Week 7 Resp: Asthma & COPD Flashcards
An adolescent who has exercise-induced asthma (EIA) is on the high school track team and has recently begun to practice daily during the school week. The adolescent uses two puffs of albuterol via a metered-dose inhaler 20 minutes before exercise but reports decreased effectiveness since beginning daily practice. What will the primary care pediatric nurse practitioner do?
A Counsel the adolescent to decrease the number of practices each week
B Increase the albuterol to four puffs, 20 minutes prior to exercise
C Order a daily, inhaled corticosteroid medication
D Prescribe cromolyn sodium in addition to the albuterol
C Order a daily, inhaled corticosteroid medication
Children with EIA should use 2 puffs of a B2-agonist and/or cromolyn MDI 15 to 30 minutes prior to exercise, but, since tolerance may develop if a B2-agonist is used more than a few times a week, it should not be used as a controller monotherapy. Those who exercise regularly should use an ICS as a controller medication. Patients with asthma should be encouraged to exercise to improve overall health. Increasing the albuterol dose will not overcome the tolerance. And ICS is a preferred controller medication.
The primary care pediatric nurse practitioner is examining a school-age child who has had several hospitalizations for bronchitis and wheezing. The parent reports that the child has several coughing episodes associated with chest tightness each week and gets relief with an albuterol metered-dose inhaler. What will the nurse practitioner order?
A Allergy testing
B Chest radiography
C Spirometry testing
D Sweat chloride test
C Spirometry testing
Spirometry testing is the gold standard for diagnosing asthma and is then used on a regular basis to monitor, evaluate, and manage asthma. Allergy testing should be considered but is not diagnostic of asthma. Chest radiography should not be routine. A sweat chloride test is used based on history.
A school-age child who uses a short-acting beta2-agonist (SABA) and an inhaled corticosteroid medication is seen in the clinic for an acute asthma exacerbation. After four puffs of an inhaled, short-acting B2-agonist (SABA) every 20 minutes for three treatments, spirometry testing shows an FEV1 of 60% of the child’s personal best. What will the primary care pediatric nurse practitioner do next?
A Administer an oral corticosteroid and repeat the three treatments of the inhaled SABA
B Admit the child to the hospital for every two hour inhaled SABA and intravenous steroids
C Give the child 2 mg/kg of an oral corticosteroid and have the child taken to the emergency department
D Order an oral corticosteroid, continue the SABA every three to four hours, and follow closely
D Order an oral corticosteroid, continue the SABA every three to four hours, and follow closely
Children with an incomplete response (FEV1 between 40% and 69% of personal best) should be given oral steroids and instructed to continue the SABA every 3 to 4 hours with close follow-up. Hospitalization is not necessary unless severe distress occurs. An FEV1 less than 40% after treatment indicates a need to be seen in the ED.
A child who has been diagnosed with asthma for several years has been using a short-acting B2-agonist (SABA) to control symptoms. The primary care pediatric nurse practitioner learns that the child has recently begun using the SABA two or three times each week to treat wheezing and shortness of breath. The child currently has clear breath sounds and an FEV1 of 75% of personal best. What will the nurse practitioner do next?
A Add a daily inhaled corticosteroid
B Administer three SABA treatments
C Continue the current treatment
D Order an oral corticosteroid
A Add a daily inhaled corticosteroid
The child is showing a need to step up treatment based on the frequency of symptoms, greater than twice each week. The PNP should order an inhaled corticosteroid maintenance medication to control symptoms and reduce the need for a SABA. The child is not having an acute exacerbation, so does not need 3 SABA treatments. Oral corticosteroids are given for moderate obstruction
An adolescent who has asthma and severe perennial allergies has poor asthma control in spite of appropriate use of a short-acting beta2-agonist (SABA) and a daily high-dose inhaled corticosteroid. What will the primary care pediatric nurse practitioner do next to manage this child’s asthma?
A Consider daily oral corticosteroid administration
B Order an anticholinergic medication in conjunction with the current regimen
C Prescribe a LABA/inhaled corticosteroid combination medication
D Refer to a pulmonologist for omalizumab therapy
D Refer to a pulmonologist for omalizumab therapy
Children older than 12 years who have moderate to severe allergy-related asthma and who react to perennial allergens may benefit from omalizumab as a second-line treatment when symptoms are not controlled by ICSs. The PNP should refer children to a pulmonologist for such treatment. Daily oral corticosteroid medications are not recommended because of the adverse effects caused by prolonged use of this route. Anticholinergic medications are generally used for acute exacerbations during in-patient stays or in the ED. A LABA/ICS combination will not produce different results.
Which of the following exam findings can be seen in a patient with COPD?
A Increased tactile fremitus and a high-positioned diaphragm
B Decreased tactile fremitus and generalized hyperresonance to percussion
C Positive egophany and dullness to percussion
D Decreased AP to lateral diameter and adventitious sounds
B Decreased tactile fremitus and generalized hyperresonance to percussion
Patients with COPD may have low, flat diaphragm, decreased tactile fremitus and hyperresonance, increased AP to lateral diameter and adventitious sounds. Positive egophany and dullness are suggestive of consolidation or mass.
The nurse practitioner seeing a patient with dyspnea and cough considers asthma and COPD as differential diagnosis since symptoms often overlap. A diagnosis of COPD is favored if:
A Symptoms present earlier in life
B Airflow limitation is not reversible
C The patient has a productive cough
D The chest x-ray shows hyperinflation
B Airflow limitation is not reversible
Airflow limitation is largely reversible with asthma, and irreversible in COPD. COPD most often presents midlife with slowly progressive symptoms. Chest x-ray is not needed to diagnose asthma or COPD but may show hyperinflation with both conditions. Cough can occur with both asthma and COPD.
Which test is the most diagnostic for chronic obstructive pulmonary disease (COPD)?
A COPD Assessment Test
B Forced expiratory time maneuver
C Lung radiograph
D Spirometry for FVC and FEV1
D Spirometry for FVC and FEV1
Spirometry testing is the gold standard for diagnosis and assessment of COPD because it is reproducible and objective. The forced expiratory time maneuver is easy to perform in a clinic setting and is a good screening to indicate a need for confirmatory spirometry. Lung radiographs are non-specific but may indicate hyperexpansion of lungs. The COPD assessment test helps measure health status impairment in persons already diagnosed with COPD.
A patient diagnosed with chronic obstructive pulmonary disease reports daily symptoms of dyspnea and cough. Which of the following is an effective first line therapy?
A Anticholinergic or LAMA
B Inhaled corticosteroid
C Antibiotics
D Theophylline
A Anticholinergic or LAMA
Anticholinergic medication such as ipratropium is used as first-line therapy in patients with daily symptoms. Inhaled corticosteroids are used with LABA therapy in a step wise approach, especially in patients with stage 3 or 4 COPD. Antibiotics are used in an exacerbation. Theophylline is a third-line agent.
A patient with COPD has an FEV1 of 45%, a CAT score of 8, and 3 exacerbations in the past year. The patient’s COPD should be classified as:
A Stage 1, Group B
B Stage 2, Group B
C Stage 4, Group D
D Stage 3, Group C
D Stage 3, Group C
Stage 3 (severe COPD) the FEV1 is between 30-50% predicted with repeated exacerbations. Group C patient group are usually GOLD 3 or 4, more than 2 exacerbations in 1 yr or more than one with hospitalization and CAT score less than 10.
Grade: FEV1 % predicted GOLD 1: >/= 80 GOLD 2: 50-79 GOLD 3: 30-49 GOLD 4: < 30
Moderate/severe exacerbation hx/ Symptoms
Group A: 0 or 1 no hospitalization/ mMRC 0-1 or CAT < 10
Group B: 0 or 1 no hospitalization/mMRC >/=2 CAT >/=10
Group C:>2 or >1 w/ hospitalization/ mMRC 0-1 CAT < 10
Group D: >2 or >1 w/ hospitalization/ mMRC >/2 or CAT >/=10
Which is characteristic of obstructive bronchitis and not emphysema?
A Damage to the alveolar wall
B Destruction of alveolar architecture
C Mild alteration in lung tissue compliance
D Mismatch of ventilation and perfusion
C Mild alteration in lung tissue compliance
Obstructive bronchitis causes much less parenchymal damage than emphysema does, so there is milder alteration in lung tissue compliance. The other symptoms are characteristic of emphysema.
A 35-year-old woman with a long history of well-controlled asthma presents with worsening of her symptoms over the last month. She has been using fluticasone MDI 110 mcg twice per day faithfully for the last 2 years. Over the last month, she has had to use her rescue inhaler in the mornings 2 to 3 times per week. She does not smoke. Her medications include an oral contraceptive pill (OCP), a multivitamin, ibuprofen as needed, and propranolol (recently added for migraine prophylaxis).
What would you advise?
Recognize that medications for arthritis (NSAIDS), hypertension (beta-blockers), or glaucoma may exacerbate asthma. It may be helpful to stop her propranolol. If that is ineffective, reevaluate for environmental factors such as new exposures at work or a smoking roommate. Consider comorbid conditions or other diagnoses, such as allergic rhinitis, obesity, GERD, or OSA. Pulmonary embolus may also be a consideration as she is taking an OCP.
potential side effects of long-term ICS as controller medication in adults
decreased bone density
sub-scapular cataracts
skin bruising
glaucoma
adrenal suppression used as a marker for systemic absoprtion - occurs at doses of 1.5 mg/day for aLL ICS except fluticasone, which occurs at 0.75 mg/day
bone mineral density should be followed in older adults on high dose ICS, esp w/ other RF for osteoporosis
Ca and Vit D supp recc for pts taking ICS w/ RF for osteoporosis
potential side effects of long-term use of LABAs
small but statistically significatn increase in ashtma-related and pulmonary death in pts using salmeterol vs placebo , focused in young African americans , unclear patho
unclear if ICS protect agaisnt this risk
black box warning: LABAs should not be used w/o ICS and should probably be given trial of ICS alone first
differences in classification of children vs adults with asthma
Classification of asthma severity is more difficult in younger children. Therefore, criteria for diagnosis and initiation of controller medications have been developed using the number of times steroids have been prescribed and factors which would predispose the child to asthma.
differences in comorbidities of children vs adults with asthma
Both the differential and the most common comorbidities seen with these patient populations require different thought processes. For example, cystic fibrosis and BPD usually come to mind at some point while working up a young child with asthma. GERD should probably be higher on our list when treating both children and adults. Allergic symptoms probably have an even greater role in children than in adults (hence the more frequent use of LTRAs)
differences in tx of children vs adults in asthma
Step 3 for children under 5 years is medium-dose ICS. However, there is an option to introduce a LABA for step 3 with a low-dose ICS for all patients 5 years and older. Concerns regarding the safety and efficacy of LABAs, particularly in the youngest children, have limited the use of LABAs in this population.
differences in referral of children vs adults in asthma
In children under 5 years old, the 2007 guidelines recommend specialist referral for treatment steps 3 and up (treatment above medium-dose ICS). Referral is recommended for treatment steps 4 and up (medium-dose ICS + LABA) for those over 5 years old.
A 10-month-old girl is brought to primary care clinic for hospital follow-up. She was admitted one week ago for three days with the diagnosis of WARI (wheezing-associated with respiratory infection). She has no additional medical history and was born at term. In addition to her well-child checks, she has been seen on two other occasions for wheezing associated with colds. She received oral steroids at one of those visits. She now appears well and is in no distress. Mom reports that she has not needed to use her albuterol for the last two days. She took her last dose of oral prednisone today.
What is her diagnosis?
persistent asthma
At what point would you consider using a controller medication in managing 10-month old with asthma?
Young children may have little to no impairment on a daily basis but still be at high risk for severe exacerbations. Inhaled corticosteroids are recommended for long-term control therapy if:
• 4 wheezing episodes in a year affecting sleep and lasting more than 1 day and who have a positive asthma risk profile**
• 2 or more exacerbations requiring oral corticosteroids in the last 6 months
• the child requires more than 2 doses of short-acting bronchodilator per week for more than 4 weeks
**Positive asthma profile:
• One or more of the following: atopic dermatitis, sensitization to aeroallergen, parental history of asthma;
or
• Two or more of the following: wheezing apart from colds, more than 4% blood eosinophilia, food sensitization.
You decide to prescribe a controller medication in the 10 month old girl with asthma. Her mother is concerned about giving long-term medications to a child this young.
What would you prescribe?
What are the risks and benefits of controller medications in young children?
Budesonide is the only inhaled glucocorticoid that is FDA approved for children under 4 years old, but others such as fluticasone and beclomethasone are also frequently used. Although budesonide is approved for children over 1 year old, efficacy has been proven even in infancy in preventing recurrent wheezing. Budesonide tends to be the most expensive; beclomethasone is the least expensive.
Both asthma itself and repeated doses of oral corticosteroids are associated with growth suppression and delayed puberty. In general, ICSs are safe in adults and children of all ages. Primary concerns include linear growth and bone density. Dose related, short-term decreases in growth velocity have been observed with ICSs in the first 2 years of therapy.
Would you use a nebulizer or a metered dose inhaler (MDI) in the 10 month old with asthma?
Certainly, it is difficult for most children under the age of 5 to coordinate their breathing with a metered-dose inhaler (MDI). Traditionally, nebulizers have been used for young children, but recent data have shown a spacer (one-way valve) with a mask to be equally effective in delivering SABAs in mild to moderate asthma exacerbations. The most important point to make is proper technique with any delivery system. Masks should fit tightly. If a spacer is used, 3 to 4 breaths with each MDI activation should be attempted. If a nebulizer is used, a mouthpiece is preferred. If using a mouthpiece is not possible (as in young children), the mask should fit snugly over the mouth and nose. Holding it 1 cm away reduces the dose by 50%, 2 cm reduces it by 80%.
What can be done to minimize medication side effects in the 10 month old girl with asthma?
If the child does not have a measurable response in 4 to 5 weeks, discontinue the medication and consider other diagnoses.
If a child does have a measurable response sustained for 3 months, consider stepping down treatment to a lower dose.
Children have a high rate of remission. More efficient delivery of medication to the lungs (as opposed to the mouth or the room) minimizes the dose needed. Therefore, the use of spacers and masks and instructions to keep nebulizer masks on the patient’s face are helpful.
Instruct patients who are old enough to coordinate their breathing with the MDI.
Have patients rinse their mouths out after use to minimize the risk of thrush and systemic absorption.
Wash the face off after nebulizer treatments to minimize effects on skin.
Dry-powder inhalers may minimize cough, throat irritation, and dysphonia if these are present.
An 8-year-old boy presents to primary care clinic with nighttime cough. On further questioning, his mother did notice this at times when he was younger, but it seemed to go away within a day or two. It now wakes him from sleep at least once a week. He sometimes has difficulty breathing when he runs, but this has been attributed to his being a little overweight in the past. On physical exam, his lungs are clear, and he is in no distress. His BMI is 21 kg/m2. Nasal mucosa is hyperemic and bluish. Chest x-ray reveals slightly hyperinflated lungs.
Does this patient have asthma?
To confirm the diagnosis of asthma, you ideally need information from spirometry. The hallmark of asthma is episodic symptoms of airway obstruction with or without hyper-responsiveness (cough, wheezing, chest tightness). This obstruction is as least partially reversible on spirometry (10%-12%). Often, these symptoms are worse at night. In fact, they may be present only at night or with exercise, particularly in children. In general, triggers can be identified such as respiratory infections, dust, smoke, air pollution, stress, menstrual cycles, changes in weather, or exercise.
What other diagnoses would you consider in the 8 year old boy w/ nighttime cough?
Ddx
allergic rhinitis, sinusitis, vocal cord dysfunction, cystic fibrosis, vascular slings, laryngotracheomalacia, foreign body, heart failure, gastroesophageal reflux, obstructive sleep apnea (OSA), and bronchopulmonary dysplasia (BPD).
In adults, the differential may also include chronic obstructive pulmonary disease (COPD), bronchiolitis obliterans (BOOP), medication-related cough (such as with an angiotensin-converting enzyme inhibitor), malignancy, or chronic pulmonary embolism.
Although history and physical exam are critically important, they may not be able to completely separate a diagnosis of asthma from other possible diagnoses. Chest x-ray can be helpful. Spirometry (showing obstruction and reversibility) is required for the diagnosis in patients older than 5 years old. It should be repeated every 1 to 2 years.
The 8 year old boy with nighttime symptoms twice a week has a Spirometry that shows FEV1 of 85% and FEV/FVC of 85%, which improves with short-acting bronchodilator treatment.
How severe is the asthma?
The first step in treating asthma is determining its severity at baseline, or intrinsic disease activity (NAEPP Guidelines, 40). Since he has nighttime symptoms more than once a week, he has moderate persistent asthma, although his lung function falls into the mild category.
The guidelines emphasize both impairment (the frequency and severity of symptoms) and risk (of future exacerbations, lung growth or damage, medication risks).1 So, if a child has more than 2 exacerbations in 6 months (if younger than 5 years old) or in 12 months (if older than 5 years old) but does not have daytime or nighttime impairment, he is still characterized as having persistent asthma. Lung function is included in the 5- to 11-year-old criteria but not in younger children.
The primary differences in classifying the younger and older ages are inclusion of lung function, classification of exacerbation frequency, and nighttime awakenings.
How should the 8 year old boy with moderate persistent asthma be treated? In addition to medication, what else should treatment include?
The treatment of asthma should be approached in a stepwise approach (NAEPP Guidelines, 42) from step 1 (occasional use of SABAs) to step 6 (high-dose ICS + LABA + oral steroids). He should be treated with medium-dose ICSs. A low-dose ICS with LABA is an equally acceptable option if the patient has failed ICS treatment alone previously. Alternative therapy includes low-dose ICS with either LTRA or theophylline. In addition to initiation of medication, there are three additional factors that should be addressed: environmental control, comorbid conditions, and patient education
environmental control tx for asthma
Planning with family to minimize known triggers such as: inhalant allergens or irritants, tobacco exposure, dust mites, animal dander, cockroaches, and mold. Other triggers may include medications (aspirin or NSAIDS), cold air, physical activity, and sulfites in foods (wine or beer, dried fruit, potato flakes).1 Food allergens other than sulfites are rarely associated with asthma exacerbations. However, patients with known food allergy and asthma are at increased risk for fatal anaphylaxis when exposed to the food allergen.
comorbid conditions with asthma that need to be addressed
sinusitis, rhinitis, gastroesophageal reflux disease (GERD), obstructive sleep apnea (OSA), obesity, stress, and depression.
education on asthma
should be tailored to the patient’s age as well as health literacy of caregivers to promote a partnership in care, including them in creating an action plan. This should include self-monitoring of symptoms (symptom or peak flow monitoring), avoidance of triggers, administration of medications, and a written asthma action plan. Peak flow monitoring may be more helpful in patients who have difficulty perceiving symptoms (ie, moderate to severe disease or history of severe exacerbations).
The 8 year old boy with moderate persistent asthma is prescribed a medium-dose ICS and have him return in 6 weeks. He continues to have a night-time cough, though it has decreased in frequency to twice per month. He is using his albuterol prior to football practice but feels some chest tightness about halfway through practices. He has not noticed any side effects of his inhalers.
Is his asthma well controlled?
His asthma is not well controlled (NAEPP Guidelines, 53). He is still waking more than once a month at night and has some limitations in activity. Treatment with SABAs immediately before exertion usually prevents exercise-induced bronchospasm (EIB). However, if significant limitations still exist, a step-up in therapy may be needed.
The goal of asthma therapy is asthma control. This means reducing impairment (prevent chronic symptoms, require infrequent use of SABAs, maintain nearly normal lung function and normal activity levels) and reducing risk (prevent exacerbations, minimize need for emergency care or hospitalization, have minimal or no adverse effects of therapy, prevent loss of lung function; or for children, prevent reduced lung growth).
How will you adjust the 8 year old boys therapy who is not well controlled on a medium-dose ICS and albuterol?
Before stepping up his medication regimen, evaluate his compliance with medications, inhaler technique, and environmental control. Screen for other comorbid conditions. Does he have symptoms of sleep apnea? GERD is common in patients with nighttime symptoms, even if they do not have common symptoms of heartburn. You may want to consider behavioral approaches (avoiding fatty or spicy foods, elevating head of bed, not eating within three hours of going to bed) or medical treatment for GERD.
After addressing the above, consider a step-up in therapy. In this case, consider switching to a medium-dose ICS plus LABA. An alternative therapy would be a medium-dose ICS plus either LTRA or theophylline.
When would you consider specialist referral in pt with asthma?
The NAEPP Guidelines recommend consideration of referral for any of the following reasons:
• recent hospitalization or life-threatening exacerbation
• additional testing is indicated (skin testing, bronchoscopy)
• complex medication regimen
• consideration of immunotherapy
• complicating comorbidities (such as OSA)
• more than two exacerbations in a year requiring oral corticosteroids
• difficult-to-control asthma
What is the duration of action for a short-acting beta-agonist (SABA) such as albuterol for the treatment of an acute asthma exacerbation?
A, 5 to 15 minutes
B. 30 to 60 minutes
C. 1 to 2 hours
D. 3 to 4 hours
D. 3 to 4 hours
The onset of action for a short-acting beta-agonist (SABA) such as albuterol is 15 minutes. The duration of action for a SABA is 3 to 4 hours.
Which of the following medications has been shown to reduce asthma symptoms, improve lung function, decrease airway inflammation, and reduce the frequency and severity of asthma exacerbations?
A. Inhaled corticosteroids
B. Short-acting beta-agonist (SABA)
C. Long-acting beta-agonist (LABA)
D. Leukotriene receptor antagonist
A. Inhaled corticosteroids
What is the onset of action for a SABA such as albuterol for the treatment of an acute asthma exacerbation?
A. 5 to 15 minutes
B. 30 to 60 minutes
C. 1.5 to 2 hours
D. 3 to 4 hours
A. 5 to 15 minutes
The onset of action for a SABA such as albuterol is 15 minutes. The duration of action for a SABA is 3 to 4 hours.
A 56-year-old female presents to primary care clinic to establish care. She has no past medical history and takes no medications. She has a 40 pack-year history of ongoing tobacco use but denies any current symptoms of COPD (specifically cough, chronic sputum production, and dyspnea). She wishes to be screened for COPD as her father was diagnosed with COPD in his 60s and died of COPD in his late 80s.
What other risk factors for COPD should you inquire about?
Advanced Age
Genetic Predisposition ( alpha-1-antitrypsin deficiency)
Smoking and exposure to environmental tobacco (primary)
Influenza and pneumonia
Malnutrition/obesity
Insufficient physical activity
Presence of comorbidities
Occupational hazards
Should the 56 year old women asking to be screened for COPD be screened for COPD? If so, using what modality?
Yes, she should be screened for COPD, Spirometry
CXR for initial screening/diagnosis (used to confirm hyperinflation or can see bullae)
Chest CT - can be used to rule out malignancy
Lab - screening for genetic disorder alpha-1-antitrypsin deficiency
Six minute walk test
What should you do for the 56 year old women patient today regarding her COPD risk?
Classify her COPD based on spirometry and symptoms
Encourage smoking cessation
Encourage increased exercise
The 56 year old female smoker returns 4 years later at age 60 after being lost to follow-up. She has continued to smoke 1 ppd. Now, she has dyspnea on exertion that has been slowly progressive over the last 6 months and a cough with scant sputum production in the morning.
What evaluation is warranted at this time and what are you specifically looking for (including physical exam, labs, and diagnostic testing)?
On physical exam, one should look for evidence of hyperresonance, hyperinflation, hypoxia (with pulse oximetry and evaluation for cyanosis), and evaluation for evidence of cor pulmonale.
. A complete blood count (CBC) should be obtained to evaluate for anemia or polycythemia, and an arterial blood gas (ABG) can be considered as well. An evaluation for alpha-1 antitrypsin should be undertaken in Caucasian patients less than 45 years old with COPD, especially those with little or no toxin exposure, or in patients with COPD who do not respond to therapy. In addition, chest x-ray should be obtained
Ddx for COPD
- Asthma
- Congestive heart failure (CHF)
- Bronchiectasis
- Interstitial lung disease
- Pulmonary fibrosis
- Tuberculosis
What are the diagnostic criteria for COPD severity based on spirometry?
Classifying Severity by Spirometry:
Stage I: Mild
FEV1 ≥ 80% of predicted
Usually, not always, chronic cough and sputum production. At this stage the individual may not be aware that their lung function is abnormal.
Stage II: Moderate
FEV1 50–79% of predicted
Worsening airflow limitation and usually a progression of symptoms, with SOB w/exertion.
Stage III: Severe
FEV1 30–49% of predicted
Further worsening airflow limitation, increase SOB with repeated exacerbations that have an impact on QoL.
Stage IV: Very Severe
FEV1 < 30% of predicted, or
FEV1 < 50% of predicted plus chronic respiratory failure present
Severe airflow limitation plus chronic respiratory failure. QoL is very impaired and exacerbations can be life threatening.
What are the goals of management for COPD?
Reduce symptoms- Control cough and secretions and improve quality of life. Decrease exacerbations
Reverse or reduce airflow obstruction
Prevent and eliminate infections
Maximize exercise tolerance/ maximize lung function
Promote smoking cessation
Control complications- Polycythemia, hypoxemia, R sided heart failure
The now 60 year old female has a pulse oximetry of 96% at rest and 92% with exertion. CBC is normal, and chest x-ray shows evidence of hyperinflation. Her spirometry results include an FEV1/FVC ratio of 0.6 and FEV1 55% of predicted
What therapy should be offered at this time?
smoking cessation should be emphasized
Influenza and pneumococcal vaccines should be given
Pulmonary rehabilitation should be considered for symptom control and quality of life
For this patient, pharmacotherapy should include long-acting bronchodilators and short-acting agents for rescue.
Inhaled steroids confer no mortality benefit but may improve symptoms and decrease exacerbations. These medications should be considered in patients with frequent or repeated exacerbations but are not currently indicated in this patient.
The now 60 year old female patient is started on salmeterol to be used twice daily and albuterol as a rescue inhaler. Two months later, she calls the office with 2 days of increased sputum volume and purulence along with increased dyspnea. She has had no fever, chills but has upper respiratory infection symptoms and a sick granddaughter at home. In the office, she is tachypneic and dyspneic but no in acute respiratory distress. She has bilateral end-expiratory wheezing and moderate air movement.
What do you do?
A chest x-ray, CBC, and basic metabolic panel (BMP) are indicated to evaluate for other etiologies of her dyspnea and for a possible pneumonia. Pulse oximetry should be measured and oxygen provided with a goal saturation of 90% to 92%
She is started on salmeterol to be used twice daily and albuterol as a rescue inhaler. Two months later, she calls the office with 2 days of increased sputum volume and purulence along with increased dyspnea. She has had no fever, chills but has upper respiratory infection symptoms and a sick granddaughter at home. In the office, she is tachypneic and dyspneic but no in acute respiratory distress. She has bilateral end-expiratory wheezing and moderate air movement.
Does she meet criteria for an acute COPD exacerbation and why?
Yes, the 3 cardinal symptoms of an exacerbation include increased dyspnea, increased sputum volume, and increased sputum purulence. She meets all 3 and has at least a moderate COPD exacerbation.
How should the 60 year old females COPD exacerbation be managed?
Treatment for COPD exacerbations should include oral steroids (40 mg daily for 5 days), increased frequency of bronchodilators (beta-agonists and/or anticholinergics—neither class has proven superior) and a short course of oral antibiotics.
Antibiotic Guidlines:
Group A: Mild exacerbation and no risk for poor outcome
B-lactam
Tetracycline
Bactrim
Group B: Moderate exacerbation and risk for poor outcome
B-lactam/B-lactamase inhibitor (augmentin)
Group C: Severe exacerbation and risk for P. Aeruginosa infection
Fluoroquinolones
Which of the following tests is used to assess the severity of chronic obstructive pulmonary disease (COPD)?
A. Chest x-ray
B. Chest CT
C. Spirometry
D. Arterial blood gas
C. Spirometry
Spirometry is used to quantify the severity of COPD, and should be used when making the initial diagnosis. Chest x-ray or chest CT may be helpful during the initial diagnosis of COPD, if diagnosis is uncertain, or during acute exacerbations but are not used to quantify the severity of COPD. Arterial blood gas may be helpful in assessing the degree of hypoxemia or hypercapnia associated with chronic COPD, but is not used to assess the severity of COPD.
Which of the following interventions has shown an increase in survival in patients with severe COPD?
A. Inhaled corticosteroids
B. Long-acting beta2 adrenergic agonists
C. Long-acting anticholinergic agents
D. Oxygen
D. Oxygen
Oxygen use in patients with severe COPD and persistent hypoxemia improves survival. Long-acting bronchodilators including long-acting beta2 adrenergic agonists (eg, salmeterol, formoterol) and long-acting anticholinergics (tiotropium) have been shown to decrease the risk of COPD exacerbation by 15% to 20% but have not been shown to increase survival in patients with severe COPD. Inhaled corticosteroids (eg, fluticasone, beclomethasone) have also been shown to decrease the risk of COPD exacerbation, but have not been shown to improve survival.
A 60-year-old man has spirometry testing that shows FEV1:FVC (forced expiratory volume in the first second of expiration / forced vital capacity) less than 0.7 as well as FEV1 45% of predicted value. What stage of COPD does he have?
A. Stage 1 (mild) COPD
B. Stage 2 (moderate) COPD
C. Stage 3 (severe) COPD
D. This patient does not have COPD
C. Stage 3 (severe) COPD
Patients with COPD have airflow obstruction which is defined as the FEV1 to FVC ratio of less than 0.7 after bronchodilator administration. Patients with FEV1 greater than or equal to 80% of predicted value have stage 1 (mild) COPD. Patients with FEV1 50% to 79% of predicted value have stage 2 (moderate) COPD. Patients with FEV1 30% to 49% of predicted value have stage 3 (severe) COPD. Patients with FEV1 less than 30% of predicted value or FEV1 less than 50% of predicted value plus chronic respiratory failure have stage 4 (very severe) COPD.
A 72-year-old man with chronic obstructive pulmonary disease (COPD) presents to the emergency department with progressively worsening shortness of breath. Using 2 L/min of oxygen at home, he is usually able to walk around the house without limitation. Over the past 4 days, however, he has had increasing dyspnea on exertion and increased cough productive of thick green sputum. He has not had chest pain or worsening of his chronic mild ankle edema. He has smoked two packs of cigarettes daily for the past 50 years. Previous pulmonary function tests (PFTs) demonstrated a decreased forced expiratory volume in 1 second (FEV1) of 35% and FEV1/FVC (forced vital capacity) ratio of less than 0.70. Physical examination shows tachycardia, tachypnea, and decreased breath sounds with diffuse wheezing bilaterally. Arterial blood gas (ABG) analysis shows acidemia from a partially compensated respiratory acidosis. He is placed on noninvasive positive-pressure ventilation with marked improvement of his acidemia. This is the patient’s second hospitalization this year for COPD.
What are the important features in the patient’s history that suggest an exacerbation?
Increased productive cough
dyspnea on exertion
thick green sputum
respiratory distress
A 72-year-old man with chronic obstructive pulmonary disease (COPD) presents to the emergency department with progressively worsening shortness of breath. Using 2 L/min of oxygen at home, he is usually able to walk around the house without limitation. Over the past 4 days, however, he has had increasing dyspnea on exertion and increased cough productive of thick green sputum. He has not had chest pain or worsening of his chronic mild ankle edema. He has smoked two packs of cigarettes daily for the past 50 years. Previous pulmonary function tests (PFTs) demonstrated a decreased forced expiratory volume in 1 second (FEV1) of 35% and FEV1/FVC (forced vital capacity) ratio of less than 0.70. Physical examination shows tachycardia, tachypnea, and decreased breath sounds with diffuse wheezing bilaterally. Arterial blood gas (ABG) analysis shows acidemia from a partially compensated respiratory acidosis. He is placed on noninvasive positive-pressure ventilation with marked improvement of his acidemia. This is the patient’s second hospitalization this year for COPD.
You are seeing this patient for follow up in primary care after his discharge from the ED and he has recovered to baseline.
What interventions will you discuss with the patient that will decrease his risk of future exacerbations?
Based on the information provided above, how would you classify his COPD and what should be included in his pharmacologic management?
STOP SMOKING
Classified as Severe COPD
Pharmacologics: SABA PRN, supplemental O2 to SpO2 of 90%, Symbicort 160/4.5 BID
During your physical exam on the 72 year old man with COPD, you note that the patient has chronic mild ankle edema and elevated JVD.
What complication do you suspect?
CHF
Cor Pulmonale
When diagnosing a patient with COPD, what are some expected findings in the patient’s history, exam and diagnostic testing?
Expected findings with COPD: shortness of breath, wheezing, chest tightness, chronic cough with sputum that may be green/white/or clear, fatigue, swelling in ankles. The patient is likely a smoker or has a history of severe asthma.
Diagnostic testing: Pulmonary function testing, chest x ray, CT scan to detect possible emphysema, arterial blood gas
emphysema vs chronic bronchitis
Emphysema: decreased mental alertness, minimal cyanosis, thin frame due to inc work of breathing, pursed lip breathing, barrel chest
Vs.
Chronic bronchitis: excessive mucus production, cough, fever, symptoms may come and go, edematous or overweight (“blue bloaters”), dusky or cyanotic in appearance
ddx of COPD
TB bronchitis pulmonary HTN pneumonia bronchiectasis asthma CHF covid PE
What are the laboratory and imaging findings in chronic obstructive pulmonary disease in the various stages and during an exacerbation?
PFTs, CXR (bullae, decreased parenchymal markings, hyperlucency), ABG during exacerbations,
Pulse OX, CMP (sodium retention), CBC (mild polycythemia), BNP, EKG
COPD tx
Offer smoking cessation meds/tools
SABAs, Anticholinergics, LABAs (alone or in combo with anticholinergic), ICS, Methylxanthines
Exacerbations (outpatient): Bronchodilators (7-days), oral steroids (5 or 7-day burst), PRN O2
- Antibiotics if increased purulence of sputum or if requiring mechanical ventilation
- B-lactam, Tetracycline, Bactrim, Augmentin, Fluoroquinolones–depending on severity of exacerbation
What is included in the criteria for supplemental oxygen use?
A. An oxygen saturation of less than 88% on room air
B. The presence of hypoxia and hypercapnia
C. The patient has a persistent cough and sputum production
D. An oxygen desaturation to less than 90% during exercise
A. An oxygen saturation of less than 88% on room air
Which of the following abnormalities on a CBC are a result of severe COPD?
A. Elevated hematocrit
B. Low platelet count
C. Low white blood cell count
D. Elevated CO2
A. Elevated hematocrit
It is important to note O2 therapy can reduce polycythemia
A child with asthma has wheezing throughout expiration, a prolonged expiratory phase, decreased breath sounds at the base and intercostal retractions on physical assessment. Based on the exam, the child’s asthma severity is
A. Mild
B. Moderate
C. Severe
D. Impending respiratory arrest
B. Moderate
Which of the following slows the progression of COPD in smokers, outside of smoking cessation?
a. Making sure the environment is free of all pollutants
b. Eliminating all pets from the environment
c. Engaging in moderate to high levels of physical activity
d. Remaining indoors with air conditioning as much as possible
c. Engaging in moderate to high levels of physical activity
Which statement about COPD is true?
a. The prevalence of COPD is directly related to increasing age
b. The incidence of COPD is about equal in men and in women.
c. Cigar or pipe smoking does not increase risk of COPD
d. Environmental factors such as smoke do not affect the potential for COPD
a. The prevalence of COPD is directly related to increasing age
“Good control” of asthma is measured by the number of times weekly a patient uses a rescue inhaler. What choice below indicates “good control”?
a. Six times monthly at nighttime
b. Once weekly
c. Three times weekly
d. Not more
b. Once weekly
Your patient (49 yo) has daily symptoms of asthma. They use their inhaled short-acting beta-2 agonist daily. The exacerbations affect activities, and they occur at least twice weekly and may last for days. They are affected more than once weekly during the night with an exacerbation. Which category of asthma severity is this?
a. Mild intermittent
b. Mild persistent
c. Moderate persistent
d. Severe persistent
c. Moderate persistent
Evidence-based practice has shown that patients with COPD will benefit the most from which of the following modalities?
a. Nutritional supplementation
b. Routine use of inspiratory muscle training
c. Pulmonary rehabilitation
d. Psychosocial interventions
c. Pulmonary rehabilitation
In trying to establish differences between chronic bronchitis and emphysema, you know that chronic bronchitis
a. Usually occurs after age 50 and has insidious progressive dyspnea
b. Usually presents with a cough that is mild and with scant, clear sputum, if any
c. Presents with adventitious sounds, wheezing and rhonchi, and a normal percussion note
d. Results in an increased total lung capacity with a markedly increased residual volume.
c. Presents with adventitious sounds, wheezing and rhonchi, and a normal percussion note
asthma S/S
hallamark = episodic wheezing associated with dyspnea, cough, and sputum production
Cough, wheeze, SOB, chest tightness, soreness
Between episodes, symptoms improve or completely resolve
exercise-induced asthma (EIB)
airway obstruction after exercise
symptoms begin 5- 10 mins after completion of exercise and resolve in 1- 4hours
premedicate 5 to 20 mins before exercise with 2 puffs of SABA, effect lasts up to 4 hours
intermittent asthma
symptoms = 2 days week nighttime awakenings = 2 times/month SABA used < 2/=days week no effect on normal activity normal FEV1 between exacerbations; FEV1 > 80% of predicted FEV1/FVC normal
mild persistent asthma
symptoms > 2 days/week but NOT daily nighttime awakenings 3-4x month SABA used > 2 days/week, but not daily and not more than once any day minor limitation on normal activity FEV1 > 80% of predicted FEV1/FVC normal
moderate persistent asthma
daily symptoms nighttime awakenings > once a week but not nightly SABA used daily some limitation on normal activity FEV1 > 60% but < 80% of predicted FEV1/FVC reduced 5%
severe persistent asthma
symptoms throughout the day nighttime awakenings often 7x/week SABA used several times/day severe limitation on normal activity FEV1 < 60% of predicted FEV1/FVC reduced > 5%
peak flow meter use
used for monitoring, not diagnosis
helps patients follow course of dx, predict exacerbations, identify triggers, and assess response to tx
During expiration, patient is to blow hard using spirometer 3 times, the highest value is recorded (personal best)
PEF based on height, age, and gender
confirm asthma dx
spirometry recommended at initial assessment to confirm dx
results consistent with asthma include an increase in FEV1 12% or greater from baseline post SABA use
determine FEV1, then administer SABA (albuterol)
repeat spirometry, signs of reversible obstruction = asthma (FEV1 will improvement & clinical improvement)
when do to spirometry in asthma pt
initial assessment to confirm dx
after tx initiated and symptoms and PEF have been stabilized
at least every 1-2 years
asthma diagnostics
spirometry peak flow measurements airway responsiveness testing pulse ox ABGs CBC if ? infection routine CXR NOT recommended allergy eval - elevated IgE levels sweat test r/o cystic fibrosis sputum culture if ? infection ECG during exacerbation w/ tachycardia, not routine
non-pharmacological management of asthma
smoking cessation avoid second hand smoke physical activity remove occupational irritants avoid environmental triggers No beta blockers or NSAIDs yearly influenza vaccine tx rhinitis, sinusitis, GERD or other comorbidities/triggers
pharmacological management of asthma
stepwise approach recommended and meds are “stepped up” or “stepped down” depending on symptoms
intermittent asthma initial tx recommendation
Step 1 (symptoms less than 2x month)
SABA PRN
mild persistent asthma initial tx recommendation
Step 2 (symptoms 2x a month or more, but less than daily) SABA PRN + Low-dose ICS
moderate persistent asthma initial tx recommendation
Step 3 (symptoms most days, or waking 1x/week) reliever med: low-dose ICS/formoterol or SABA PRN Preferred controller choice: low-dose ICS/LABA Other controllers: medium/high dose ICS + LTRA
Severe persistent asthma initial tx recommendation
step 4 (symptoms most days, waking w/ asthma 1x/week or more, low lung function) Reliever med: low-dose ICS/formoterol or SABA PRN Preferred controller: medium/high dose ICS/LABA
seasonal allergic asthma tx
start ICS immediately upon onset of symptoms and DC using 4 weeks after exposure ends
step 5 asthma tx
symptoms most days or waking with asthma 1x/week or more, low lung function
consult
when to “step down” asthma tx
if symptoms improve and well controlled for at least 3 months and lung function has plateaued as evidence by FEV1 or PEFR may “step down”
well-controlled asthma
in the past 4 weeks the patient has had NONE of the following:
- day time symptoms more than 2x week
- night time awakening d/t asthma
- reliever med needed more than 2x/week
- activity limitation
symptoms and use SABA < 2 days/ week
partly controlled asthma
in the past 4 weeks the patient has had 1-2 of the following:
- day time symptoms more than 2x week
- night time awakening d/t asthma
- reliever med needed more than 2x/week
- activity limitation
uncontrolled asthma
in the past 4 weeks the patient has had 3-4 of the following:
- day time symptoms more than 2x week
- night time awakening d/t asthma
- reliever med needed more than 2x/week
- activity limitation
assessment of RF for asthma control
assess RF at diagnosis and periodically every 1-2 years
measure FEV1 at start of tx, after 3-6 months of controller tx to record “personal best”, then periodically for ongoing assessment
RF for poor asthma outcomes
increase risk of exacerbations:
- ICS not prescribed, poor adherence, or incorrect inhaler technique
- high SABA use
- low FEV1, especially if <60% predicted
- higher bronchodilator reversibility
- psychological or socioeconomic problems
- exposures: smoking, allergens
- comorbidities: obesity, chronic rhinosinusiitis, confirmed food allergy
- sputum or blood eosinophilia
- pregnancy
- ever being intubated on in ICU for asthma
- 1 or more exacerbation in last 12 months
green zone
PEF 80%- 100%
reflects good asthma control and it’s safe to proceed
continue daily controller meds
yellow zone
Caution
PEF 50%- 80%
symptoms that interfere with daily activities may be present: cough, wheeze, chest tightness, SOB, nocturnal awakening, exposure ot known triggers
continue green zone meds and add or increase dose
red zone
Danger zone = emergent tx
PEF < 50% and dyspnea
Immediate use of inhaled rescue bronchodilator therapy (SABA w/ MDI, spacer, or nebulizer) and initiating or increasing oral corticosteroid therapy are necessary
follow up visit frequency in asthma
after initial dx 2-4 weeks
follow up every 1- 3 months after starting tx
every 3- 12 months after that
pregnancy - visits evert 4- 6 weeks
asthma meds safe in pregnancy
b2-adrenergic agonists (albuterol)
if antiinflammatory meds required - budesonide or cromolyn considered relatively safe
zafirlukast (leukotrine modifier)
inhaled glucocorticoids
budesonide
flunisolide
fluticasone propinate
mometasone furoate
leukotriene modifiers
montelukast
zafirlukast
zikeuton
SABA
albuterol
levalbuterol
drug of choice for all age groups to relive acute asthma symptoms including bronchoconstriction and to prevent exercise-induced bronchoconstriction
LABA
aclindinium bromide arformoterol formoterol indacaterol salmeterol
ALWAYS use with an ICS in asthma tx
used alone increase risk of death from asthma
anticholinergics
ipratropium
tritropium
What does peak flow measure?
a. exercise capacity
b. oxygen saturation
c. peak flow capacity
d. expiratory flow
d. expiratory flow
measures peak expiratory flow (air flow out of patient’s lungs). peak flow is sensitive to changes in respiratory tubules and so reflects narrowing of the airways. The utility of a peak flow meter is especially important for patients with asthma bc of their rapid changes that occur prior to an asthma exacerbation. There is little to no benefit of measuring these changes in pts with COPD/PNA
What drug class is never to be used to tx COPD?
a. long acting bronchodilator
b. long acting anticholinergic
c. leukotriene blockers
d. systemic steroids
c. leukotriene blockers
There is no data to suggest their efficacy in treating COPD.
LABAs (salmeterol) is commonly sed
long-acting anticholinergic (tritopium) can be used once daily
systemic steroids used frequently in exacerbations
Mild persistent asthma is characterized by:
A. limitation in activity d/t bronchoconstriction
B. symptoms occurring more than 2x/week
C. wheezing/coughing during exacerbations
D. SOB with exercise
B. symptoms occurring more than 2x/week
mild persistent asthma is characterized by symptoms that occur more than 2x/week but not daily or 3-4 nocturnal awakenings per month d/t asthma
It is treated with inhaled steroid daily and a bronchodilator PRN for exacerbations
if symptoms occur more than 2x/week, therapy should be stepped up
Generally a long-acting bronchodilator is added to steroid when therapy is stepped up
A pt with COPD as been using albuterol with good relief for SOB. He is using it 3-4x daily over the past 4 weeks. How should the NP manage this?
A. encourage its use
B. add a LABA
C. tell him to use it only once daily
D. add an oral steroid
B. add a LABA
The pt is taking the albuterol too frequently, it should be used no more than 2x/week bc it will lose its effectiveness over time (tachyphylaxis)
Albuterol should be used as a rescue med ONLY
The pts med regimen needs adjusting. The best choice is to consider adding a LABA or long acting inhaled anticholinergic and have him use the albuterol as a rescue inhaler only
Step up therapy
1st - SABA as rescue inhaler
2nd - low dose ICS if using SABA too often
3rd - ICS/LABA or medium strength steroid if not enough
4th - medium strength ICS w/ LABA
5th - high potency ICS w/ LABA
6th - when in exacerbation oral corticosteroids
asthma exacerbation “asthma attack” S/S
severe wheezing, inspiratory or expiratory
increase in cough
dyspnea, rapid breathing
chest tightness, tightened neck muscles, difficulty talking
anxiety or panic
pale, sweaty face
tripod position
diaphoresis
cyanosis
minimal or no breath audible breath sounds
PEF < 40%
prolonged expiratory phase
thoracic hyperresonance
hyperinflation
asthma exacerbation causes
atopic symptoms
allergies
URI (mostly): presence of URI automatically moves pt to YELLOW zone on asthma action plan
atopic triad
atopic asthma
atopic dermatitis (eczema)
allergic rhinitis
much more severe asthma, will need inhaler more, more likely to have severe exacerbations
asthma triad aka Samters triad
atopy
nasal polyps
ASA sensitivity
when NOT to step down asthma therapy
during pregnancy
when traveling
during active URI
All risks for worsening asthma/flare
systemic oral corticosteroid tx in asthma
indicated in moderate to severe asthma exacerbations
oral prednisone preferred 5-10 days
asthma exacerbations are reduced with?
routine use of ICS
asthma exacerbation tx
SABA up to 4- 5 puffs every 20 mins for 1st hour or nebulizer
O2 to keep sats 93%-95%
oral corticosteroids for 5-7 days
increase controller med dose (ICS/LABA) for 2- 4 weeks, if not on controller med, add ICS
abx NOT recommended if no evidence of infection
avoid sedation
if poor/ no response to SABA tx - transfer ED
What is the first-line tx for asthma?
A. ICS
B. LABAs
C. leukotriene inhibitors
D. SABAs
A. ICS
Inflammation in lungs (asthma) is best treated by ICS. SABAs and LABAs are bronchodilators, which treat the bronchoconstriction caused by inflammation. Leukotreine inhibitors help control inflammation, but ICS are better
Which of the following is a major RF for fatal asthma?
A. exercising in cold weather
B. smoking and vaping
C. hospital admission in past year
D. allergy to pet dander and dust mites
C. Hospital admission in past year
Hospital admission in past year with ICU admission/intubation is a major RF of fatal asthma. The other major RF are ED visits in past year or recent hx of poorly controlled asthma
What is the preferred reliever med for asthmatics according to the Global Initiative for Asthma (GINA, 2020) treatment guideline?
A. low-dose ICS with formoterol
B. SABA
C. LABA
D. Leukotriene receptor antagonist
A. low dose ICS w/ formoterol
According to the GINA asthma treatment guidelines (2020) the preferred reliever (rescue) med is low dose ICS with formoterol or ICS-LABA combo. SABA is the alternative, but use it with an ICS. The ICS-LABA combo inhalers are used as relievers and also as preventative (maintenance) tx.
intermittent asthma 0-4 y.o.
symptoms = 2 days/week
NO night time awakenings
SABA = 2 days/week
No activity limitations
Step 1 tx SABA PRN
mild persistent asthma 0-4 y.o
symptoms > 2 days not daily
nighttime awakenings 1-2x month
SABA > 2days/week not daily
minor activity limitation
Step 2 tx low dose ICS
moderate persistent asthma 0-4 y.o.
symptoms daily
nighttime awakenings 3-4x month
SABA daily
some activity limitation
Step 3 tx medium dose ICS or consider short course of oral corticosteroids
severe persistent asthma 0-4 y.o.
symptoms throughout day
nighttime awakenings > 1x/week
SABA several x/day
activity extremely limited
Step 3 tx medium dose ICS or consider short course of oral corticosteroids
consult with asthma specialist in 0-4 y.o. when
if step 3 or higher is required
consider consult at step 2
Step 5 asthma tx 0-4 y.o.
high dose ICS + LABA or montelukast
step 6 asthma tx 0-4 y.o.
high dose ICS + LABA or montelukast
oral corticosteroids
intermittent asthma 5- 11 y.o.
symptoms = 2 days/week nighttime awakenings = 2x/month SABA = 2 days/week No activity limitations FEV1 > 80%
Step 1 tx SABA PRN
mild persistent asthma 5- 11 y.o.
> 2 days/week not daily nighttime awakenings 3-4 x month SABA > 2/days/ week not daily minor activity limiation FEV >/= 80%
Step 2 tx low-dose ICS
moderate persistent asthma 5- 11 y.o.
daily symptoms nighttime awakenings 1x/week not nightly SABA daily some activity limitation FEV1 60%- 80%
Step 3 tx low dose ICS + LABA, LTM or theophylline
severe persistent asthma 5- 11 y.o.
symptoms throughout day nighttime awakenings 7x/week SABA several times a day extremely imited activity FEV1 < 60%
Step 3: low dose ICS + LABA, LTM or theophylline
OR
Step 4: medium dose ICS + LABA
step 5 asthma tx 5- 11 y.o.
high dose ICS + LABA
step 6 asthma tx 5- 11 y.o.
high dose ICS + LABA + oral corticosteroids
lung cancer screening USPSTF guideline
adults 50 to 80 y.o. with a 20 pack-year smoking hx and currently smoke or have quit in past 15 years
screen for lung cancer with low-dose CT every year
Stop screening once person has not smoked for 15 years or health problem that limits life expectancy
COPD
preventable dx characterized by airflow limitation that is not fully reversible
presents in 5th and 6th decades of life
includes chronic bronchitis and emphysema
COPD RF
SMOKING
hereditary patten a1-antitrypsin deficiency
frequent viral infections
air pollution - burning wood/ other fuels
good response to asthma exacerbation home tx
no wheezing or dyspnea
PEF >/= 80%
contact PCP for follow-up instructions and further management
may continue SABA q3-4 hr for 24-48 hr
consider short course of oral corticosteroids
incomplete response to asthma exacerbation home tx
persistent wheezing and dyspnea
PEF 50%- 79%
Add oral corticosteroid
continue SABA
consult PCP urgently (same day)
poor response to asthma exacerbation home tx
marked wheezing and dyspnea
PEF < 50%
add oral corticosteroid
repeat SABA immediately
call doctor and proceed to ED
COPD symptoms
dyspnea
chronic cough
sputum production
COPD early stages
asymptomatic
normal PE
S/S noticed in late stages when irreversible changes have occurred
COPD PE late stages
hyperinflation, tobacco stains, clubbing
tripod & pursed lip breathing
increased resonance
diminished breath sounds, early inspiratory crackles
increased expiratory phase
COPD diagnosis
clinical: dyspnea, cough, increased sputum a/w smoking/ environmental factors
confirm w/ spirometry (gold standard)
post bronchodilator FEV1:FVC <70% confirms persistent airflow obstruction
GOLD I COPD
FEV1 >/= 80%
FVC/FEV1 < 0.7 (70%)
occasional cough and increased sputum production
GOLD II COPD
FEV1 50- 79%
FVC/FEV1 < 0.7
progressing symptoms a/w dyspnea on exertion
GOLD III COPD
FEV1 30- 49%
FVC/FEV1 < 0.7
worsening dyspnea and repeated exacerbation
GOLD IV COPD
FEV1 < 30% or < 50% a/w chronic resp failure
FVC/FEV1 < 0.7
quality of life severely impaired, frequent life-threatening exacerbations
COPD assessment test (CAT)
adjunct to s/s, spirometry abnormality, and ID of risk for exacerbations for the assessment of the level of COPD severity and choosing pharm tx
8 questions rated from 0- 5; total scores range from 0- 40
score < 10 = low impact of COPD on pt well being & ADLs
score > 10 = high impact on QOL/ ADLs
COPD non-pharm management
smoking cessation avoid other pulmonary irritants educate hydration, nutrition, avoid URI exercise training pulmonary rehab flu and pneumo vaccines (no live)
oxygen supplementation and COPD
24 hr supplementation if
SPO2 < 88% on RA
PaO2 < 55 mm Hg
HCT > 55% + PaO2 56- 59 mm Hg (O2 improves polycythemia)
15 hrs a day decreases mortality
Group A COPD
<2 exacerbatins
0 hospitalizations
CAT < 10
SABA or SAMA
or
LABA/LAMA
group B COPD
< 2 exacerbatins
0 hospitalizations
CAT > 10
LABA or LAMA
Group C COPD
> /= 2 exacerbations
/= 1 hospitalization
CAT < 10
LAMA
Group D COPD
> /= 2 exacerbations
/= 1 hospitalization
CAT > 10
LAMA
or LAMA & LABA (highly symptomatic CAT > 20)
or ICS & LABA (if eso >/= 300)
COPD pharm managment
ALL pts with COPD should be prescribed SABA or SAMA for acute relief
start SABA/SAMA (both) if not controlled on LABA/LAMA (or both), if exacerbations or more severe add on ICS
avoid long term use of oral corticosteroids
COPD complications
sleep disorders
acute respiratory failure
cor pulmonale
COPD diagnostics
spirometry: postbronchiodilator FEV1/FVC < 0.7 and FEV1 < 80% = airflow limitation thats not reversible
pulse ox CAT CXR ABGs if o2 sat < 92% alpha 1 antitrypsin deficiency eosinophils (determines if will respond to ICS)
COPD exacerbation most common cause
URI viral or bacterial
COPD exacerbation presentation
acute worsening of resp symptoms
increased dyspnea, sputum/viscosity
increased cough, wheeze
COPD exacerbation diagnostics
suspected based on presentation, hx symptoms, objective measure of airflow obstruction
CXR when presents w/ fever or low saO2
COPD exacerbation tx
SABA w/ or w/o SAMA = 1st line
can add LABA or LAMA or combined LABA/LAMA if pt not currently on one
add ICS to reduce future exacerbations
oral corticosteroids - prednisone 5-7 days
oxygen for hypoxemia o2 sat target 88-92%
antimicrobials if indicated for infection
