Respiratory & Endocrine (PHAR 253) Flashcards
1
Q
What do pulmonary function tests measure?
A
- Lung capacity
- How quickly air can move in and out of lungs
- Gas exchange efficiency
2
Q
What are the four compartments of air in the lungs?
A
Tidal Volume: air exhaled during normal respiration
Inspiratory Reserve Volume: maximum air inhaled above TV
Expiratory Reserve Volume: maximum air exhaled below the tidal volume
Residual Volume: volume of air remaining in the lungs after maximal expiration
The sum of the above four components is defined as the total lung capacity (TLC)
3
Q
What is the functional residual capacity?
A
This is the volume of air in the lungs at the end of normal expiration
4
Q
What is vital capacity?
A
This is the total volume of air exhaled after a maximal inhalation
5
Q
What are some airflow measures used in pharmacy?
A
FEV1 (Forced Expiratory Volume in 1 second)
FVC (Forced Vital Capacity)
FEV1/FVC ratio
6
Q
What is FEV1?
A
Forced Expiratory Volume in 1 second
Patient inspired to TLC and exhales maximally. The volume of air exhaled in the first second
This is the best measure for assessing severity of airflow obstruction
7
Q
What is FVC?
A
Forced Vital Capacity
This is the total volume of air expired as rapidly as possible from TLC
8
Q
How is FEV1/FVC clinically relevant?
A
Helps to differentiate restrictive from obstructive lung disease
ex. FEV1=4L of air and FVC=5L, FEV1/FVC ratio is 80%
9
Q
What are the types of pulmonary function tests?
A
- Spirometry
- Peak Expiratory Flow Meter
- Carbon Monoxide Diffusing Capacity
10
Q
What are some potential uses for spirometry?
A
The following is not an exhaustive list:
- Diagnosing lung disease and assessing severity
- Monitoring the course of disease or result of therapeutic intervention
- Assessing surgical risk
11
Q
How does a patient take a spirometry test?
A
The test should be conducted by trained personal who follow a quality assurance program
- Take the deepest breath
- Exhale into the sensor as hard as possible for at least 6 seconds
12
Q
What are the results of spirometry compared against?
A
- Predicted normal values based on height, age, and sex
- Patient’s “Personal Best” lung function (particularly helpful to monitor progression or treatment of disease states)
13
Q
What is a limitation of spirometry?
A
Requires full cooperation of the patient
This can be challenging for some patient groups (children under 6, dementia patients, etc.)
14
Q
What are some contraindications for spirometry?
A
Spirometry causes the following and could be damaging in certain disease states
- Increases intracranial or intraocular pressure
- Increases in intra-thoracic and intra-abdominal pressure (avoid especially if patient had a thoracic procedure)
- Increases in mycardial demand or changes in BP
- Increased risk of infection
15
Q
What is obstructive lung disease?
A
The inability to get air out of the lung (asthma and COPD)
FEV1 is reduced, therefore FEV1/FVC ratio is lower
16
Q
What is restrictive lung disease?
A
The inability to get air into the lung and maintain normal lung volumes (interstitial lung disease, patients that are not fully cooperating)
FEV1/FVC ratio is either normal or increased
17
Q
What is the utility of conducting spirometry tests when diagnosing asthma?
A
After a patient is confimed to have an obstructive lung disease. Practitioners must determine if it is asthma or COPD
When an asthma patient is given salbutamol (beta 2 agonist), their airways will open up. This will increase FEV1 (acute bronchodilator response).
If the use of salbutamol does not change FEV1, it is likely this obstructive lung disease is COPD
18
Q
Why are peak expiratory flow rate devices not preferred to measure pulmonary function?
A
Although they are more portable, they have less reproducible results
Results are compared to personal best or predicted values
19
Q
What is Carbon Monoxide Diffusing Capacity?
A
It is a measurement of the ability of carbon monoxide to diffuse across the alveolar-capillary membrane
20
Q
What happens to CO Diffusing capacity when the lungs are diseased?
A
This capacity will be reduced in all clinical situations where gas transfer from alveoli to capillary blood is impaired
21
Q
What do pulse oximeters measure?
A
They help determine oxygenation status
22
Q
In what situations will pulse oximeters give an inaccurate reading?
A
- Patients who are cold
- Wear dark nail polish
- Patient is in shock
- Patient has smoke inhalation
23
Q
Why are arterial blood gas levels important in determing pulmonary function?
A
ABG’s reflect how well lungs are oxygenating the blood and are useful to assess acid-base status
24
Q
What is asthma?
A
It is a chronic inflammatory disorder of the airways characterized by the following:
- Sudden occurence or persistent symptoms
- Dyspnea, chest tightness, wheezing, sputum production and cough
- Airway hyper-responsiveness to a variety of stimuli
25
Do pediatric asthma patients "grow out" of asthma ?
Yes many patients no longer have asthma or a less severe form in adulthood
26
What is the prognosis of asthma?
If asthma is adequately managed, then the following apply:
Most do not die from long-term progression of asthma
Lifespan is unaltered
Can maintain all activities of daily living
27
What is the etiology of asthma?
Genetic predisposition (60-80%)
Environmental factors (smoke, allergens, cold air)
Drugs (Aspirin and other NSAIDs, sulfites, non-selective b-blockers, etc.)
Sex (males affected initially, but women are affected more by asthma after 20)
Obesity
28
What is the difference between atopic and non-atopic asthma?
Atopic (Extrinsic): asthma is in response to allergy to antigens
Non-atopic (Intrinsic): Secondary to chronic/ recurrent infections. Hypersensitivity to bacteria and viruses
29
What are some predictive factors that contribute to persistebt adult asthma?
1. Atopy
2. Onset during school age
3. Presence of bronchial hyperactivity
30
What are the consequences of untreated bronchial hyperactivity in asthma?
Without anti-inflammatory treatment, airway remodelling can occur
31
What does the early asthmatic response look like?
Occurs in minutes (bronchospasm)
Activation of mast cells and macrophages
32
What does the late asthmatic response look like?
Occurs in hours
Bronchospasm returns, submucosal edema, hyperresponsiveness
Activation of inflammatory cells
33
What does chronic asthma look like?
Occurrs in days
Hyperreactive airways, epithelial cell damage, mucous hyper secretion
Leads to airway remodelling
34
What are the two asthma phenotypes?
Type 2 and Type 1
35
What are some examples of Type 2 asthma?
Early onset allergic asthma
Aspirin exacerbated respiratory disease (AERD)
Exercise-induced asthma
36
What are some examples of Type 1 asthma?
Obesity-related asthma
Very late onset asthma
Smoking-related
Cormorbidities
37
What are the four elements of asthma diagnosis?
1. Medical history
2. Physical exam
3. Pulmonary Function Tests
4. Other laboratory tests (CBC, Allergy skin tests, sputum test)
38
When diagnosing asthma, what information should a practitioner collect for a good history?
*Symptoms and severity:*
Most patients with asthma will experience intermittent episodes of expiratory wheezing, coughing and dyspnea
*Family history*
*Precipitating factors*
*Triggers*
39
What are some common triggers for asthma?
1. Exercise
2. Time of day
3. Aero-allergens
4. Irritants
5. Respiratory tract infections
6. Drugs (Aspirin and other NSAIDs in particular)
7. Stress
8. Hormonal fluctuations
9. GERD
40
Are physical exams for asthma always useful?
No, asthma is a heterogeneous disease and it can present different signs or symptoms at different times
This can make gauging severity of asthma difficult
41
What is the pulmonary function criteria for asthma diagnosis?
FEV1/FVC is less the 75-80% below predicted values
and
More than 12% improvement in FEV1 and at least 200mL from baseline 15 min post quick acting b-2 agonist challlenge (shows reversibility)
42
Is the threshold for diagnosis for children more conservative or liberal compared to guidelines for adults?
It is a more conservative threshold (FEV1/FVC ratios below 80-90% are grounds for asthma diagnosis and treatment in children)
43
What are some other laboratory tests used in the diagnosis of asthma?
CBC (eosinophil count, IgE concentration, FeNO (breath test))
Allergy skin tests
Sputum eosinophils
44
What are the two organizations that create asthma guidelines?
1. Canadian Thoracic Society (Clinical guideline)
2. Global Initiative for Asthma (less clinical, but practcal guideline)
45
Which criteria were modified in the new CTS guidelines for asthma control?
1. Daytime symptoms: No more than 2 days/week
2. Need for a reliever (SABA or budesonide/formoterol): No more than 2 doses per week
Under this new definition, more people will be classified with having uncontrolled asthma
46
When is a patient considered to have well controlled asthma?
1. Avoid symptoms during the day and night
2. Need little or no reliever medication
3. Have productive, physically active lives
4. Have normal or near-normal lung function
5. Avoid serious asthma flare ups
47
What are the six principles of asthma treatment?
1. Environmental control
2. Pharmacologic treatment
3. Appropriate use of inhalation therapy
4. Regular consultation with certified asthma education
5. Graduated approach to therapy
6. Regular follow up
48
What are some environmental control measures for asthma patients?
Avoid animals (use HEPA filters and wash pets if you already have animals in your home)
Mold/fungus (use dehumidifier and fix leaky pipes)
Minimize outdoor activity when pollen/poor air quality
Avoid allergens
Maintain personal hygiene
49
What are the two main categories of pharmacological therapy used in asthma?
1. Reliever medication (only use for acute flare-ups)
2. Controller medication (take everyday, and it acts slowly over time)
50
What is an example of a reliever medication used in asthma?
SABA (selective b-2 adrenergic agonists)
ex. Salbutamol
These drugs have little impact on long-term inflammation reduction, but they can be used in acute situations
51
Are beta-1 or beta-2 agonists better for asthma treatment?
beta-2 agonsists specificially activate receptors in the lungs. b-2 agonism causes dilation of the airways
This action by b-2 agonists is preferred over different types of adrenergic agonists
52
Are drug interactions with SABAs common?
No, DIs are not awfully common because SABAs are not always absorbed into the blood, but some concerns exist
Be careful when using beta blockers and a SABA (oppose the actions of one another)
QT prologation possible
53
What is a common dose for SABAs in asthma patients?
Usually dosed 1-2 puffs every 4-6 hours PRN
In a serious asthma attack, it is safe to take puffs every few minutes
54
How do long-acting beta agonist (LABA) work?
They work slowly over 12h period
Need to take LABAs every day
Formoterol is special because it is approved for rescue
55
What drug class is the most common and effective type of controller?
Inhaled Corticosteroids (ICS)
ICS can take days, weeks, and months to see changes in controlled asthma
56
What are some side effects for inhaled corticosteroids?
Side effects are dependent on drug, dose, and inhalation technique irritation
1. Dysphoria, hoarseness, throuag itching, and cough
2. Candida oral infections
3. Growth retardation in children
57
What are some patient education points that pharmacists should convey to their patients about LABAs?
LABAs need to be taken regularly, daily and delayed onset
Use spacer if provided to younger child.
Rinse out mouth following every inhaler use
58
What are some contraindications for inhaled corticosteroids?
Do not start using ICS during untreated respiratory tract infections
59
What is the utility of oral or intravenous corticosteroids?
They are used for short periods of time in acute, severe asthma
60
What are some commonly used oral/IV corticosteroids used in asthma?
1. Prednisone
2. Prednisolone
3. Dexamethasone
61
What is the utility of Leuktriene Receptor Antagonists in asthma treatment?
They are an alternative to increasing steroid doses in patients who remain symptomatic
62
Can LABAs be used without corticosteroids?
No, LABAs can never be used alone. They must be used in conjuction with a corticosteroid
Use a combo product for convienence and full adherance
63
What is the utility of Methylxanthines in asthma?
Less effective bronchodilators than beta agonists
Used as a add on therapy for patients that need high dose corticosteroid (used in severe asthma cases)
Also require close monitoring due to narrow therapeutic index
64
What was the first biologic for asthma?
Omalizumab (anti IgE antibody)
Used for atopic asthma that is poorly controlled despite high dose steroids and and add on therapy
65
Which biologic has EDS coverage for asthma?
Mepolizumab
It is useful in patients with eosinophillic asthma who experience exacerbations despite of high doses of inhaled corticosteroids
66
What is the role of tiotropium in asthma treatment?
Tiotropium is used as an add-on therapy for patients over the age of 12 for asthma that is uncontrolled despite combo ICS/LABA therapy
67
Why should patients avoid increasing the frequency of their SABA over adding ICS?
Excessive SABA use on its own can increase mortality rates, but using an ICS in conjunction can reduce mortality rates
68
What is the rationale against using SABA alone?
ICS + LABA vs. SABA alone = 2/3 reduction in exacerbations with a lower ICS dose
69
Which patients are at higher risk for exacerbations?
1. History of a previous severe asthma exacerbation
2. Poorly controlled Asthma as per CTS criteria
3. Overuse of SABA (more than 2 inhalers of SABA in a year)
4. Current smoker
70
What is the minimum age required for Symbicort (budesonide/formoterol)?
need to be at least 12 years old
71
What is the next agent added to SABA and ICS if asthma is no longer under control?
If under 12: increase ICS
If over 12: Add LABA
72
Review Slide 129 for treatment algorithm for asthma
73
What is the definition of uncontrolled asthma?
Previously asymptomatic patient intermittently develops symptoms
74
What is the definition of severe asthma?
They are 5% of asthma patients, but up to 50% of direct costs
They require treatment with high-dose ICS + and a second controller for the previous year
75
How can uncontrolled asthma be investigated?
1. Watch patient use their inhaler
2. Assess adherance
3. Remove risk factors and assess/manage comorbidities
4. Confirm diagnosis of asthma
5. Consider step-up therapy
76
How should asthma treatment be monitored following add-on therapy?
1-3 months after treatment started, then every 3-12 months
If patient is pregnant, check every 4-6 weeks
If patient experienced exacerbation (check back within a week)
77
How is asthma treatment stepped up?
Sustained step-up: done for at least 2-3 months if asthma is poorly controlled
Short-term step up (1-2 weeks) ex. viral infection
Day-to-day adjustment (PRN basis)
78
When should therapy be stepped down?
1. Patient's asthma has been under control for more than 3 months
2. Goal is to find lowest effective dose
3. Ensure patient is on board
4. Choose an appropriate time for the patient
5. Have a plan in place if step down fails
79
Is discontinuing an ICS reccomended in adults when stepping down therapy?
No, due to increased risk of exacerbations
80
Is discontinuing a LABA recommended in adults when stepping down therapy?
No, due to increased risk of exacerbations
81
Review slide 137 for a good guideline for asthma treatment step down
82
What is the clinical benefit of asthma action plans?
Can reduce hospitalizations, physician visits, and can increase pulmonary functions due to improved self-management of symptoms
83
What are the most important components of a asthma action plan?
1. How to monitor and measure their symptoms
2. Daily preventative management strategies
3. When and how to adjust medications
4. When to seek urgent care
84
Which asthma patient group uses peak expiratory flow meters regularly as a way of tracking condition?
Moderate to severe asthmatics
OR
asthmatics who are poor percievers of airway obstruction
85
What is the utility of peak flow meters in asthma treatment?
Allows patient more responsibility and control in disease management
1. Monitor treatment course
2. Determine when emergency care is necessary
3. Identify allergens
4. Detect asymptomatic deterioration in lungs
86
What are the requirements of good asthma education?
1. What is asthma
2. Definition
3. Role of inflammation in the airways
4. Signs and symptoms
5. Common triggers and management
6. Goals
87
What are the components of asthma self-management?
1. Self-monitoring
2. Written asthma action plan
3. Regular medical review
88
What are some things pharmacists should tell patients about their asthma medications?
1. How they work
2. Long-term control
3. Quick relief
4. Beneficial and adverse effects
5. Reliever vs. controller
6. PRN vs. regular
89
Are conversations about adherance apply to the drug alone?
No, patient must be adherant to drug and device (need to have good technique)
90
What are the first signs of an asthma exacerbations?
1. Worsening pattern of symptoms
2. Exercise intolerance
3. Unusual fatigue
4. Noctural awakening
91
What does an asthma exacerbation look like?
Prolonged, severe episode of asthma unresponsive to usual treatment, develops over hours to days
ex. Tachycardia, tachypnea, anxiety, etc.
92
What is used to treat asthma exacerbations?
Use two short acting bronchodilators (SABA+Short acting anticholinergic agent)
High frequency dosing (every 20 minutes)
Usually given via nebulizer or MDI+spacer
93
Can ICS be used in treating asthma exacerbations?
No, inhaled corticosteroids do not pack the same punch as oral or IV corticosteroids
See improvement within 2 hours (6h max)
94
What are the criteria for home management following an asthma exacerbation?
1. Patient can follow their action plan
2. PEF above 60% of personal best
3. No comorbidities
95
When should a patient be hospitalized for an asthma exacerbation?
1. PEF is below 60% of personal best
2. Breathlessness at rest, severe drowsiness, cannot speak full sentences
3. Comorbidities (recent exacerbation, angioedema, fever)
4. Symptoms worsen despite increased SABA/controller use
96
What causes exercise-induced broncho-constriction?
Body attempts to warm/humidify increased volume of air. Can result in release of mediators (leukotrienes and histamine)
97
What are some treatment options for exercise-induced broncoconstriction?
1. Wear a scarf or mask
2. Enhance fitness level
3. Optimize asthma to decrease bronchial hyperresponsiveness
4. Prophylactic therapy (SABA a few min before exercise)
5. LTRAs
6. Warm up before exercise
98
How many asthma patients experience ASA/NSAID induced asthma?
7-10% of asthmatics
Develops over months to years
99
What are some predisposing factors to developing ASA/NSAID induced asthma?
1. Chronic rhinitis
2. Chronic nasal congestion
3. Inflammation in lower airway
4. Acute sensitizaiton to NSAIDs
100
Can acetaminophen be used in patients with ASA/NSAID induced asthma?
At lower doses (below 1000mg/dose), tylenol is fine to use in these patients
101
What is the effect of beta blockers in asthma treatment?
Risks for decreased response to beta-agonists
Increased airway hyper-responsiveness
Non-cardioselective beta-blockers have the greatest risk for the above
102
What are some common careers that are associated with occupational asthma?
Not an exhaustive list
Painting, hair dressing, cleaning, HCPs, and bakers
103
What are the symptoms of occupational asthma?
1. Worse at work or after hours
2. Symptoms disappear on vacation, but return once patient goes back to work
3, May start when patient is in contact with new chemical
4. Co-workers may have similar symptoms
104
Is asthma treatment safe in pregancy?
Yes, most therapies except biologics are fine to use by pregnant women
105
Why is asthma control important during pregnancy?
Premature birth, low birth weight, congenital abnormalities
Maternal BP changes
Not worth the minimal risk of controlling asthma
106
What is the preferred dosage form for asthma treatment?
Inhaled
107
What factors should be considered when selecting a device?
1. Availability
2. Cost
3. Skills/ability of patient (patients with limited dexterity)
108
What are metered dose inhalers (MDI)?
Pressurized inhaler that delivers medication by using a propellant spray
109
How are MDIs used?
1. Shake inhaler well before use (3 or 5 shakes)
2. Remove cap
3. Breathe out, away from your inhaler
4. Bring inhaler to your mouth. Place it in your mouth between your teeth
5. Start to breathe in slowly. Press the top of your inhaler once and keep breathing in slowly until you have taken a full breath
6. Remove inhaler from mouth and hold breath for about 10 seconds, then breathe out
7. If a second puff is needed, wait 30 seconds before starting process again
110
What are spacers in relation to MDIs?
They are tube-like chambers added on to a metered dose inhaler
111
What is the benefit of spacers in asthma treatment?
They allow the patient to inhale the medication slowly and deeply over multiple breaths
This is a great features for children, elderly, debilitated, and is recomended for all patients
112
Are nebulizers better than MDI+spacer?
No, they are clinically equivalent
MDI+spacers are preferred due to their relative portability
113
What are the two inhalation techniques used for spacers?
1. Tidal volume (normal breathing) technique
2. one slow, deep inspiration
114
Once a dose has been released into the spacer, can it remain there for an extended period of time?
No, if dose is left in the spacer for more than a few seconds, it will deposit onto the internal walls
115
How to use MDI+spacer?
Same as MDI technique (review page 184)
116
What types of inhalers require inhalation and device actuation to occur at the same time?
MDIs and SMIs require these two events have to be coordinated
DPIs are breath activated, so timing of inhalation is not an issue
117
What is inspiratory resistance in DPIs?
DPIs are breath activated, but different devices require more or less breathing force to be effective
118
What are some qualities of Turbuhaler devices?
DPI (breath activated)
only need a small inspiratory flow rate for effective delivery
Emphasize fast breath (unlike MDIs)
Best for patients over the age of 5
Contains rattling dessicant
No taste or feel of drug
ex. Pulmicort (ICS), Symbicort (ICS/LABA), Bricanyl (SABA)
119
How are Turbuhalers used?
1. Uncrew cap and hold inhaler upright
2. Twist coloured grip and then twist it back to hear a click
3. Breath out away from the device
4. Put device in between teeth and breath in forcefully and deeply
5. Remove turbuhaler before breathing out
120
What are some characteristics of DIskus inhalers?
DPI (breath activated)
Breathe in quickly
Can feel the drug
Maintain parallel to ground once activated
Drug delivery is constant across a range of air flow rates
Has a dose counter
ex. Flovent (ICS), Ventolin (SABA), Advair (ICS/LABA)
121
How to use Diskus inhalers?
1. Open diskus inhaler and use thumb to push grip until patient hears click
2. SLide lever away from you to allow it to collect drug
3. breathe out away from device and breathe in deeply and hold for 10 seconds
122
What are some characteristics of Handihaler inhalers?
DPI (breath activated)
Breath in slowly (unlike other DPIs) and deeply
Lots of set up (need to load capsule every time)
Each capsule is equivalent to a dose, so no dosing counter is required
Drug delivery consistent across a range of air flow rates
ex. Spiriva
123
How to use a Handihaler?
1, Remove capsule from blister pack and load into device
2. Close mouthpiece and hear a click to ensure proper closure
3. Hold handihaler upright, with mouthpiece facing up
4. Depress side button to release drug into device
5. Exchale and breathe in slowly and deeply (unlike other DPIs) until lungs are full
6. Hold breath for 10 seconds and breathe out
7. Take second breath in to ensure all drug has been taken up and hold breath for 10 seconds
124
What are some characteristics of Ellipta inhalers?
Pre-loaded doses
Simply open cap to prepare dose
Ensure air vent is not covered during inhalation and breathe in
Short expiry date
ex. Breo (ICS/LABA), Arnuity (ICS), Trelegy (LAMA, ICS, LABA)
125
What are some pros of Soft Mist Inhalers (SMI)?
Slow moving mist gives time for inhalation (no need for coordination)
Improved delivery to lungs
Dose indicator
126
What are some cons of Soft Mist Inhalers (SMI)?
Requires reasonable strength to load spring loader (just do it before dispensing)
Not approved for kids under 5
Cannot use with spacer
Need to prime again if left unused for 3-7 days depending on drug
127
How is a SMI like Respimat used?
1. Prime inhaler
2. Turn clear base 1/2 turn
3. Open the cap and breathe out slowly away from device
4. Without covering air vents, inhale a slow, deep breath (hold for 10 seconds)
5. Breathe normally
128
What are some common errors seen in SMIs like Respimat?
1. Too deep of a breath may cause irritation at back of throat
2. Not pressing the button while breathing
3. Not loading the canister
129
In general, how quickly should you take a second dose if multiple doses are prescribed for the same time?
Wait 30 seconds to 1 min between doses of the same medication
130
What are nebulizers?
They are electric or battery powered machines that turn liquid medicine into a fine mist that is inhaled into the lungs
131
How can pharmacists ensure effective use of nebulizers?
1. Choose right device (consider patient skills and cost)
2. Check inhaler technique at every opportunity
3. Correct poor technique
4. Confirm your knowledge
132
What is COPD?
COPD (Chronic Obstructive Lung Disease)
Respiratory disorder largely caused by smoking
Characterized by progressive and partially reversible airway obstruction
Difficulty exhaling (due to increased resistance from mucosal inflammation, airway remodelling)
Lung hyperinflation (Obstruction of the small airways)
Increased frequency and severity of exacerbations
133
What is emphysema?
Abnormal enlargement of the airspace distal to the terminal bronchioles (accompanied by wall destruction)
134
How common is COPD in the Canadian population?
4% of Canadians aged 35 and older
135
What is the underlying cause of most patients with COPD?
Smoking
136
What are some risk factors for COPD?
Exposure to Particles (smoking, occupational dusts, air pollution)
Infections (frequent childhood respiratory problems, prior TB, HIV)
Host factors (1-antitrypsin deficiency, age, issues with lung growth and development)
137
What causes exacerbations?
Triggered by infection, environmental pollutants or unknown
During an exacerbation (increased hyperinflation and gas trapping, with decreased expiratory flow)
138
What are the three most significant symptoms seen in patients with COPD?
1. Shortness of breath
2. Chronic cough
3. Phlegm
139
What are some end stage COPD symptoms?
Patient is in positions that relieve shortness of breath (dyspnea)
Use of accessory respiratory muscles
Cyanosis (blue extremities)
140
Review slide 229 for differences between asthma and COPD
141
Which patients should be screened for COPD diagnosis?
Smokers over 40 who have the following:
Persistent cough or sputum production
Frequent respiratory tract infections
Progressive activity-related shortness of breath
Evening wheeze
142
What test is performed to confirm a COPD diagnosis?
Spirometry (FEV under 80%, FEV1/FVC ratio below 0.7)
143
What are some good screening questions for COPD diagnosis?
Do you cough regularly (is there phlegm)
Do simple chores leave you short of breath
Do you wheeze when you exert yourself or at night
Do have longer colds
144
How is risk from lifetime smoking assessed?
Total pack years= (# of cigarettes smoked per day/20)x(# of years of smoking)
145
What is the mMRC Dyspnea scale?
It assesses shortness of breath in patients on a scale from Grade 0 to Grade 4, with Grade 4 being the most severe
146
What is the CAT test in COPD diagnosis?
A validated, short (8-item) and simple patient completed questionairre
It is a measure of the impact of COPD on a patient's health status
147
What are some goals of treatment for COPD?
1. Prevent disease progression and exacerbations
2. Alleviate shortness of breath
3. Improve exercise tolerance
4. Prevent complications of COPD
5. Improve health status and reduce mortality
148
What are some potential treatments of COPD?
1. Smoking cessation
2. Eliminate occupational and environmental exposures
3. Comprehensive patient/ family education
4. Avoid sedatives/narcotics in severe disease
5. Rehab programs for pulmonary function
6. Vaccines (prevent respiratory tract infections)
7. Long-term oxygen therpay
8. Pharmacologic treatment
149
What are the main pharmacological agents used in COPD therapy?
Bronchodilators are the mainstay of therapy (QID PRN)
Muscarinic antagonists (SAMA and LAMA) play a bigger role, and ICS serve a smaller role in COPD vs. asthma treatment
150
How are short-acting bronchodilators used in COPD therapy?
PRN use
recommended in patients with any stage of disease
Can increase dose beyond recommended dose in severe disease
SABA+SAMA used in initial COPD treatment
ex. salbutamol + ipratropium
151
Review slide 263 for the different short-acting bronchodilators used in COPD treatment
152
What is the mechanism of action of muscarinic antagonists (SAMA and LAMA) in COPD?
Inhaled SAMA or LAMA prevent acetylcholine from binding to smooth muscle cells in the lungs (keeps muscles relaxed)
153
What are some potential adverse effects for SAMA & LAMAs?
Dry mouth (rinse mouth folowing use), cough, constipation
Avoid eye contact (can cause glaucoma)
154
What are some examples of a LAMA?
Tiotropium (more evidence bc it has been around the longest)
Aclidinium
Glycopyrronium
Umeclidinium
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What are the differences between LABAs and LAMAs?
Both improve symptoms
LAMA (tiotropium) may be better at reducing exacerbations
LAMAs are better tolerated (fewer withdrawals)
LAMA side effects; dry mouth, constipation
LABA side effects: headache, dose-dependent CV effects
156
Can ICS be used first line for COPD?
No, they should also never be used as monotherapy in COPD
Bronchodilators first and then ICS is added if patient is not controlled
157
What is the benefit of ICS add-on therapy in COPD?
1. Reduces exacerbations
2. Better for patients with higher eosinophil count
158
Review slide 270 for combo agents used in COPD therapy
159
When selecting a specific agent for COPD, what factors should be considered?
Evidence (oldest agents are most studied)
Available devices
Adherence (OD vs. BID treatment)
Onset (LABAs and LAMAs work within minutes)
Side effects (LAMAs have anticholinergic effects, LABAs have potential CV events, steroids (ICS))
Guideline approach
160
What is the role of prophylactic azithromycin in COPD treatment?
Patients on 250mg OD x 1 year experienced lower exacerbation rates
Recommended for patients with normal QT interval and no significant drug interactions
161
What is the role of N-acetylcysteine in COPD treatment?
It has antioxidant properties and is used when other therpay options have been exhausted
Regular dosing may reduce exacerbations
162
What is the role of Roflumilast in COPD treatment?
It is a phosphodiesterase IV inhibitor and is an add-on therapy
Considered in patients that are already on triple treatment for COPD (LAMA+ICS/LABA) when the have had at least 1 exacerbation in the last year
Less tolerated than inhaled medications
163
Review slide 276 for a good treatment guideline for COPD
164
What are the three levels of COPD exacerbations and what some potential interventions?
1. Mild exacerbation (worsening or new respiratory symptoms without change in therapy)
2. Moderate exacerbation (Prescribed antibiotics and/or oral corticosteroids)
3. Severe exacerbation (requiring a hospital admission or emergency visit)
165
What are some characteristics of a COPD patient who has a low-risk of a COPD exacerbation?
Patient has less than 1 or less moderate exacerbation in the last year and did not require an emergency visit or hospitalization
166
What are some characteristics of a COPD patient who has a high-risk of a COPD exacerbation?
Patient has had at least 2 moderate or 1 severe exacerbation in the last year requiring a hospital admission/emergency visit
167
What drugs are used in patients with low COPD exacerbation risk?
LAMA/LABA and ICS if COPD is not adequately managed by LAMA/LABA
168
What drugs are used in patients with high COPD exacerbation risk?
LAMA/LABA/ICS + Add-on therapy (azithromycin or Roflumilast or N-acetylcysteine)
169
What are some surgical interventions used in COPD patients?
1. Lung Volume Reduction Surgery (remove poorly functioning lung tissue that is contributing to inflammation abd reducing lung elasticity)
2. Lung Transplantation (considered when survival is less than 2 years and FEV1 is 25% of the predicted value (5-year survival rate of 60%)
170
Is stepping up COPD treatment common?
Yes, COPD is a progressive disease
Consider revaluation 6 months after initiation of therapy, and every 12 months after
171
Is stepping down COPD treatment common?
Not really
Usually done when treatment benefits not realized, side effects exceed benefits
OR
Patients on ICS that have low risk of morbidity and mortality and are stable for long periods of time
Need to monitor patient very carefully if stepping down
172
What are acute exacerbations of COPD?
Sustained worsening of dyspnea, cough or sputum production leading to an increase in the use of maintenance medications
Cause of most medical visits, hospitalizations, and death among COPD patients
173
What are the consequences of AECOPD (acute exacerbation COPD)?
1. Reduced health-related quality of life
2. Increased mortality
3. Accelerated decline in lung function
4. Increased health resource utilization and costs
174
What are some treatment options for AECOPD?
1. Bronchodilators (SAMA and SABA are added to LAMA/LABA therapy)
2. Steroids (systemic, improve spirometry and restore lung function quicker)
3. Antibiotics (give to patients on mechanical ventilation or those who have changes in sputum colour, increased sputum volume and dyspnea)
175
Are infections a common cause of AECOPD?
Yes, up to 50% of AECOPD cases are infectious in natures (many are viral, but some are bacterial)
176
What are some characteristics of a COPD patient who should be hospitalized?
Severe symptoms (Resting dyspnea, high respiratory rate, decreased oxygen saturation, confusion, drowsiness)
Acute respiratory failure
Physical symptoms (cyanosis, peripheral edema)
Failure to respond to intial management
Presence of serious comorbidities
Insufficient home support
177
Review slide 289 for criteria for discharge for patients that have been hospitalized for AECOPD
