COPD

Question 1

What is COPD?

Answer 1

Inflammation affecting small airways:

• predominance of neutrophils, macrophages and cytotoxic T lymphocytes
• progressive narrowing
• fibrosis, destruction of lung parenchyma, destruction of alveolar walls (emphysema)

Question 2

COPD results in…

Answer 2

airway closure on expiration

air trapping and hyperinflation

Question 3

COPD includes:

Answer 3

emphysema and chronic bronchitis

they are treated the same

Question 4

Sxs of COPD?

Answer 4

Include: wheezing, pursed lip breathing, chronic cough, barrel chest, dyspnea, easily fatigued, freq. respiratory infections, use of accessory muscles to breath

Question 5

Risk factors for development of COPD?

Answer 5

tobacco smoker, occupational dusts/chemicals, air pollution, genetic (alpha 1 antitrypsin), airway hyper responsiveness, impaired lung growth

Question 6

Goals of COPD tx?

Answer 6

prevent disease progression, relieve sxs, improve exercise tolerance, improve overall health status, prevent exacerbation, prevent/tx comp. Reduce morbidity and mortality.

Question 7

GOLD COPD classifications based on postbronchodilator FEV1:

Answer 7

1: mild= FEV1 80%
2: moderate= FEV1 50%-80%
3: severe FEV1 30%-50%
4: very severe FEV1 less than 30%

Question 8

What are the COPD assessment questionnaires?

Answer 8

CAT

mMRC (modified medical research council dyspnea questionnaire)

CCQ

Question 9

the mMRC assessment tool only assess..

Answer 9

breathlessness

Question 10

Class A COPD? Tx?

Answer 10

0-1 exacerbations (not leading to admission)

mMRC 0-1
CAT <10

Tx: bronchodilator

Question 11

Class B COPD? Tx?

Answer 11

0-1 exacerbations (not leading to admission)

mMRC >2
CAT >10

Tx: LABA or LAMA if persistent sxs–> LAMA + LABA

Question 12

Class C COPD? Tx?

Answer 12

> 2 exacerbations or 1 or more leading to admission

mMRC 0-1

CAT <10

LAMA if still not better –> LAMA +LABA or LABA + ICS

Question 13

Class D COPD? Tx?

Answer 13

> 2 exacerbations or 1 or more leading to admission

mMRC >2
CAT >10

Tx: LAMA –>
LAMA + LABA ot LABA + ICS –>

LABA + LAMA + ICS

Question 14

What should be considered in class D COPD pts who are former smokers?

Answer 14

A Macrolide

Question 15

Effect of albuterol in COPD pts?

Answer 15

response generally less than that is seen in asthma

only small improvement in FEV1

may improve respiratory sxs and exercise tolerance

Question 16

ADEs of beta agonist?

Answer 16

sinus tachycardia, rhythm disturbances, skeletal muscle tremors can occur initially

Question 17

Effect of long acting beta agonists and antimuscarinic

Answer 17

superior outcomes in lung func. (spirometry)

sxs including dyspnea

reduce in exacerbation freq.

improved QOL

Question 18

Name 2 antimuscarinic (bronchodilators)

Answer 18

Ipratropium (short acting)

Tiotropium (long acting)

Question 19

Ipratropium MOA?

Answer 19

bronchodilation by competitively inhibiting cholinergic receptors in bronchial smooth muscle

Question 20

ADEs of Antimuscarinic

Answer 20

dry mouth, nausea, occasional metallic taste

Question 21

What are the anti-inflammatory mechanisms of corticosteroids?

Answer 21

reduction in capillary permeability to decrease mucus

inhibition of release of proteolytic enzymes from leukocytes

inhibition of prostaglandins

Question 22

ADEs of corticosteroids

Answer 22

osteoporosis, muscular atrophy, thinning of the skin, development of cataracts, adrenal suppression with insufficiency

Question 23

What are some examples of LABA & ICS?

Answer 23

salmeterol + fluticasone

Budesonide + Formoterol

Mometasone + Formoterol

Question 24

What drug class is Trelegy Ellipta?

Answer 24

Combination of an inhaled corticosteroid (ICS), a LAMA and a LABA

delivered once in dry powder inhaler

Question 25

What is Phosphodiesterase 4?

Answer 25

the major phosphodiesterase found in airway smooth muscle cells and inflammatory cells and is responsible for degrading cAMP

Question 26

Name a phosphodiesterase 4 Inhibitor. Indication?

Answer 26

Roflumilast (Daliresp) ``` adjunct to bronchodilator therapy in class C and D COPD pts and are not controlled by inhaled bronchodilators ```

Question 27

Roflumilast MOA?

Answer 27

selectively inhibit phosphodiesterase-4 anti-inflammatory effects

Question 28

Both....and Roflumilast have similar MOA through inhibition of phosphodiesterases

Answer 28

Theophylline

Question 29

ADEs of Phosphodiesterase 4 inhibitors

Answer 29

HA, dizziness, insomnia, diarrhea, weight loss,, nausea, decreased appetite, back pain

Question 30

Contraindication for phosphodiesterase 4 inhibitors?

Answer 30

hepatic impairment

Question 31

phosphodiesterase 4 inhibitors drug interactions?

Answer 31

Cimetidine and Ciprofloxacin both increase the concentration of Roflumilast Roflumilast make increase the effect of immunosuppressants

Question 32

Indication of Alpha 1 antitrypsin replacement therapy

Answer 32

inherited AAT deficiency associated emphysema tx is focused on reduction of risk factors such as smoking and sxs tx with bronchodilators weekly infusions of pooled human AAT

Question 33

What is included in the 5 step strategy for smoking cessation program?

Answer 33

5As Ask, Advise, Assess, Assist, Arrange

Question 34

First line Pharmacotherapies for smoking cessation?

Answer 34

Bupropion SR, Nicotine gum, Nicotine inhaler, Varenicline (Chantix)

Question 35

Common complaints associated with pharmacotherapies for smoking cessation?

Answer 35

Bupropion: insomnia, dry mouth Nicotine (gum, inhaler, nasal spray, patches): sore mouth, nasal irritation, skin rxn, insomnia Varenicline: nausea, sleep disturbances

Question 36

Cardinal sxs of acute COPD?

Answer 36

worsening dyspnea, increase in sputum volume, increase in sputum purulence upper respiratory tract infection

Question 37

Staging of acute exacerbations of COPD

Answer 37

Mild (1): 1 cardinal sxs plus at least one of following:URI within 5 days, fever w/out explantation, increased wheezing, increased cough, increased RR or HR >20% Moderate (2): 2 cardinal sxs Severe (3): 3 cardinal sxs

Question 38

When can you give abx for acute COPD exacerbation?

Answer 38

if 2 or more: - increased dyspnea - increased sputum production - increased sputum purulence

Question 39

Therapeutic options for acute exacerbations of COPD?

Answer 39

Abx, corticosteroids, bronchodilators, controlled oxygen therapy, noninvasive mechanical ventilation

Question 40

When is Noninvasive mechanical ventilation not recommended for acute COPD exacerbations?

Answer 40

in pts with AMS, severe acidosis, respiratory arrest or cardiovascular instability

Question 41

Recommended abx therapy for uncomplicated COPD exacerbation in pt with less than 4 exacerbations per yr, no comorbid illness and >50% FEV1? `

Answer 41

likely pathogens: s. pneumoniae, H. influenzae, M. matarrhalis, H. parainfluenzae Macrolide, 2 or 3 gen cephalosporin, Doxycycline

Question 42

Recommended abx therapy for complicated COPD exacerbation?

Answer 42

Likely pathogen: same as uncomplicated + drug resistant pneumococci, Beta lactamase-producing H. influenzae and M. catarrhalis Amoxicillin/Clavulanate, Fluoroquinolone w/ enhanced pneumococcal activity

Question 43

Tx for complicated COPD exacerbation w/ risk of p. aeruginosa?

Answer 43

fluoroquinolone w/ enhanced pneumococcal and P. aeruginosa activity (levofloxacin)

Question 44

What puts someone at risk for p. aeruginosa infection?

Answer 44

chronic bronchial sepsis, need for chronic corticosteroid, resident at nursing home w/ > 4 exacerbations/yr

Question 45

Who should be given long term Oxygen therapy?

Answer 45

in pts with severe resting chronic hypoxemia

Question 46

Vaccinations recommended for COPD pts?

Answer 46

flu pneumococcal