COPD Flashcards
(28 cards)
Cardinal symptoms that would raise suspicion for COPD
Cardinal symptoms: SOB and activity limitation
SOB is persistent, progressive, worse with exercise
Other symptoms: persistent cough, sputum production
Symptoms of AECOPD
Sustained (>48 hours) worsening SOB and cough beyond day-to-day variance with increased sputum volume with purulence –> leads to increase in maintenance meds and/or additional meds
two most common conditions that contribute to COPD?
emphysema (destruction of alveoli)
chronic bronchitis (chronic inflammation of bronchioles)
What are the major comorbidities leading to hospitalizations and morbidity/mortality in COPD?
mild to moderate: cardiovascular disease is leading cause of hospitalization
severe: resp failure and pneumonia
When should a diagnosis of COPD be considered?
Pt is 40 and older with:
- dyspnea: progressive, persistent and worse with exercise
- chronic cough AND
- increased sputum production
AND
one of following:
- hx of exposure to cigarette smoke
- hx of environmental/occupational exposure to smoke, dust, gas/fumes
- frequent res infections OR
- family hx of COPD
What will CXR show in COPD?
hyperinflation (air trapping)
not used in diagnosis but can determine or rule out other comorbidities (eg HF, TB, pneumonia)
Lung function between symptoms will show ______ in COPD
persistent air flow limitation
FEV1 may improve with therapy but post-bronchodilator FEV1/FVC <0.7 persists
COPD severity is determined by:
- current level of symptoms (dyspnea scale)
- spirometry (FEV1)
- health status (COPD assessment tool)
- risk of exacerbation
- comorbidities
5 A’s for smoking cessation
ask at every visit advise assess readiness assist with quitting arrange f/u
Components of Lifestyle and Self Management of COPD
- smoking
- physical activity
- diet
- pulmonary rehab
- air quality
- smoking: quit
- physical activity: stay active despite symptoms of dyspnea
- diet: maintain BMI 20-25 (low weight and anorexia is risk factor for COPD progression)
- air quality: stay indoors when poor
- pulmonary rehab is moderate to severe COPD
Immunizations recommended in COPD
annual flu vaccine COVID pneumococcal polysaccharide Tdap (if not received in adolescence) shingles
Management of AECOPD
3 components
- short acting bronchodilator
- salbutamol 400-800 mcg MDI
- po prednisone
- 40-50 mg x 5 days
- no tapering needed
- not to exceed 5 days
- antibiotics
- if symptoms and risk factors for bacterial infection
- 5-7 days
Treatment of COPD
Step 1 first line treatment for short term relief of SOB
Step 1: SAMA or SABA for acute short term relief of SOB
• Moderate to severe COPD: SAMA or SABA monotherapy recommended
○ SAMA may reduce risk of AECOPD and improve QoL
If not well controlled on monotherapy, try combo SABA + SABA
SAMA = ipratropium (atrovent) SABA = salbutamol (ventolin)
Treatment of COPD
Step 2 for symptom relief and prevent exacerbations
Add LAMA or LABA
LAMA preferred (tiotropium = Spiriva)
if monotherapy does not control, can try LAMA + LABA combo
(tiotropium + oladaterol = Inspiolto Respimat)
*do not use SAMA and LAMA together (two muscarinic antagonists)
Treatment of COPD
Step 3: to prevent exacerbations
Step 3: Triple therapy of LABA + ICS and LAMA to prevent exacerbations
• Moderate to severe COPD and repeated exacerbations (<50% predicted and 2+ exacerbations in last 12 months)
ICS + LABA = fluticasone + salmeterol (Advair)
Budesonide + formeterol (Symbicort)
Fluticasone + vilanterol (Breo ellipta)
Do not use ICS monotherapy in COPD
Acute exacerbation of COPD
6 possible differential diagnoses
pneumonia pneumothorax pleural effusion pulmonary embolism pulmonary edema cardiac arrhythmias (Afib/flutter)
COPD
6 possible differential diagnoses
- asthma
- CHF
- bronchiectasis
- TB
- obliterative bronchiolitis
- diffuse panbronchiolitis
COPD
use of ICS
monotherapy not recommended
associated with increased risk of pneumonia especially at high doses
used in combo with LABA
eg advair (fluticasone + salmeterol)
Breo Ellipta (fluticasone + vilanterol)
Symbicort (budesonide + formeterol)
COPD
use of azithro
- indication
- dose
- side effects
- caution
Azithromycin: macrolides have anti-inflammatory properties
maintenance dose to reduce risk of AECOPD
• 250 mg daily or 250 mg 3x/week
• Side effects: QT prolongation, hearing, nasopharyngeal colonization with macrolide resistant bacteria
Caution: fatal cardiac arrhythmias (eg long QT, lyte imbalance, arrhythmia, cardiac insufficiency, concurrent long QT meds, elderly)
COPD
first line antibiotic treatment for AECOPD if < 4 exacerbations/year
duration?
sign of first line failure?
amoxil 1 g po TID
OR
doxy 200 mg x 1 then 100 mg BID
OR
septra DS BID
Duration: 5-7 days
Sign of failure: no improvement after finishing or worst after 72 hours
COPD
antibiotic treatment for AECOPD if 4 or more exacerbations per year OR failure of first line OR antibiotics in last 3 months
amox-clav BID x 5-10 days
OR
cefuroxime BID x 5-10 days
OR
levofloxacin OD x 5 days (only if beta-lactam allergic or failure to first line)
*if failure of first line: use different antibiotic class
Azithro and Clarithromycin (macrolides):
*poor Haemophilus coverage and S pneumoniae resistance
SAMA
- example
- indication
- side effects
- caution
SAMA
Regular Pharmacare
• Ipratropium (Atrovent)
Indication: short term symptom relief (step one)
Side effects: headache, dry mouth, cough, throat irritation, metallic taste
Caution: risk urinary retention (eg BPH), narrow angle glaucoma
SABA
- example
- indication
- side effects
- caution
SABA
Regular Pharmacare except ventolin diskus
• Salbutamol (Ventolin MDI or diskus, Airomir MDI)
• Terbutaline (bricanyl turbuhaler)
Indication: for short term symptom relief (step one)
Side effects: tremor, tachycardia, restlessness, headache, muscle craps
Caution: cardiovascular d/o (CAD, arrhythmias, HTN)
LAMA
- example
- indication
- side effects
- caution
- teaching
LAMA
Incruse and Spiriva Respimat covered under regular benefit
SA for others if failed trial of Incruse / Spiriva Respimat
No product is superior: consider usability and adherence
* Umeclidinium (Incruse Ellipta) * Tiotropium (Spiriva Respimat or Handihaler) * Glycopydrronium (Seebri Breezhaler) * Aclidinium (Tudorza Genuair)
Indication: symptom relief and prevent exacerbation (step 2)
Side effects: headache, dry mouth, urinary retention, metallic taste
Caution: existing urinary obstruction (eg BPH), narrow angle glaucoma
Teaching: rinse mouth, avoid spraying to eyes
