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COPD (Cut off for Exam 3) Flashcards

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1
Q

COPD Guidelines

A
  • GOLD 2019

- Frequently updated

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2
Q

COPD + Death

A
  • 3rd leading cause of death in US

- >15 million diagnosed (assumed to be underestimated)

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3
Q

COPD Definition

A
  • Common, preventable, treatable
  • Persistent respiratory symptoms
  • Airflow limitation due to airway or aveolar abnormalities
  • Caused by significant exposure to noxious particles or gases
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4
Q

Factors + Diagnosing COPD

A
  • Medical History
  • Physical exam
  • Spirometry - required to establish diagnosis
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5
Q

Characteristics + Increased COPD

A

->40 y.o.
-Dyspnea
-Chronic cough
-Chronic sputum production
-Family history of COPD
-Recurrent lower respiratory tract infections
History of exposure to risk factors

NOT diagnostic, perform spirometry in any patients > 40 y.o. with any of the indicators

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6
Q

COPD - Dyspnea

A
  • Cardinal symptoms
  • Major cause of disability and anxiety
  • Increased effort to breathe, heaviness, air hunger, gasping
  • Chronic and progressive
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7
Q

COPD - Cough (chronic)

A
  • Often the first symptom
  • Often discounted by patients as a consequence of smoking or environmental exposures
  • May start as intermittent but becomes chronic
  • May or may not be productive
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8
Q

COPD - Other Presentations

A
  • Sputum production
  • Wheezing and chest tightness
  • Fatigue
  • Weight loss
  • Anorexia
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9
Q

Spirometry + COPD

A
  • Most reproducible and objective measurement of airflow limitation
  • Most common pulmonary function test (PFT)
  • Measures FEV1:FVC like in asthma (closer to 0.8 in health patients, lower in those with obstructive lung disease)
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10
Q

FEV1 + Severity

A
  • Used to diagnose severity in those with FEV1:FVC < 70%
  • GOLD 1: Mild, FEV1 >= 80%
  • GOLD 2: Moderate, FEV1 50-79%
  • GOLD 3: Severe, FEV1 30-49%
  • GOLD 4: Very Severe, FEV1 <30%
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11
Q

Other Patient Factors to Consider….

A
  • Current level of patient’s symptoms (CAT or mMRC questionnaire)
  • Exacerbation risk
  • Presence of co-morbidities

Exacerbations and level of symptoms used to place them in treatment groups, Groups A-D

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12
Q

COPD - Treatment Goals

A
  • Relieve symptoms
  • Improve exercise tolerance
  • Improve health status
  • Reduce exacerbations
  • Prevent disease progression
  • Reduce morality
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13
Q

COPD - Treatment Principles

A
  • Treatment often cumulative
  • Maintenance of regular treatment for long periods of time
  • Individuals differ in response to treatment
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14
Q

COPD + Non-Pharm Therapy

A
  • Smoking cessation
  • Oxygen: O2 saturation < 88%, =88% with pulmonary HTN, heart failure, or polycythemia
  • Pulmonary rehabilitation (Groups B-D) - exercise, nutrition, education, smoking cessation, behavioral health
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15
Q

Vaccinations + COPD

A
  • Important part of preventative therapy
  • Annual influenza vaccination
  • Pneumococcal vaccination
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16
Q

MDI

A
  • Metered dose inhaler
  • Difficult to coordinate
  • Valved holding chamber helpful
  • Contains propellants
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17
Q

DPI

A
  • Dry powder inhaler

- Requires forceful inhalation

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18
Q

SMI

A
  • Soft Mist Inhaler
  • Slow steady mist
  • No skaing or spacer required
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19
Q

Nebulizer

A
  • Not portable
  • Expensive
  • No coordination of breath required
  • Continue only if symptomatic benefit clear
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20
Q

Bronchodilator Therapy Key Points

A
  • Inhaled treatment preferred
  • Long acting bronchodilators preferred (LABA and LAMA)
  • Consider combinations of mechanisms
  • Theophylline - not recommended unless other long-term treatment bronchodilators are unavailable or too expensive
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21
Q

Bronchodilators Benefits

A
  • Improves FEV1: dose response is relatively flat, increasing dose may provide subjective benefit in acute episodes, not helpful in stable disease
  • Toxicity is dose related
  • Improve exercise performance, dyspnea, health status
  • Reduce exacerbation rates, decrease hospitalizations
  • Given as-needed or on a regular basis
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22
Q

Muscarinic Antagonists

A
  • Frequently used in COPD
  • Short-acting (SAMA) and LAMA
  • Greater effect on exacerbation rates versus LABA
  • Nebulization with mask over eyes may precipitate acute glaucoma
  • Questionble evidence of CV events and mortality with ipratropium and Spiriva Respimat in COPD patients
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23
Q

Albuterol - MDI

A
  • SABA
  • Proventil, ProAir, Ventolin
  • 2 puffs (90 mcg/puff)
  • Every 4-6 hours PRN
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24
Q

Albuterol - Nebulizer

A
  • SABA
  • AccuNeb
  • Nebulized solution
  • 2.5 mg
  • Every 4-6 hours PRN
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25
Levalbuterol - MDI
- SABA - Xopenex HFA - 2 puffs (45 mcg/puff) - Every 4-6 hours PRN
26
Levalbuterol - Nebulizer
- SABA - Xopenex - Nebulized solution - 0.63 mg - Every 6-8 hours PRN
27
Ipratropium - MDI
- SAMA - Atrovent HFA - 2 puffs (17 mcg) - Four times daily, up to 12 puffs per day
28
Ipratropium - Nebulizer
- SAMA - 0.5 mg - Every 6-8 hours
29
Combivent
- Ipratropium + Albuterol - SAMA + SABA - Respimat (SMI) - 1 inhalation (20/100 mcg) - Four times daily, up to 6 inhalations per day
30
Duoneb
- Ipratropium + Albuterol - SAMA + SABA - Nebulizer Solution - 0.5/2.5 mg - Every 6 hours; up to every 4 hours
31
Serevent
- LABA - Salmeterol - Diskus (DPI) - 1 inhalation (50 mcg) - BID
32
Perforomist
- LABA - Formoterol - Nebulizer solution - 20 mcg - BID
33
Brovana
- LABA - Arformoterol - Nebulizer solution - 15 mcg - BID
34
Arcapta
- LABA - Indacterol - Neohaler (DPI) - 1 inhalation (75 mcg cap) - Once a day
35
Striverdi
- LABA - Olodaterol - Respimat (SMI) - 2 inhalations (2.5 mcg) - Once a day
36
Spiriva
- LAMA - Tioptropium - Handihaler (DPI) or Respimat (SMI) - DPI: 1 inhalation (18 mcg) - SMI: 2 inhalations (2.5 mcg) - Once daily
37
Turdorza
- LAMA - Aclidinium - Pressair (DPI) - 1 inhalation (400 mcg tab) - BID
38
Incruse
- LAMA - Umeclidinium - Ellipta (DPI) - 1 inhalation (62.5 mcg) - Once a day
39
Seebri
- LAMA - Glycopyrrolate - Neohaler (DPI) - 1 inhalation (15.6 mcg) - BID
40
Yupelri
- LAMA - Revefenacin - Nebulizer solution - 1 vial (175 mcg) - Once a day
41
Anoro
- LABA + LAMA - Vilanterol + Umeclidinium - Ellipta (DPI) - 1 inhalation (62.5/25 mcg) - Once a day
42
Stiolto
- LAMA + LABA - Olodaterol + Tiotropium - Respimat (SMI) - 2 inhalations (2.5/2.5 mcg) - Once a day
43
Utibron
- LABA + LAMA - Indacaterol + Glycopyrrolate - Neohaler (DPI) - 1 inhalation (27.5/15.6 mcg) - BID
44
Bevespi
- LABA + LAMA - Formoterol + Glycopyrrolate - Aerosphere (MDI) - 2 actuations (9/4.8 mcg) - BID
45
Duaklir
- LABA + LAMA - Aclidinium + Formoterol - Pressair (DPI) - 1 inhalation (400/12 mcg) - BID
46
Theophylline
-Available but NOT frequently used for COPD -Metabolized by P450 (drug interactions) -Clearance declines with age Adverse effects: toxicity is dosed related -Arrhythmias, convulsions, headaches, insomnia, nausea
47
Anti-Inflammatory + Long-term ICS Monotherapy
- NOT recommended | - Increases risk of pneumonia, oral candidiasis, hoarse voice, skin bruising
48
Anti-Inflammatory + ICS/LABA
-More effective improving lung function, health status, and reducing exacerbation in moderate to very severe disease
49
Anti-Inflammatory + ICS/LAMA/LABA
- Improves lung function, symptoms, health status, and reduces exacerbations - Compared to ICS+LABA, LABA+LAMA, or LAMA
50
Anti-Inflammatory + PDE4
-Severe to very severe COPD AND -History of exacerbations
51
Long-Term Azithromycin + Erythromycin
-Reduce exacerbations over 1 year
52
ICS Monotherapy
- NEVER used for COPD - Long-term safety is unknown with COPD - Withdrawal form use may cause exacerbations and increased symptoms - Long term use also hasn't been shown to reduce long-term decline
53
COPD + Pneumonia
- ICS use increases the risk - Current smokers - >= 55 y.o. - BMI < 25 kg/m^2 - Poor mMRC dyspnea grade - Severe airflow limitation - Prior exacerbations or pneumonia
54
Advair
- LABA + ICS - Used in COPD - Fluticasone propionate + Salmeterol - Diskus (DPI) - 1 inhalation (250/50 mcg) - BID
55
Symbicort
- LABA + ICS - Used in COPD - Budesonide + Formoterol - MDI - 2 puffs (160/4.5 mcg) - BID
56
Breo
- LABA + ICS - Used in COPD - Fluticasone furoate + Vilanterol - Ellipta (DPI) - 1 inhalation (100/25 mcg) - Once a day
57
Trelegy
- LABA + ICS - Used in COPD - Fluticasone furoate + Umeclidinium + Vilanterol - Ellipta (DPI) - 1 Inhalation (100/62.5/25 mcg) - Once a day
58
Roflumilast
- Daliresp - Used in COPD - PDE4 - Inhibits inflammation by breakdown of cAMP, no direct bronchodilator effect - Used in combination with at least 1 long lasting bronchodilator - Reduces exacerbations in patients with severe COPD (FEV1 < 50%, chronic bronchitis, frequent exacerbations) - AE: Nausea, reduced appetite, abdominal pain, diarrhea, sleep disturbances, headache (reduce over time) - Monitor for weight loss and depression
59
Antibiotics + COPD
- Not for antimicrobial activity - Reduce risk of exacerbations in those with increased risk of exaberations - No data beyond one year - Azithromycin: 250mg/day or 500 mg three times per week - Increases incidence of bacterial resistance and impaired hearing tests - Erythromycin: 500 mg BID
60
Other Medications for COPD
- Oral steroids: numerous SE, recommended only for short-term management of acute exacerbations - Little evidence for mucolytics or leukotriene modifiers - Antitussives have no conclusive evidence
61
Group A Initial Therapy
Bronchodilator
62
Group B Initial Therapy
- LABA | - LAMA
63
Group C Initial Therapy
-LAMA
64
Group D Initial Therapy
- LAMA - LAMA + LABA - ICS + LABA
65
Follow-Up Treatment
If response to initial therapy is appropriate, maintain it - If not, consider predominent treatable trait to target (exacerbations, dyspnea, etc.) - Exacerbation > dyspnea - Place patient in box corresponding to current treatment and follow indications - Recommendation not dependent on ABCD designation
66
Dyspnea Treatment
- Start with LABA or LAMA - Then go to LABA + LAMA - If still no response, consider switching inhaler device, molecules, or investigating/treating other causes of dyspnea - If on ICS, get off if there is a lack of response, has pneumonia, or inappropriate original indication
67
Exacerbation Treatment
- Start on LABA or LAMA - Go up to LABA + LAMA if blood levels or normal - LABA + ICS is eosinophil >= 300, OR eos >= 100 AND >= 2 moderate exacerbations/1 hospitalization - Get off of ICS if inappropriate (same reasons as dyspnea card) - Can increase from LABA + LAMA to LABA + LAMA + ICS - Can also alternatively add on roflumilast (FEV1 < 50% and chronic bronchitis) OR azithromycin (former smokers)
68
Monitor + Follow-up
- Lung function is expected to wrosen over time - Use symptoms/objective measures of airflow limitation to determine to modify therapy - Monitor symtoms, physical exam, smoking status, medication regimen every visit - CAT/mMRC every 2-3 months - Spirometry at least annually
69
COPD Comorbidities
- Heart failure, atrial fibrillation, and HTN should be treated - In Afib, use of high doses of beta-agonists can make heart rate control more difficult - Use beta-blockers if necessary

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