COPD

Question 1

CXR findings - COPD

Answer 1

hyperlucency (trapped air)
barrel chest
vertically oriented heart
flattened diaphragm

Question 2

Normal decrease in FEV1 for non-smokers

Answer 2

25-30 mL/yr after age 35

Question 3

Decrease in FEV1 for smokers

Answer 3

> 60 mL/yr

Question 4

What scale can determine prognosis of COPD progression?

Answer 4

BODE

BMI
Obstruction (degree of airflow limitation)
Dyspnea
Exercise capacity (6 min walk test)

Question 5

Goal of therapy for COPD

Answer 5

(NO CURE)

1. symptom control
2. prevention of exacerbations

Question 6

What is the BEST intervention for COPD?

Answer 6

Stop smoking!

Question 7

Anticholinergic Agents - MOA

Answer 7

acts on enzyme guanylate cyclase -> increases cGMP -> -> -> bronchodilation

Question 8

What is the biggest issue with Ipatropium (SAMA)?

Answer 8

QID

MDI - need spacer or proper # of steps (harder to use)

Question 9

Tiotropium - counseling for technique

Answer 9

pill form for inhalation…not for PO!

Question 10

Tiotropium - class and indication

Answer 10

Long acting anti-cholinergic (LAMA)

COPD

Question 11

Ipratropium - class and indication?

Answer 11

short acting anti-cholinergic (SAMA)

asthma exacerbation and COPD

Question 12

ICS for COPD - who?

Answer 12

more severe patients (b/c higher risk of death and pneumonia)
GOLD 3 and 4 (FEV1<2L)

Question 13

Roflumilast (Dalisresp) - class and indication

Answer 13

PDE4-inhib
severe COPD (GOLD 3 and 4)

Question 14

PDE-4 Enzyme Inhibitor (Roflumilast) - MOA

Answer 14

inhibits phosphodiesterase 4 (PDE4) which results in accumulation of cAMP in lungs –> anti-inflammatory, mild bronchodilation, remodeling

Question 15

Roflumilast - ADE

Answer 15

weight loss - 20% lose 5-10%, 7% lose > 10%

this is a problem b/c already thin

Question 16

Are the decreases in exacerbation from Roflumilast clinically relevant?

Answer 16

No.
Not a first line…add to other drugs.
Who is a candidate? severe patient trying to keep out of hospital and can afford.

Question 17

Are mucolytic agents recommended for COPD?

Answer 17

No

Doesn’t really help and has not been proven.

Question 18

Vaccines for COPD patients

Answer 18

Pneumococcal and influenza

Question 19

Supplemental home O2 - who can get?

Answer 19

PaO2 < 55 mm Hg (ABG) or SaO2 <88%
or
PaO2 56-59 mm Hg + (evidence of pulmonary hypertension or secondary erythrocytosis (Hct 55%) or right sided heart failure)

Question 20

*Drugs to use with caution in COPD

Answer 20

Beta blockers
Respiratory depressants (opiods, benzodiazepines)

Question 21

*GOLD Guidelines: non-pharmacologic

Answer 21

A - smoking cessation + physical activity + vaccines

B - above + pulmonary rehab

Question 22

*GOLD Guidelines: First Line

Answer 22

A - SAMA prn or SABA prn
B - LABA or LAMA
C/D - (ICS + LABA) or LAMA

Question 23

Most common cause of COPD exacerbation

Answer 23

viral resp tract infection

Question 24

*COPD Exacerbation - DOC

Answer 24

1. Albuterol + Ipatropium

2. Systemic steroids (Prednisolone 30-40 mg qd x 10-14 days)

Question 25

If a patient has fever, increased purulent sputum, dyspnea or mechanical ventilation, what should be added to the COPD regimen?

Answer 25

Antibiotics --> Macrolide (azithro or clarithro) 3rd gen ceph Resp FQ (Moxi, Levo)

Question 26

Desired O2 sats during O2 therapy for COPD exacerbation

Answer 26

88-92% (because used to being low) in high 02 sat, brain will have less drive to breathe and will retain more CO2

Question 27

*Ipratropium - class?

Answer 27

SAMA (Anticholinergic)

Question 28

*Aclidinium bromide (Tudorza Pressair) and Tiotropium bromide (Spiriva) - class?

Answer 28

LAMA (Anticholinergic)

Question 29

Why are LAMAs associated with decreased COPD exacerbations compared to LABA?

Answer 29

Patients feel better probably because of easier technique for administration and more convenient dosing.

Question 30

What medication used for COPD is a SAMA + SABA?

Answer 30

Ipratropium + albuterol (Combivent)

Question 31

*What PDE-4 Enzyme Inhibitor is used for severe COPD?*

Answer 31

Roflumilast (Daliresp)

Question 32

*COPD - classifications*

Answer 32

1 - Mild, FEV1>80%, with or without symptoms 2- Moderated, FEV1 50-80%, with or without symptoms 3- Severe, FEV1 30-50%, with our without symptoms 4- Very severe, FEV1 <70%

Question 33

*Can you give Ipatropium (SAMA) and Tiotropium (LAMA) together?*

Answer 33

No because they have the same MOA…need to pick a short and long from two different classes.

Question 34

*Can you given Ipatropium (SAMA) and Salmetrol (LABA) together?*

Answer 34

Yes because they have different MOA (different classes).

Question 35

*Ipatropium vs Tiotropium dosing

Answer 35

Ipatropium 2 inhalations qid | Tiotropium 1 inhalation (cap) qd

Question 36

Preferred admin of inhaled bronchodilator and ICS

Answer 36

MDI with spacer - slows down med/gets deeper but bulky.