3-COPD

Question 1

COPD is inflammation of the small airways due to

Answer 1

Narrowing
Fibrosis (chronic bronchitis)
Destruction of parenchyma
Destruction of alveolar walls (Emphysema)

Question 2

COPD has a predominance of what types of cells

Answer 2

Neutrophils
Macrophages
TC1 cells (cytotoxic T)

Question 3

COPD results in

Answer 3

Airway closure on expiration
Air trapping/hyperinflation
SOB and exercise limitation

Question 4

How does GOLD reach categorization COPD

Answer 4

Spirometry confirmed diagnosis (FEV1:FVC <0.7)
Assessment of airflow limitation
Assessment of symptoms and risk of exacerbations

Question 5

What are the GOLD COPD groups

Answer 5

1: FEV1 *)+
2: FEV1 50-79
3. FEV1 30-49
4: FEV1 <30

Question 6

What are the GOLD COPD ABCD groups

Answer 6

A: 0-1 exacerbations, no hospital. mMRC 0-1, CAT <10
B: 0-1 exacerbations, no hospital, mMRC 2+, CAT 10+
C: 2+ exacerbation or 1+ hospital, mMRC 0-1, CAT <10
D: 2+ exacerbation or 1+ hospital, mMRC 2+, CAT 10+

Question 7

How do you treat the different groups

Answer 7

A: Bronchodilator
B: LAMA or LABA- if Sx persist, LAMA+LABA
C: LAMA- if Sx persist, LAMA+LABA
D: LAMA+LABA, if Sx persist LAMA+LABA+ICS (can add Macrolide if ex-smoker)

Question 8

Are SABA great COPD drugs?

Answer 8

not really, only small improvement in FEV1 (per spirometry)
response is usually less than seen in asthma
BUT, can improve respiratory Sx and exercise tolerance

Question 9

Side Effects of Bronchodilators

Answer 9

Tachycardia, Tremors, Rhythm disturbance

Question 10

Are LABA’s good COPD drugs?

Answer 10

Yes; 
Relieve dyspnea
improve QoL
improve lung function
reduce exacerbation frequency

Question 11

How do anti-muscarinics work

Answer 11

Competitively block cholinergic receptors in bronchial smooth muscle= Bronchodilation

Question 12

What are the different anticholinergics

Answer 12

SAMA: Ipratropium. Slower onset but more prolonged effect vs albuterol
LAMA: Tiotropium, umeclidinium. Improve lung fun significantly, comparable to LABA. Decrease exacerbations, lower mortality risk

Question 13

Side effects of anticholinergics are

Answer 13

Dry mouth
Nausea
Metallic taste

Question 14

How do corticosteroids affect COPD (anti-inflammatory MOA)

Answer 14

Reduce capillary permeability (decrease mucus)
Inhibit LT enzyme release
Inhibit prostaglandins (PLA2, COX2)

Question 15

When are systemic corticosteroids used

Answer 15

In chronic management, to slow disease progression

Question 16

Side effects of Systemic corticosteroids are

Answer 16

Osteoporosis 
Muscular atrophy
Thinning skin
Cataracts
(Adrenal suppression/insufficiency)

Question 17

How do you treat Alpha Anti-Trypsin deficiency associated Emphysema

Answer 17

AAT infusion

Bronchodilators prn

Question 18

What is a LABA+ICS

Answer 18

Salmeterol+Fluticasone
Formoterol+Budesonide
-Better at improving FEV1 and decreasing exacerbations

Question 19

What did the FDA approve for COPD therapy in 2017

Answer 19

Triple therapy all in one inhaler QD, Trelegy Ellipta (Fluticasone+Umeclidinium+Vilanterol)
ICS+LAMA+LABA

Question 20

Five step strategy for smoking cessation is

Answer 20

Ask
Advise
Assess
Assist
Arrange

Question 21

What agents are first line smoking cessation meds

Answer 21

Bupropion SR (oral)
Nicotine gum, inhaler, nasal spray, patch
Varenicline/Chantix (oral)

Question 22

When should you use oxygen therapy

Answer 22

Severe resting chronic hypoxemia, to improve survival

Question 23

When shouldn’t you use oxygen therapy

Answer 23

Stable COPD and resting or exercise induced moderate desaturation

Question 24

When should you use Non-invasive ventilation

Answer 24

Severe chronic hypercapnia

Hx ARF

Question 25

What are the "cardinal symptoms" of COPD

Answer 25

Increasing Dyspnea, Sputum volume, Sputum purulence

Question 26

What are the stages of acute COPD exacerbations

Answer 26

Mild: 1 cardinal Sx + 1 (URI w/in 5 days, fever, wheezing, cough, HR/RR increase >20% baseline) Moderate: 2 cardinal Sx Severe: 3 cardinal Sx

Question 27

What therapies can be used in acute COPD exacerbations

Answer 27

``` Antibiotics Corticosteroids Bronchodilators Oxygen therapy Non-Invasive mechanical ventilation ```

Question 28

What therapy is recommended in anyone with moderate or severe exacerbation

Answer 28

Antibiotics

Question 29

What is the caveat to corticosteroid use

Answer 29

if longer than 14 days, taper down to avoid HPA axis suppression

Question 30

Bronchodilators can be used in what form

Answer 30

Moderate dose inhaler or Dry powder inhaler (just as efficacious as nebulizers)

Question 31

What bronchodilators would you use

Answer 31

``` Beta agonists (also increase mucociliary clearance) LAMA and LABA not for acute relief ```

Question 32

How should oxygen therapy be administered

Answer 32

Titrate O2 to >90% | monitor ABG for hypercapnia

Question 33

When should you NOT use Non-invasive mechanical ventilation

Answer 33

AMS Severe acidosis Respiratory arrest Cardiovascular instability

Question 34

What vaccines should COPD patients get

Answer 34

Flu vaccine yearly | Pneumococcal vaccine

Question 35

Who gets the pneumococcal vaccines

Answer 35

PCV13: 65+, 19-64 with low immunity PPSV23: 65+, 19-64 or <2 y/o smoker, chronic illness, cochlear implant or CSF leak, low immunity

Question 36

What Abx should you use if pt has Uncomplicated exacerbation (<4 exacerbations x year and FEV1 >50%)

Answer 36

Azithromycin, Clarithromycin (Macrolide) 2-3 gen Cephalosporin Doxycycline

Question 37

What abx should you NOT use if pt has uncomplicated exacerbation (<4 exacerbations and FEV1 >50%)

Answer 37

Bactrim Amoxicillin 1 gen cephalosporin Erythromycin

Question 38

What abx should you use if patient has a complicated exacerbation (65+, >4 exacerbations, FEV1 35-50%)

Answer 38

Augmenting | Levo/Moxi/Gemifloxacin (Fluoroquinolone anti-pneumo)

Question 39

What abx should you use if patient has complicated exacerbation with P. Aureginosa RF (nursing home w/ 4+ exacerbations, FEV1 <35%, chronic corticosteroid use, chronic bronchial sepsis)

Answer 39

Levofloxacin (anti-pneumo and anti-pseudo Fluoroquinolone) | +/- IV therapy