COPD Flashcards
pathophysiology behind COPD
- diagnosis & assessment of pts.
Patho
- smoking & other inhaled pollutants injury the lungs, impari lung function & trigger inflammation
- usually by way of chronic bronchitiis or emphysema
- limits (OBSTRUCTION) of airway due to increased mucus & decrease ability to breath out air (damaged alveoli)
Symptoms
- dyspnea (progressive & worsening)
- recurrent wheezing
- chronic cough
- recurrent LRI
- history of (smoking, smoke from cooking fuel, occupational risk, genetic factors)
single best predictor of COPD = smoking 55-pack years + wheezing + self-reported wheezing
Diagnosis: NEED SPIROMETRY
- get FEV1, FVC, FEV1/FVC ratio
- confirm a dx: FEV1/FVC ratio < .7
Factors which influence & determine severity of COPD?
How do we assess symptoms to determine INITIAL treatment (names of tests/questionaires)
Factors
- how severe the airflow limitation is (FVC1)
- frequency of exacerbations and severity of those
- symptoms (mMrc and CAT)
- presence of co-morbid conditions (HF, Heart disease, MSK disorders, depression)
Assess Symptoms
- mMRC: pt. describtion of how much they get Out of breath
- CAT: PREFERRED over mMRC assess quality of life and is more comprhensive in questions
Stepwise progression of how we approach treatment of COPD
- get spirometry (& dx. with post-dialtor ratio < .7)
- determine airflow limitation (FEV1) by GOLD criteria
GOLD 1: FEV1 >80%
GOLD 2: FEV1 50-80
GOLD 3: FEV1 30-50
GOLD 4: FEV1 < 30 - assess symptoms + risk via the A, B, E box for INITIAL treatment
number of hospitalizations (0-1, 2+) and then mmrc score (< 10, > 10)
main drug class for treatment of COPD?
- categories and indication for use
Bronchodialators!!
- short or long acting are initial therapy (depending on which category pt. falls into)
- all pts. should be given a SABA as rescue
- combo LAMA/LABA has been shown to reduce sx., increased FEV1 and reduce exacerbations
- minial efficacy of theopylline but it can help
when are ICS used in the setting of COPD?
- specifics about triple therapy
- specifics about blood eosinophil count
- when do we use ICS in COPD?when do we absolutely not?
ICS long-term monotherapy is NOT recommended in COPD
- LABA + ICS is discouraged (but we will see it)
- LABA + LAMA + ICS is preferred!!!!
- triple therapy improves lung function & reduces exacerbations
- consider the pts. blood eosinophil count when deciding if triple therapy is useful
- ** blood eosinophils > 300 = use triple therapy and meet criteria for LAMA + LABA use**
- ICS can increase risk of pneumonia, oral candiasis and hoarse voice
when to use ICS?
- 2+ exacerbations & prior hospitalization
- blood eos. > 300
- concurrent asthma with COPD
DO NOT USE
- history of mycobacterial infections
- repeated pneumonia
- blood eosinophils < 100
what is some non-pharm treatment that can be used for COPD pts?
- for group A
- for group B & E
- for all groups?
Group A: smoking cessasion
Group B &E: smoking cessaion & pulmonary rehab
For all…
- physical activity & exercise
- up to date on vaccinations (PCV, flu, COVID, pertussis shingles)
Treatment (inital and to be continuing) therapy for COPD
(think based on category)
Group A: no hospitalizations, 1-2 exacerbations, mmrc 0-1 or CAT < 10 : A broncodialator (SABA, LAMA, LABA)
Group B: no hospitalizations, 1-2 exacerbations, mmrc 2+, CAT >10 : LABA + LAMA (if in combo thats even better)
Group E: 2+ exacerbations leading to 1+ hospitalization, any mmrc or cat score : LAMA + LABA (+ ICS is blood eosinophils > 300)
ALL PTS. MUST HAVE A SABA RESCUE INHALER FOR EXACERBATIONS!!!!
names of some COPD medications
SABA
LABA
LAMA
LAMA + LABA combos
ICS + LABA + LAMA combos
SABA: albuterol
SAMA: ipratropium
LABA: formoterol, salmeterol
LAMA: tiotropium, aclidinium bromide
LABA/LAMA: umeclidinium/vilanterol
LABA/ICS: salmeterol/fluticasone, budesonide/formoterol
LAMA/LABA/ICS: umeclidinium/vilanterol/fluticasone furoate
what is the monitoring which needs to be done with pts. with COPD
specifica monitoring for a DPI
- yearly spirometry
- questionaires (mmrc or CAT) every 2-3 months
- subjective sx. at each visit
- smoking staus
- inhaler technique
- exacerbations
- ADRs!
- ICS: candidiasis
- SABA/LABA: tachycardia/hypokalemia
- LAMA: dry mouth
for a dry powder inhaler: looking at the PEFR –>if PEFR is < 60ml the DPI may not be a good inhaler to choose for them
how is pharmacological FOLLOW-UP TREATMENT determined in pts. with COPD?
- NOT THE ABE GUIDELINES
- decide is Dyspnea the issue or Exacerbations
if the problem is DYSPNEA
- put them on a combo LAMA/LABA
- consider 1 inhaler for max. pt. adhearance
- consider switching device modes
- treat other causes of dyspnea
if the problem is Exacerbations
if pt. currently on a LAMA OR LABA
- blood eosinophils >300 = LABA + LAMA + ICS
- blood eosinophils < 300 = LABA + LAMA
if pt. currently on a LAMA/LABA
- blood eosinophils >100 = triple therapy
- blood eosinophils < 100 = roflumilast or azithromycin
if pt. currently on triple therapy
- ** add-to the triple roflumilast or azithromycin**
indications fro Roflumilast = < 50% FEV1 & chronic bronchitis
indications for azithromycin = those who are NOT current smokers
how does Rofumilast a PDE4 inhibitor work?
-MOA
- indications
- ADRS
- monitoring
a phosphodiesterase type 4 inhibitor
MOA: decreases inflammation (NOT a bronchodialator)
indications: reduced risk of exacerbation in those with a FEV1 < 50% AND have chronic bronchitis
- good for those who have hx. of exacerbations with LAMA/LABA with blood eosinophisl < 100
- good for those who are on triple therapy with hospitalizaion for exacerbations
ADRs
- weight loss
- decreased appetite
- diarrhea, nausea
- back pain, insomnia
Monitor
- weight lotss
- psychiatric events (suicide)
how does azithromycin work for COPD?
- MOA
- indications
- side effects
MOA: decreases inflammation & decreases exacerbations
indications
- for those who have copd, are NOT CURRENT SMOKERS
- they are on triple – add it in
- they are on LAMA/LABA with blood eosinophils < 100
Side effects
- hearing loss
- pneumonia
- GI upset
- QTC prolongation
how are Acute COPD Exacerbations defined?
- most commonly associated with what
- what to do with… mild, moderate or severe?
acute exacerbation: an event of dyspnea, cough/sputum that worsens over 14 days
most commonly due to a URI
mild: fixed with SABA rescue
moderate: SABA and OCS +/- abx.
severe: hospitalization
hospitaliztion
SABA + ipratropium
systemic steroids (prenisone)
O2 for sat. 88-92%
when should ABX. be given during COPD exacerbations?
3 cardinal symptoms
1. increased dyspnea
2. increased sputum volume
3. increased sputum purulence
if pt. has all three – given azithromycine
if pt. has 2 but 1 is the increased purulence – give
if pt. need mechanical ventilation – give
