COPD

Question 1

True or false: COPD is chronic, progressive, and not reversible

Answer 1

True

Question 2

The two principal COPD conditions are_______________________ and ______________ , which are referred to as phenotypes.

Answer 2

chronic bronchitis and emphysema

Question 3

What are the COPD guidelines called?

Answer 3

GOLD

Question 4

1) What defines chronic bronchitis?
2) Define emphysema

Answer 4

1) Excessive mucus secretion w. cough for at least 3 months of the year for at least two consecutive years
2) Permanent enlargement of the airspaces + destruction [of terminal bronchiole walls]

Question 5

COPD affects ___________ million Americans

Answer 5

16-28

Question 6

Describe the etiology of COPD

Answer 6

1) Cigarette smoking
2) Environmental factors (like tobacco smoke)
3) Genes
4) α1-antitrypsin (AAT): correlates w. development of emphysema and pulmonary dysfunction
-Accounts for < 1% of all COPD cases

Question 7

1) Cigarette smoking is the most common risk factor of COPD and accounts for ___________ of cases of COPD in the United States
2) ______% of all smokers develop COPD

Answer 7

1) 85-90%
2) 50%

Question 8

What is the pathophys of COPD?

Answer 8

Neutrophilic

Question 9

Do glucorticosteroids work for COPD?

Answer 9

Variable effect (compared to asthma, where they inhibit inflammation)

Question 10

Describe the effects COPD has on the lungs in mmHg

Answer 10

↓ PaO2 = 45-60 mm Hg
↑ PaCO2 = 50-60 mm Hg

Question 11

What happens as COPD progresses?

Answer 11

1) pH balance will be maintained by kidneys
Patients at risk for respiratory acidosis
2) Development of pulmonary hypertension
Right ventricle hypertrophy > right-sided heart failure
3) Thoracic hyperinflation
4) Systemic effects incl: cachexia (ie, weight loss & muscle wasting)

Question 12

What improves diagnostic accuracy for COPD? Describe

Answer 12

Spirometry combined with physical examination:
Reduction in FEV1/FVC ratio to less than 70% (0.70)
(specifically postbronchodilator spirometry)

Question 13

COPD:
1) When should Sx assessment be measured? Using what?
2) What is group E and who is in it?

Answer 13

1) At baseline and then during routine visits using CAT or mMRC
2) Patients with at least two exacerbations in the last 12 months, or one exacerbation requiring hospitalization, are considered high risk for future exacerbations (group E)

Question 14

Describe how to score the grades of COPD with the GOLD scale

Answer 14

1) Mild: >/=80%
2) Moderate: 50-80%
3) Severe: 30-50%
4) Very severe: <30%

Question 15

How do you score a CAT?

Answer 15

<10 means less symptoms, >/= 10 means more symptoms

Question 16

Describe the initial pharmacological COPD Tx: What are the criteria for groups A and B?

Answer 16

Group A: mMRC 0-1; CAT <10. Group B: mMRC >/=2, CAT >/=10.
Both: 0 or 1 moderate exacerbations (not leading to hospital admission).

Question 17

Describe the initial pharmacological COPD Tx: What are the treatments for groups A and B?

Answer 17

Group A: Any bronchodilator
Group B: LABA + LAMA*
*pts also need emergency SABA

Question 18

Describe the initial pharmacological COPD Tx: What are the criteria for group E? What is the Tx?

Answer 18

> /=2 moderate exacerbations or >/=1 leading to hospitalization
Tx: LABA + LAMA
*also emergency SABA
*consider adding ICS if blood eos >/=300

Question 19

What are the 4 major aspects of COPD Tx?

Answer 19

Assess and monitor the condition, avoid or reduce exposure to risk factors, manage stable disease, and treat exacerbations

Question 20

1) True or false: Most treatments for COPD have not been shown to improve survival or to slow the progressive decline in lung function.
2) What do many COPD therapies do?

Answer 20

1) True
2) Improve pulmonary function and quality of life as well as reduce the risk of COPD exacerbations and duration of hospitalization

Question 21

What is the only COPD intervention proven to affect long-term decline in FEV1 and slow the progression?

Answer 21

Smoking cessation

Question 22

What are the first line pharmacotherapies for smoking cessation?

Answer 22

1) Bupropion SR 150mg PO for up to 3 days, then BID for 12wks-6months
2) Nicotine gum up to 12wks
3) Nicotine patches up to 8wks
4) Chantix (varenicline) for 12wks

Question 23

Nicotine cessation products:
1) Who should you avoid bupropion for?
2) Who is NRT contraindicated for?
3) What does varenicline do?

Answer 23

1) For patients with PMH of seizures or eating disorders
2) With recent (w/in 2 weeks) stroke or MI
3) Relieves physical withdrawal symptoms and reduces the rewarding properties of nicotine

Question 24

Nicotine cessation products:
1) What is the MOA of varenicline?
2) What are the other options?
3) What is allowed for Tx in the UK but not US?

Answer 24

1) Partial agonist on nicotinic receptors
2) Tricyclic antidepressants, behavioral therapy and hypnosis
3) E-cigarettes; due to missing long-term safety data (UK is exception)

Question 25

What are some non-pharmaceutical Txs for COPD?

Answer 25

1) Pulmonary rehabilitation 2) Oxygen 1 to 2 L/min (if <55mmHg)

Question 26

List 5 vaccines that can prevent respiratory conditions

Answer 26

1) Influenza 2) Tdap 3) RSV 4) COVID-19 5) Pneumonia

Question 27

Adult pneumonia vaccines (2025): 1) What are the recommendations for 19-49 yr/olds? 2) What abt for adults 50 years and older?

Answer 27

1) 19-49 years old w/ COPD; other indications have same recommendations (eg, smoking or heart failure) 2) One dose: Prevnar-15, Prevnar-20, or Capvaxive (PCV21)

Question 28

List 2 categories of short acting bronchodilators

Answer 28

1) Short-acting beta agonist (SABA) 2) Short-acting anticholinergics (also known as antimuscarinics)

Question 29

Short-acting beta agonists (SABA): 1) Give two examples and what each are 2) What are some adverse effects?

Answer 29

1) Albuterol (Ventolin, ProAir, Proventil): Racemic mixture of (R)-albuterol, which is responsible for the bronchodilator effect, and (S)-albuterol, which has no therapeutic effect -Levalbuterol (Xopenex): Single-isomer formulation of (R)-albuterol 2) Tremors, palpitations, tachycardia, jitteriness

Question 30

Short-acting anticholinergics (also known as antimuscarinics): 1) What is the MOA? 2) Give an example of a med in this category 3) What are some adverse effects?

Answer 30

1) M1 – 3 acetylcholine antagonist 2) Ipratropium (Atrovent) -Less risk of causing skeletal muscle tremor and tachycardia 3) Dry mouth; may precipitate narrow-angle glaucoma symptoms

Question 31

Long-acting bronchodilators: 1) Are they appropriate for acute COPD relief? 2) Is LABA monotherapy appropriate? 3) What do the 2023 guideline update recommendations say? 4) What 2 drugs in this category have the most outcome evidence to support use?

Answer 31

1) No 2) Not associated with increased mortality and is recommended as part of international guidelines 3) Combination therapy (LAMA + LABA) for group B + E 4) Salmeterol and formoterol

Question 32

List 5 long-acting bronchodilators that are long-acting β2-agonists (LABAs) and how they're used

Answer 32

1) **Salmeterol (Serevent Diskus)** -dry powder inhaler (DPI) 2+3) **Formoterol (Perfomist) + Arformoterol (Brovana)** -nebulized solutions 4) **Indacaterol (Arcapta)** -DPI 5) **Olodaterol (Striverdi)** -soft mist inhaler (SMI)

Question 33

List 5 long-acting bronchodilators that are long-acting muscarine-agonists (LAMAs) and how they're used

Answer 33

1) Tiotropium (Spiriva Respimat or Spiriva Handihaler) -SMI and DPI 2) Aclidinium (Tudorza Pressair) -DPI 3) Glycopyrrolate (Lonhala Magnair or Seebri Neohaler) -Nebulized or DPI 4) Umeclidinium (Incruse Ellipta) -DPI 5) Revefenacin (Yupelri) -Nebulized

Question 34

Corticosteroids: 1) True or false: ICS monotherapy for patients with COPD is not recommended 2) What should you counsel pts using these meds to do? 3) What is there a risk of?

Answer 34

1) True 2) Recommend adequate intake of calcium and vitamin D and consider periodic bone mineral density testing for patients at risk of osteopenia -Wash mouth after use (oral candidiasis) 3) Pneumonia and mycobacterial pulmonary infections

Question 35

Combination dual and triple therapy for COPD; is it effective?

Answer 35

Significant improvement compared with LABA or LAMA monotherapy

Question 36

True or false: ICS/LABA dual Tx is not recommended for COPD pts, but is for asthma pts

Answer 36

True

Question 37

When may triple therapy with ICS/LABA/LAMA may be considered instead of LAMA/LABA for COPD pts?

Answer 37

For pts w. blood eosinophil ≥ 300 cells/μL (0.3 x 109/L) or ≥ 100 cells/uL [and ≥ two moderate exacerbations or one exacerbation requiring hospitalization in the last year (high risk)]

Question 38

Dupilumab (Dupixent, a biologic): 1) What is the MOA? 2) It decreases exacerbations and improves lung function for COPD patients with what? 3) What is the dose?

Answer 38

1) MAB directed at blocking interleukin-4 + 13 receptors 2) PMH of exacerbations + eosinophil count > = 300 cells / mcl and concurrent use of LAMA/LABA/ICD 3) 300 mg injection every other week

Question 39

Dupilumab (Dupixent): 1) List 2 warnings for it 2) List some adverse rxns

Answer 39

1) Anaphylaxis, helminth infections, 2) Injection site reactions, increased risk of herpes + UTIs, arthralgias

Question 40

Methylxanthines: List 2

Answer 40

Theophylline (PO) and aminophylline (IV)

Question 41

Methylxanthines (Theophylline (PO) and aminophylline (IV)): 1) What is the MOA? 2) What may they do for pts with COPD? 3) What is the target amt to reduce seizure risk?

Answer 41

1) Inhibition of phosphodiesterase +inhibition of release of mediators from mast cells and leukocytes 2) May offer improvements in lung function and gas exchange 3) Target = troughs = 15 mcg/mL

Question 42

1) Methylxanthines (theophylline (PO) and aminophylline (IV)) can cause what at > 20 mcg/mL? 2) Why?

Answer 42

1) Toxicities: arrhythmias and seizures (QT prolongation) 2) Narrow therapeutic index

Question 43

Roflumilast (Daliresp) (a phosphodiesterase 4 (PDE4) inhibitor): 1) What is the MOA? 2) Who is it recommended for?

Answer 43

1) Relaxation of airway smooth muscle cells and decreased activity of inflammatory cells 2) Pts with recurrent exacerbations despite treatment with triple inhalation therapy (LAMA/LABA/ICS) or if eosinophil count (<100 cells/μL [0.1 x 109/L])

Question 44

Theophylline should not be given with what? Why?

Answer 44

Roflumilast (Daliresp); similar MOA

Question 45

Roflumilast (Daliresp) (a phosphodiesterase 4 (PDE4) inhibitor): 1) Adverse effects? 2) How do you dose?

Answer 45

1) Neuropsychiatric effects such as suicidal thoughts, insomnia, anxiety, and new or worsened depression 2) Start at 250 mcg PO Qday for 4 weeks, then increase to a maintenance dose of 500 mcg PO Qday

Question 46

Ensifentrine (Ohtuvayre)(Phosphodiesterase 3 & 4 inhibitor; a new drug): What can it cause?

Answer 46

Psychiatric symptoms

Question 47

Azithromycin (macrolide): 1) Who is this Tx of no benefit to? 2) How is it dosed? 3) What is there an increased risk of? 4) What is an adverse effect? List 2 drug interactions

Answer 47

1) Current smokers (avoid combination) 2) 250mg Qday or 250mg three times weekly; reassess after 12 months 3) Hearing loss for COPD cohort 4) QT-prolongation; Flecainide and fluconazole

Question 48

α1-Antitrypsin Replacement Therapy: is there a lot of evidence for its use in COPD Tx?

Answer 48

Sparse evidence to recommend use + expensive

Question 49

1) There's a lack evidence for routine use of what OTC med in treating COPD pts? 2) When are opioids like morphine used in treating COPD?

Answer 49

1) Mucolytics – guaifenesin 2) End-stage dyspnea

Question 50

Define an exacerbation

Answer 50

A change in the patient's baseline symptoms (dyspnea, cough, or sputum production)

Question 51

How can COPD exacerbations be treated?

Answer 51

1) O2 therapy 2) Noninvasive positive-pressure ventilation (NPPV) (Patients with severe acidosis (pH <7.25), respiratory arrest, or cardiovascular instability should be not considered for NPPV) 3) Bronchodilators (avoid theophylline) 4) Systemic corticosteroids: Prednisone 40 mg PO daily (or equivalent) for 5 days 5) Antibiotics

Question 52

List the types of COPD exacerbations

Answer 52

1) Type 1 = mild 2) Type 2 = moderate -2 cardinal Sx 3) Type 3 = severe -3 cardinal Sx

Question 53

What do the treatments for all 3 types of acute COPD exacerbations have in common?

Answer 53

All should be treated with a short-acting bronchodilator

Question 54

List the treatments for the 3 types of COPD acute exacerbations

Answer 54

1) Mild: short-acting bronchodilators only 2) Moderate: short-acting bronchodilators + antibiotics or systemic corticosteroids 3) Severe: all of the above + hospitalization/ ER visit