Week 2: COPD Flashcards
what is COPD
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
COPD etiology
etiology:
smokking and pollutants
patho: imopaired lung growth, accelerated decline,mlung injury, lung and systemic inflammation
—> small airway disorders (chronic bronchitis, emphysema), systemic effects
risk factors for copd development
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
clinical presentation of COPD
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
Dx of COPD
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
Pharm Treatment options for Chornic Stable COPD
Bronchodilators pearls
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
Pharm Treatment options for Chornic Stable COPD
beta 2 agonists
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:
Short Acting Beta Agonists(SABAs)
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
Long Acting Beta Agonists (LABAs)
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
Muscarinic antagonists considerations
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
Muscarinic antagonists
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
Long Acting Muscarinic Antagonists
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
Short acting bronchdilator combos
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
Long Acting Bronchodilator combos
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
Methylxanthines (Theophylline) use in COPD
less effective and less tolerated than LONG ACTING BRONCHdilators
not recommended if other agents are availabe
ICS use in COPD
only used in combo w. LABAs or LAMAs
not used as monotherapy
ICS/LABA combo products also side effects
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
oral glucocorticoids for copd
used in exacerbations
no role in chornic daily treatment. lack of benefit an dhigh risk of sysrtemic complicaitns
Tripple therapy inhaler
not first line treatment
Fluticasone furoate/ umeclidinium/ vilanterol (trekegy Ellipta)-DPI: 1 inhalation once daily
Budesonide/ glycopyrrolate/formoterol (Breztri Aerosphere: 2 inhalations twice daily
Roflumilast
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
Asthma-COPD overlap
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
asthma-copd overlap temrinology
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
COPD and asthma overlap outcomes
frequent exacerbations
poor QOL
more rapid decline in lung function
higher mortality
greater health care utilization
Asthma copd overlap (ACO) feautures
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
stepwise approach to dx and initial treatment of ACO via GINA and GOLD guidelines
- dx airway disease
yes:go to step 2
no: onsider other disease first - 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. - perform spirometry
- commence initial treatment:
notes: no LABA monotherapy in asthma pats.
no ICS monotherapy in COPD.
*ket: if ACO, initiate ICS or ICS bronchdilator combo.
goals of assessment for copd
determine the laevel of airflow limitation
determine impact on patients health status
determine risk for furture events (exacerbations, hospitalization, death)
to guide therapy
ABCD assessment tool general categories
Used for initial assessment of copd
1.Assess degree of airflow limitation
2. assess symptoms
3. assess risk of exacerbations
Assess degree of airflow limitation categories
and use considerations
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.
Assesment of symptoms categories
- 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
Assessment of Exacerbation Risk
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
assessment of exacerbation risk using exacerbation hx
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
ABCD essessment box categories
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
copd comorbidities
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
goals of therpay for stabled COPD
reduce symtoms
reduce disease progreesion, risk, exacerbatoins, and mortaility
goals of therpay for stabled COPD
reduce symtoms
reduce disease progreesion, risk, exacerbatoins, and mortaility
Summary of COPD management
selecting initial therapy
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
Initial Pharm Treatment based on category
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
Follow up Pharm treatment summary
- if response to initial treatment is appropriate,maintain it.
- 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.
Follow up pharm treartmnt for dyspnea
!!!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
Follow up treatment for exacerbations
!!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
which drug within a class?
based on ..
therapy
cost/formulary
pt response
delivery device
bronchdilators role in stable COPD
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-
ICS
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
clinical outcomes
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
Other copd treatments
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
non pharm
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
monitoring for copd
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
Define acute exacerbatino of copd
acute worsening of respiratory symptoms that results in additional therapy or medications
acute cop exacerbATION patho
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%
SS of acute COPD exacerbation
increased dyspnea
increased sputum purulence (change in color) and volume
increased cough and wheeze
Lasts about 7-10 days
causes of acute copd exacerbations
in order
1. viral
*rhinoviruses
2.bacterial
3.fungal
4.other
*pollution
*ambient temp
*fine particulate matter exposure
classifying COPD exacerpations
severity treatment
mild SABDs only
moderate SABDs+abx+/-oral cortico,
severe requires hospitalization or ED
visit +/- severe acute resp
failure
initial assessmentfor acute copd exacerbation
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
non pharm Treatment of copd exacerbation
O2 sat: <90
goal sao2: 88-92%
ventilation: noninvensive mechanical ventilatioin(NIV)
intubation and mechanical ventilation
pharm treatment acue copd brronchodilators
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
cardinal symptoms indicating pharm treatmement with abx in acute copd exacerbation
dyspnea
increased sputum volume
increased sputum purulence
abx treatment for acute copd exacerbation
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)
other recommendations for acute copd exacerbations
smokkind cessation
immunizations (influenza, pneumococcoal, tdap (pertussis), covid 10
dvt prophylaxis
medications not to use in acute copd exacerbations
IV/PO theophylline
chronic suppressive abx
monitoring for acute copd exacerbations
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)
