COPD Flashcards by Alixandria Keller

Effects of inflammation of small airways

predominance of neutrophils, macrophages, cytotoxic T lymphocytes

progressive narrowing

fibrosis

destruction of lung parenchyma

destruction of alveolar walls

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Results of inflammation

airway closure on expiration

air trapping and hyperinflation – DOE and exercise limitation

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COPD: reversible

mucus and inflammatory cells and mediators in secretions

bronchial smooth muscle contraction in airways

dynamic hyperinflation during exercise

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COPD: irreversible

fibrosis and narrowing of airways

reduced elastic recoil and loss of alveolar surface area

destruction of alveolar support with reduced patency of small airways

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COPD: symptoms

chronic progressive dyspnea
cough
sputum production
wheezing and chest tightness

fatigue, weight loss, anorexia, syncope, rib fractures, ankle swelling, depression, anxiety

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COPD: goals

prevent disease progression
relieve symptoms

improve exercise tolerance
improve overall health status
prevent and treat exacerbations 
prevent and treat complications
reduce morbidity and mortality

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Classification of airflow limitation (post bronchodilator FEV1)

gold 1: mild: 80+%
gold 2: moderate: 50-79%
gold 3: severe: 30-49%
gold 4: very severe: <30%

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COPD exacerbation

acute worsening of respiratory symptoms that result in additional therapy

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Mild Exacerbation

treated with SABDs only

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Moderate Exacerbation

treated with SABDs + antibiotics +/- oral corticosteroids

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Severe Exacerbation

requires hospitalization or ER

may also be associated with acute respiratory failure

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Blood Eosinophil Count

may predict exacerbation rates (in patients treated with LABA without ICS)

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Bronchodilator: Beta Agonist: short acting

ex: albuterol

rapid onset (5 min)
duration: 2-6 hr

not as effective as in asthma

small improvement in FEV1

may improve respiratory symptoms and exercise tolerance

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Bronchodilator: Beta Agonist: long acting

superior outcomes in lung function

reduced exacerbation frequency

improved quality of life

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Bronchodilator: Beta Agonist: ADEs

sinus tachycardia, rhythm disturbances

skeletal muscle tremors (subside as tolerance develops)

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Bronchodilator: Antimuscarinic (Anticholinergic)

ex: ipratropium (short), tiotropium (long)

competitively inhibit cholinergic receptors in bronchial smooth muscle –> bronchodilation

long acting: equal or greater efficacy than LABA

improve lung function
improve quality of life
reduce frequency of exacerbation/hospitalizations
lower morbidity and mortality risk

ADE:
dry mouth
nausea
metallic taste

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LAMA + LABA combination therapies

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StioltoRespimat - tiotropium bromide/olodaterol

Anoro Ellipta - umeclidinium bromide/vilanterol

Bevespi Aerosphere - glycopyrrolate and formoterol

Utibron Neohaler - glycopyrrolate/indacaterol)

LAMA + LABA combination therapies

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StioltoRespimat - tiotropium bromide/olodaterol

Anoro Ellipta - umeclidinium bromide/vilanterol

Bevespi Aerosphere - glycopyrrolate and formoterol

Utibron Neohaler - glycopyrrolate/indacaterol)

Corticosteroids

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antiinflammation

reduce capillary permeability –> dec mucus
inhibit release of proteolytic enzymes
inhibit prostaglandins

potentially slows disease progression

ICS for

severe COPD
high risk of exacerbations

Corticosteroids: ADEs

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osteoporosis
muscular atrophy
thinning of skin
cataracts
adrenal suppression

LABA + ICS

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improvements in

FEV1
health status
frequency of exacerbations

salmeterol + fluticasone
budesonide + formoterol
mometasone + formoterol

LABA + ICS

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improvements in

FEV1
health status
frequency of exacerbations

salmeterol + fluticasone
budesonide + formoterol
mometasone + formoterol

LABA + LAMA + ICS

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trelegy ellipta (dry powder)

Phosphodiesterase 4 Inhibitor: Roflumilast

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active N oxide metabolite

selective PDE4 inhibition
antiinflammation (suppression of cytokine release)
dec remodeling and mucociliary malfunction

PDE 4

degrades cAMP

PDE 4 Inhibitor: ADEs

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

PDE 4 Inhibitor: contraindication

mod-sev hepatic impairment

PDE 4 Inhibitor: drug interactions

cimetidine, ciprofloxacin: inc serum concentration of roflumilast roflumilast enhances effect of immunosuppressants (except: beclomethasone, budesonide) similar mechanism to theophylline - dont use together

Alpha Antitrypsin Replacement Therapy

inherited AAT deficiency associated emphysema replace with pooled human AAT potential reduction in lung tissue loss/destruction

Five Step Strategy for Smoking Cessation

``` ask advise assess assist arrange ```

Smoking Cessation Pharmacotherapies

``` Bupropion SR (insomnia, dry mouth) Nicotine gum (sore mouth, dyspepsia) Nicotine inhaler (sore mouth, throat) Nicotine nasal spray (nasal irritation) Nicotine patches (skin reaction, insomnia) Varenicline (nausea, sleep disturbances) ```

COPD: prevention and maintenance therapy

inhaler technique influenza, pneumococcal vaccination pulmonary rehabilitation long term oxygen (severe resting chronic hypoxemia)

COPD: Staging Acute Exacerbations

1. mild: one cardinal symptom + URTI/fever/inc wheezing/inc cough/inc respiratory or HR 2. moderate: 2 cardinal symptoms 3. severe: 3 cardinal symptoms

Cardinal Symptoms

worsening dyspnea inc sputum volume inc sputum purulence

COPD: therapy for acute exacerbations

``` antibiotics corticosteroids (oral or IV) bronchodilators controlled oxygen therapy noninvasive mechanical ventilation (for acute respiratory failure) ```

Noninvasive Mechanical Ventilation: contraindications

altered mental status severe acidosis respiratory arrest cardiovascular instability

``` Which antibiotics: uncomplicated <4 exacerbations/year no comorbid illness FEV1 >50% ```

macrolide 2nd/3rd gen cephalosporin doxycycline

``` Which antibiotics: complicated 65+ years old >4exacerbations/year FEV1 <50% but >35% ```

amoxicillin/clavulanate | fluoroquinolone w/ enhanced pneumococcal activity (levofloxacin, gemifloxacin, moxifloxacin)

Which antibiotics: complicated exacerbations with risk of P. aeruginosa chronic bronchial sepsis need for chronic corticosteroid therapy resident of nursing home with <4 exacerbations per year FEV1 <35% of predicted

Fluoroquinolone with enhanced pneumococcal and P. aeruginosa activity (levofloxacin) IV therapy if required: β-lactamase resistant penicillin with antipseudomonal activity 3rd- or 4th-generation cephalosporin with antipseudomonal activity

Indications for supplemental oxygen

arterial hypoxemia - PaO2 < 55 - SaO2 <88% OR PaO2>55 but <60 with R heart failure or erythrocytosis

COPD Flashcards

(40 cards)