinophils 100-300 cell/mcL
When strong support for ICS with COPD
History of hospitalizations for exacerbations of COPD
>2 moderate exacerbations of COPD per year
Blood eosinophils > 300 cells/mcL
History of, or concomitant, asthma
Who should not get Roflumilast for COPD?
HIV patients (protease inducers) Those who have depression or anxiety
Indication for Roflumilast in COPD?
FEV <50% and chronic bronchitis with repeat exacerbations
Indication for Azithromycin in COPD?
Former smokers with repeat exacerbations
Clinical benefits of Macrolide antibiotics?
Long term use of Azithromycin and erythromycin reduce exacerbation rates
Key points for anti-inflammatory agents in COPD?
- ICS + LABA maybe considered in pt with exacerbations despite being on appropriate treatment with LABA
- In pt w/ exacerbations despite LABA +/- ICS, w/ chronic bronchitis and FEV <50%…consider PDE4 inhibitor
- Monotherapy with ICS or Oral Steroid = not recommended
Vaccinations recommended in COPD
Flu
Penuomococcal
Tdap
Alpha-1 Antitrypsin Replacement therapy is used in patients with…
alpha-1 antitrypsin deficiency
Non-pharmacologic treatment Options for COPD
Risk factor avoidance (#1 = stop smoking) Long-term oxygen therapy (15hr< day) Ventilatory Support Surgery Palliative Care Pulmonary Rehab Physical Activity Education
What is pulmonary Rehab
training program, usually about 6 weeks
exercise training, smoking cessation help, education, nutrition counseling
Patient Group A recommendations
Essential: stop smoking
Recommended: Physical activity
Depend on guidelines:
Flu, Pneumococcal, Tdap, COVID-19, Zoster pt >50
Patient Group B,C,D recommendations
Essential: Stop smoking, Pulmonary Rehab
Recommended: Physical Activity
Depend on guidelines:
Flu, Pneumococcal, Tdap, COVID-19, Zoster pt >50
Initial Therapy: Group C
LAMA
Initial Therapy: Group D
LAMA
LAMA/LABA ( CAT >20)
ICS/LABA (eon > 300)
Initial Therapy: Group A
A bronchodilator
Initial Therapy: Group B
LAMA or LABA
Monitoring and Follow-up COPD
Symptoms = at each visit
Exacerbations = at each visit
Spirometry = at diagnosis + yearly
Risk factors, meds, comorbid conditions
COPD Comorbid conditions
CVD Osteoporosis Anxiety/Depression Lung cancer Sleep Apnea GERD Bronchiectasis Metabolic Syndrome & Diabetes (usually need to give extra insulin w/ pt on steroids)
Can you use beta blockers in patients with CVD and COPD
Yes, since it helps with mortality benefit.
Friends don’t let Friends use atenolol
Mild COPD Exacerbation
Treated with a short acting bronchodilator only
Moderate COPD Exacerbation
Treated with Short acting Bronchodilators + antibiotics +/- oral corticosteroids
Sever COPD Exacerbation
require hospitalization or visit to ER
Cause of acute exacerbation of COPD
Infection (Big reason, #1)
Air pollution
Allergy
Unknown
Cardinal Symptoms for in COPD exacerbations
Increased Breathlessness
Increased Sputum Volume
Increase in Sputum Purulence
Who gets Antibiotics in COPD Exacerbation?
3 cardinal Symptoms
2 cardinal Symptoms (if Sputum purulence is 1 of them)
Severe exacerbation that require mechanical ventilation
Summary for COPD Exacerbations
SABA/SAMA = increased dose/frequency
Corticosteroids = 40mg prednisone X 5 days
Antibiotics 5-7 days if meet criteria
