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TXP: Pulm/ Tox. And Rheumatology > Week 2: COPD > Flashcards

Week 2: COPD Flashcards

1
Q

what is COPD

A

preventable and treatable disease characterized by ..

persistent respiratory symptoms and airflow limitation that is due to airway and alveolar abnormalities usually caused by significant exposure to noxious particles or gases

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2
Q

COPD etiology

A

etiology:
smokking and pollutants

patho: imopaired lung growth, accelerated decline,mlung injury, lung and systemic inflammation

—> small airway disorders (chronic bronchitis, emphysema), systemic effects

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3
Q

risk factors for copd development

A

Environmental riak factors
cigarrette smoke: MOST SIGNIFICNT RISK FACTOR + other types of tobacco and marijuana

occupational dust and chemicals

environmental tobacco smoke (ETS)

indoor and outdoor air pollution

Host risk factors
*Aging Populations
*Genes: Alpha-1 antitrypsin deficiency
*Hx of severe childhood respiratory infections
*Poverty/ lower socion-economic status

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4
Q

clinical presentation of COPD

A

dyspnea: progressive, persitent and characteristically worse with exwercise

chest tightness=often occurs post exertion

cough:m often 1sr symptom of COPD
*intermittent or persistent
*productive or unproducctiive

chronic sputum production
wheezing: varies
comorbidities: depression, anxiety, ankle swelling, weightloss, fatigue, rib factures

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5
Q

Dx of COPD

A

spirometry
*post-bronchodilator FEV1/FEV<0.70
*required to make dx of COPD

chest x ray
*not used to dx copd
*value in excluding alternative dx or comorbidities

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6
Q

Pharm Treatment options for Chornic Stable COPD

Bronchodilators pearls

A

mainstay of COPD therapy

increase FEV1 or change spirometric variables (change reflects widening of the airways rather than change in lung elastic recoik

improve lung emptying

improve exercise performance

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7
Q

Pharm Treatment options for Chornic Stable COPD

beta 2 agonists

A

mao: relaxes airway smooth muscles by stimulating beta 2 agrenergic receptors, increases cAMP and antagonizes bronchoconstriction-> bronchdilation

types:
*short acting: onset: 5-15 min
duration: 4-6h
recommended prn > atc
long acting: duration>/12 hrs( some up to 24hrs

ADR: tachycardia, trmor, hypokalemia, tachyphylaxis

CI:

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8
Q

Short Acting Beta Agonists(SABAs)

A

1)Albuterol (ProAir, Proventil HFA, Ventolin HFA (MDIs), ProAir Respiclick (DPI), Generics

dosage: 90 mcg/inhilation
1-2 puffs q4-6hrs prn

1.225-5 mg q4-8 hrs via nebulizer

2) Levalbuterol (Xopenez HFA (MDI), Generics
dosage: 45 mcg/ inhalation
1-2 puffs q4-6h prn

0.63 mg every 6-8 hrs via nebulizer

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9
Q

Long Acting Beta Agonists (LABAs)

A

Salmeterol (Servent):
DPI:1 inhalation BID

Formoterol (Performist)
nebulizer: 20mcg via nebulizer BID

Olodaterol (Striverdi Respimat)
SMI: 2 inhalations QD

Aformoterol (Brovana)
nebulizer only: 15 mcg BID via nebulizer (max 30 mcg/day)

indacaterol (arcapta) Neohaler
Neohaler DPI: one 75mcg capsule via neohaler once daily

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10
Q

Muscarinic antagonists considerations

A

block bronchoconstrictor effects of ACh on the M3 muscarinic receptors expressed in the airway smooth muscle

SAMAs have slightly longer duration of action than SABAs

poor systemic absorption:

ADR: dry mouth, tiotropoium may cause metalslic taste, cough, nausea, blurred vision, reports of glaucoma with use of face mask

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11
Q

Muscarinic antagonists

A

Ipotropium bromide (Atrovent HFA
MDI:2 puffs (34 mcg 4 times a day or prn. MDD 12 puffs a day
nebulizer solution: 500 mcg 3-4 times a day via nebulizer

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12
Q

Long Acting Muscarinic Antagonists

A

Tiotropium (Spirica Handi Haler, Spiriva Respimat)
Handilhaler: one 18mcg capsule via inhalation daily (DPI)

Aclindinium Tudorza Pressair): One oral inhalation (400 mcg) twice daily (DPI)

Umeclidinium (incruse Ellipta)
One inhalation (62.5 mcg) once daily (DPI)

Glycopyrollate (seebri Neohaler): One (15.6 mcg capsule via neohaler twice daily (DPI)
nebulizeR: 25mcg BID

Revefanecin (Yupelri)
nebulizer: 175 mcg (1 vial once daily via nebulizer

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13
Q

Short acting bronchdilator combos

A

used for PRN symptoms or scheduled.

SABA+SAMA
improve efficacy
equal or lesser side effects

ex: Albuterol/ipatrpprium (combivent respimat) SMI
1 puff QID (in place of long acting bronchodilator or PRN

Albuterol/ ipotropium (Duoneb (nebulizer solution)
3 mL q6h via nebulizer
CI in soybean/ peanut allergy

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14
Q

Long Acting Bronchodilator combos

A

LABA+LAMA

Indacaterol/ Glycopyrrolate (Utibron Newohaler)
inhale contents of one capsule via nebulizer

tiotropium/ olodaterol (Stiolto Respimat (SMI): 2 puffs once daily

Umeclidinium/ Vilanterol (Anoro Ellipta) (DPI)
1 inhalation once daily

Glycopyrrolate/ Fomoterol (Bevespi Aerosphere (MDI)
2 inhalations twice daily

Aclidinium/ Fomoterol (Duaklir Pressair (DPI): 1 inhalation twice daily

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15
Q

Methylxanthines (Theophylline) use in COPD

A

less effective and less tolerated than LONG ACTING BRONCHdilators

not recommended if other agents are availabe

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16
Q

ICS use in COPD

A

only used in combo w. LABAs or LAMAs

not used as monotherapy

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17
Q

ICS/LABA combo products also side effects

A

fluticasone/ furoate/ vilanterol (Breo Ellipta)-DPI: 1 inhalation once daily

fluticasone proprionate (Advair Diskus and HFA, Wixela Inhub, AirDuo REspiclick-DPI and MDI: 1 inhalation twice daily

budesonide/fomoterol (Symbicort)-MDI 2 puffs twice daily

Mometasone/ formoterol (Dulera)-MDI 2 puffs twice daily; used off lable for COPD

AE: oral thrush, horse voice

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18
Q

oral glucocorticoids for copd

A

used in exacerbations

no role in chornic daily treatment. lack of benefit an dhigh risk of sysrtemic complicaitns

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19
Q

Tripple therapy inhaler

A

not first line treatment

Fluticasone furoate/ umeclidinium/ vilanterol (trekegy Ellipta)-DPI: 1 inhalation once daily

Budesonide/ glycopyrrolate/formoterol (Breztri Aerosphere: 2 inhalations twice daily

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20
Q

Roflumilast

A

PDE4 inhibitor reduces inflammation by inhibiting the breakdown of intracellular cAMP

dose: 500 mg PO QD

AE: nausea, diarrhea, weightloss (caution in those with low BMI), sleep disturbances, headache, may worsen depression/ associated w. suicidal ideation

DDI: 3a4 inhibitors, 3a4 and 1a2 inducers. do not use w. theophylline

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21
Q

Asthma-COPD overlap

A

persistent airflow limitation with several feautures usually associated w. asthma and several features usually associated w. COPD. it is identified by the feaTURES that it shares with both asthma and COPD

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22
Q

asthma-copd overlap temrinology

A

asthma copd overlap is not a single disease entity

includes pts w. several forms of airway disease (Phenotypes)

feautures caused by a range of underlying mechanisms

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23
Q

COPD and asthma overlap outcomes

A

frequent exacerbations

poor QOL

more rapid decline in lung function

higher mortality

greater health care utilization

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24
Q

Asthma copd overlap (ACO) feautures

A

usually > 40 y.o

may have had symptoms in early childhood

persistent airflow limitation, not fully reversible, and with variability

often has hx of childhood asthma, allergies, exposure to smoke or other irritants, or FH of asthma

treatment only partially decreases symptoms

chest xray similar to copd

exacerbations more common than in copd alone

eosinophils and/ or neutrophils in sputum

comorbidities may lead to further impairment

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25
Q

stepwise approach to dx and initial treatment of ACO via GINA and GOLD guidelines

A
  1. dx airway disease
    yes:go to step 2
    no: onsider other disease first
  2. syndromic dx of asthma, COPD, or ACO
    using chart, if pt has 3 or mroe of either asthma or COPD, there is a strong likilood that is the correct dx.
  3. perform spirometry
  4. commence initial treatment:
    notes: no LABA monotherapy in asthma pats.
    no ICS monotherapy in COPD.
    *ket: if ACO, initiate ICS or ICS bronchdilator combo.
26
Q

goals of assessment for copd

A

determine the laevel of airflow limitation

determine impact on patients health status

determine risk for furture events (exacerbations, hospitalization, death)

to guide therapy

27
Q

ABCD assessment tool general categories

A

Used for initial assessment of copd

1.Assess degree of airflow limitation
2. assess symptoms
3. assess risk of exacerbations

28
Q

Assess degree of airflow limitation categories

and use considerations

A

Gold 1:
Mild: FEV1 >/=80% predicted

Gold 2:
Moderate: 50%</=FEV1<80% predicted

Gold 3:
Severe: 30%</-FEV1<50% predicted

Gold 4:
Very severe: FEV1<30% predicted

*not used to select pharmacotherpay on FEV1 alone
*may be used in cases such as dosage form choise of theapy.

29
Q

Assesment of symptoms categories

A
  1. Modified British medical research council (mMRC) questionaire
    *measures breathlessness
    predicts future mortality, and relates to other measures of health status
    mMRC0-4

2.COPD Assessment Test (CAT
*comprehensive assesment of symptoms

30
Q

Assessment of Exacerbation Risk

A

COPD exacerbations defined as acute worsening of respiratory symptoms that result in additional therapy. (

mild: (treated with SABAs only)

moderate: treated with SABAs plus abx or oral corticosteroids

severe: pt requires hospitalization or visits to ED. severe exacerbations may also be associated w. acut respiratory failure

*note: blood eosinophil count may alsopredict exacerbation rates in pts treated w. LABA w.o ics

31
Q

assessment of exacerbation risk using exacerbation hx

A

HIGH RISK:
2 or more exacerbations in the last year OR
1 or more exacerbation that led to hospitalization

NOT HIGH RISK
no exacerbations in the last year or
1 exacerbation in the last year that did not lead to hospitalization

32
Q

ABCD essessment box categories

A

CD
AB

left:(moderate or severe exacerbation hx)

I. >/2 exacerbations or >/1 exacerbation that led to hospitalization

II. 0-1 exacerbation not leading to hospitalization

bottom: assessment of symtpoms
mMRC >/1 or CAT<10: mMrc>/2 OR cat>/10

33
Q

copd comorbidities

A

copd pts at risk for

cv disease
osteoporosis
respiratory infections

anxiety and depreesion

diabetes

lung cancer

bronchiectasis

thes comorbid ocnditions may influenc mortaility and hospitalizations and should be looked for routinely and treated appropriately

34
Q

goals of therpay for stabled COPD

A

reduce symtoms

reduce disease progreesion, risk, exacerbatoins, and mortaility

34
Q

goals of therpay for stabled COPD

A

reduce symtoms

reduce disease progreesion, risk, exacerbatoins, and mortaility

35
Q

Summary of COPD management

selecting initial therapy

A

assess severity of airflow limitation base don fev1

assess symptoms/ exacerbations and stae (group ABCD)

use initial pharm treatment algorithm to select theraoy based on group ABCD

36
Q

Initial Pharm Treatment based on category

A

Group A: A bronchodilator (can be short or long acting, for ex short acting in pts w. occasional dyspnea)

Group b: A long acting bronchdilator (LABA OR LAMA)(no preference of one over other

gorup C: LAMA

Group D: LAMA or LAMA+LABA* or ICS+LABA**

*CONSIDER IF cat score>20
*consider if eos>/300

also note: rescue inhalers are recommended too. +SABA, SAMA, OR SABA/SAMA(preffered over either alone for improving FEV1 and symptoms) combo

37
Q

Follow up Pharm treatment summary

A
  1. if response to initial treatment is appropriate,maintain it.
  2. if not..
    a) consider predominant treatable trait to target (dyspnea or exacerbations)
    b)place pt in a box corresponding to current treatment and follow indications.
    c)assess response, adjust and review
    these recommendations do not depend on the ABCD assessment at dx.
38
Q

Follow up pharm treartmnt for dyspnea

A

!!!DYSPNEA!!!

if on……
LABA OR LAMA
v
LABA+LAMA
v
consider switching inhaler device or molescules
investigate or treat other causes of dyspnea

if on…
LABA+ICS
v
LABA+LAMA+ICS

notes:consider ICS if eos>/300 or
>/= 100 AND 2 moderate exacerbations/1 hospitalization

also consider ICS deescalation or switch if pneumonia , inapropriate original indication, or lack of response to ICS

39
Q

Follow up treatment for exacerbations

A

!!EXACERBATIONS!!!

                     LABA or LAMA
       v                                         v LABA+LAMA                           LABA +ICS   v          v                                         v   v           v > *LABA +LAMA+ICS*< v   v                                v  v> > > > > > > > >>>>v<<<<<<<<<<<<
                                v
                                v <<<<<<<<<<<<<<<<<>>>>>>>>>>>>>>>> V                                                                 v Roflumilast if                                   Azithromycin                                      FEV1<50% &                                  in former  chornic bronchitis                              smokers

notes:consider ICS if eos>/300 or
>/= 100 AND 2 moderate exacerbations/1 hospitalization

also consider ICS deescalation or switch if pneumonia , inapropriate original indication, or lack of response to ICS

40
Q

which drug within a class?

A

based on ..
therapy
cost/formulary
pt response
delivery device

41
Q

bronchdilators role in stable COPD

A

mainstay of COPD therapy

increase fev1 and or change spirometric values

alter smooth muscle tone; improvements in expiratory flow reflect widening of the airways (rather than elastic recoil)

improve emptying of lunfs, decrease hyperinflation

improve exercise performance

dose response curves are relatively flat (toxicity is dose related-

42
Q

ICS

A

for use inselect pts w. copd

relationship btw eos count in ICS effects

GOLD uses theeshold >/300 or >100+exacerbations) to predict probability of treatment beenfit

ics increases risk of pneumonia

asthma hx or features of asthma present? ics combo therapy indicated

43
Q

clinical outcomes

A

pharm therapy slow decline of fev1

saba/sama combo superior than either alone

lama has greater reduction in exacerbations vs laba

laba/lama reduce SS and exac, inc. outcomes, and red. hospitalizations better than when used alone

44
Q

Other copd treatments

A

ABX: infectious exacerbations , also macrolides can decrease exacerbation rate

mucolytics, antioxidants (guafenisin, carbocysteine, NAC reduce exacerbations and modestly improve health status

antitussives: regular use not recommended, due to cough having protective role in copd

45
Q

non pharm

A

A)smoking cessation: greatest capacity to influence natural history of copd

B)vaccinations:
*influenza dec. lower respiratory tract infections

pneumococcal vaccination dec lower resp. tract infections

tdap in those not vaccinated to rpevent pertussis

covid 19

C)pulmonary rehab

D) long term oxygen therapy: in pts. with severe resting chornic hypoxemia, long term oxygen therapy (15 hrs/dau) improves survivial.
*given when pao2< 55 mmhg or sao2 <88% or
*pao2>55 but <60mmhg (>7.3 pka but <8kpa)

given to bring sao2 </90

46
Q

monitoring for copd

A

annual spirometry testing

ask pts to mointor any changes in their symptoms(ie sleep, exercise ability, sob)

CAT or mMRC

smoking status

med side effects

adherence

disease progression and development of complications

47
Q

Define acute exacerbatino of copd

A

acute worsening of respiratory symptoms that results in additional therapy or medications

48
Q

acute cop exacerbATION patho

A

increased airway inflammation
increased mucus production

marked gas trapping

increased eosinophils in significant number of patients

pts w. longstanding copd retain co2, causing chronic respiratory acidosis. drive to breath is hypoxia. if overoxygenated, c an cause repsiratory depression, thats why o2 goal is 88-92%

49
Q

SS of acute COPD exacerbation

A

increased dyspnea

increased sputum purulence (change in color) and volume

increased cough and wheeze

Lasts about 7-10 days

50
Q

causes of acute copd exacerbations

A

in order
1. viral
*rhinoviruses
2.bacterial
3.fungal
4.other
*pollution
*ambient temp
*fine particulate matter exposure

51
Q

classifying COPD exacerpations

A

severity treatment
mild SABDs only
moderate SABDs+abx+/-oral cortico,
severe requires hospitalization or ED
visit +/- severe acute resp
failure

52
Q

initial assessmentfor acute copd exacerbation

A

hx: compare SS to baseline, severity of symptoms, subjective signs, smoking, O2

physical exam: vitals, conciousness , temp(fever, taCHYPNEA, tachycardia, o2 stat

resp exam: wheezing, coughing, decreased breath sounds

Labs
possbile ABG
WBC
K+, Mg (dependent on bronchodilator used), glucose (stoeroids
vit D. if severe definciency (<10 ng/ml or 25 nM…supplement
dx: sputum sample, gram stain/culture, chest xray

53
Q

non pharm Treatment of copd exacerbation

A

O2 sat: <90
goal sao2: 88-92%

ventilation: noninvensive mechanical ventilatioin(NIV)
intubation and mechanical ventilation

54
Q

pharm treatment acue copd brronchodilators

A

1)bronchodilators: Albuterol(A)(preffered), Ipratropium(I), A/I combo,
*A or I MDI1 puff inh Q1h 2-3 doses then 2 puffs Inh q 24-hrs

2)corticosteroids: predinosone 40 mg or equiv for 5 days

abx: treart for 5-7 days if moderately ill w. 3 cardinal signs or have 2 cardinal symptoms w. one being sputum purulence

oxygen supplementation: if sao2<90%.titrate to goal of 88-92%

home medications: adjust as needed

55
Q

cardinal symptoms indicating pharm treatmement with abx in acute copd exacerbation

A

dyspnea
increased sputum volume
increased sputum purulence

56
Q

abx treatment for acute copd exacerbation

A

organisms needing coverage: Hemophilus influenzae, stereptococcus pneumoniae, moraxella catarrhalis

options
Aminopenicillin/clavulanic acid (augmentin) 875 mg po BID or Unasyn 3gmIV q6h (renal elimination) for 5-7 days
*note. augmentin and unasyn must be renally dosed

macrolide-azithromycin 500 mg po dailyx3 days or 500 mgx1, then 250 mg days 2-5 days (can do 3 days due to long half life of upto 3 days)

a tetracycline-doxycycline 100 mg PO BID for 5-7 days

if risk for pseudamonas: cefepime, piperacillin/tazobactam, levofloxacin, carbapnem (hospotal antibiogram)

57
Q

other recommendations for acute copd exacerbations

A

smokkind cessation

immunizations (influenza, pneumococcoal, tdap (pertussis), covid 10

dvt prophylaxis

58
Q

medications not to use in acute copd exacerbations

A

IV/PO theophylline

chronic suppressive abx

59
Q

monitoring for acute copd exacerbations

A

copd control:

o2 sat, clinical symptoms, HR

physical exam (wheezing, accessory muscle use, cyanosis

medication efficacy/ toxicity
control of copd, as above
stroids : monitor WBC, glucose (daily), consider short acting insulin if needed
abx: wbc, neutrophils, temp, cultures, Scr,Crcl,eGFR (if renal elimination)
bronchodilators: HR, frequency of use(ATC v. PRN)

TXP: Pulm/ Tox. And Rheumatology (7 decks)

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