Exam #2 Flashcards
Risk factors for COPD
1: smoking: usually takes about 20 pack years to see signs
- environmental exposures
- genetics
- other (poor nourishment, socioeconomic status, chronic asthma, repeated lower respiratory tract infections, ..)
Definition of COPD
a common, preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and lungs to noxious particles or gases. Exacerbations and comorbidities contribute to the overall severity in individual patients.
inability to get air OUT is characteristic of this
what are comorbidities for COPD?
cardiovascular disease osteoporosis & depression metabolic syndrome and diabetes lung cancer GERD (independent risk factor for exacerbation & associated w/worse health status)
screening and diagnosis of COPD
should be suspected in any adult over 40 y.o. with…
- classic symptoms (chronic cough, chronic sputum production, dyspnea –> progressive, persistent & usually worse on exertion)
- exposure to risk factors for the disease (smoking history, usually > 20 pack years, occupational dust & chemicals)
- family history of COPD (especially alpha 1 antitrypsin deficiency)
spirometry (gold standard) should be considered in all patients suspected of COPD
What parameters are evaluated with spirometry?
FVC (forced vital capacity): maximum volume of gas (L) that can be expired forcefully after a maximum inspiration
FEV1 (forced expired volume in 1 sec): volume of gas (L) expired during first second of FVC
performed 15 minutes AFTER administration of a SABA (short acting beta agonist)
have to do this 3 times, because you need 2 to be reproduceable
How do you use spirometry to diagnose COPD?
FEV1/FVC ration < 0.70 (post SABA) confirms presence of persistent airflow limitation
grading: % predicted FEV1 (post SABA) indicates severity of obstruction
What information can you get fro pulmonary function tests? (PFT)
total lung capacity (amt of air in lungs at full inspiration) residual volume (amt of air left in lungs after maximal expiration) - both of these increase with air trapping (emphysema) diffusion capacity (DLCO): gas-transfer function of the lungs. reduced value consistent with emphysematous changes
What is the GOLD grading of airflow limitation?
ALL levels have FEV1/FVC < 0.70 (all measurements are post-bronchodilation)
Gold 1 (mild): FEV1 % predicted >/= 80% Gold 2 (moderate): 50-79% Gold 3 (severe): 30-49% Gold 4 (very severe): < 30%
How do you figure out what quadrant a COPD patient is in? (A, B, C or D)
Go to the quadrant that is most severe
Gold classification of airflow limitation 1 or 2 means bottom, 3 or 4 means top
0 or 1 exacerbation that did not require hospitalization means bottom, 2 or more OR one that caused hospitalization means top
CAT score < 10 = left side
CAT score >/= 10 = right side
A = 0-1 exacerbation or GOLD 1 or 2 and CAT < 10
B = 0-1 exacerbations or GOLD 1 or 2 and CAT >/= 10
C = >/= 2 exacerbations (or 1 hospitalization) or GOLD 3 or 4 and CAT < 10
D = >/= 2 exacerbations (or 1 hospitalization) or GOLD 3 or 4 and CAT >/= 10
what do gold copd patient groups mean?
A: low risk, less symptoms
B: low risk, more symptoms
C: high risk, less symptoms
D: high risk, more symptoms
What is CAT?
COPD assessment test
self-administered
what is MMRC?
modified medical research council dyspnea scale
another scoring method for COPD quadrant, used when CAT isn’t available (CAT is preferred). This is more specific for dyspnea
What are the goals of treatment of stable COPD?
reduce symptoms *** (relieve symptoms, improve exercise tolerance, improve quality of life) reduce risk (prevent progression, prevent & treat exacerbations, reduce mortality)
What are non-pharmacological recommendations for stable COPD?
smoking cessation vaccinations (yearly flu and pneumococcal for people 65 yrs and older OR 19-64 years old if chronic lung disease or smoker) pulmonary rehabilitation oxygen surgery
what is the only intervention for COPD that has been proven to slow the progression of the disease?
smoking cessation
what is pulmonary rehabilitation?
comprehensive multidisciplinary program: exercise, smoking cessation, nutrition counseling, education
increases QOL, recovery from exacerbation, increases exercise capacity & possibly survival, decreases hospitalizations, depression/anxiety and breathlessness
what kind of surgery can be done for COPD?
lung volume reduction surgery (LVRS): parts of lungs are resected to reduce hyperinflation
usually upper lobes of lung - then air can expand better
OR transplant (lung)
When should long-term oxygen therapy be used?
patients with documented hypoxemia +/- complications of chronic hypoxemia: > 15 hrs/day is needed (24 hrs is ideal)
can improve mortality
can improve symptoms
can reverse long term complications
what are pharmacological options for management of stable COPD?
inhaled bronchodilators: (mainstay of therapy)
-beta 2 agonists: SABA & LABA
-anticholinergics: SAMA and LAMA
inhaled corticosteroids (ICS)
phosphodiesterase-4 (PDE-4) inhibitor: roflumilast (Daliresp)
oral bronchodilators (theopylline)
bronchodilator therapy pearls
mainstay of therapy - all improve symptoms & exercise tolerance
not proven to alter progression of disease
combining beta2 agonists + cholinergic antagonists can result in improved efficacy with reduced risk for SE
long acting are more convenient & effective than short acting
decrease hospitalizations & exacerbations & improve QOL
how do you manage stable COPD for patient groups A, B, C and D
All patients should have SABA prn for acute symptoms Group A first choice: SABA prn (or SAMA prn) alternative: LAMA or LABA or SABA + LAMA other possible treatments: theophylline Group B first choice: LAMA or LABA alternative: LAMA + LABA other possible treatments: SAMA or SAMA + SABA or theophylline
Group C:
first choice: ICS + LABA or LAMA
alternative: LABA + LAMA or LAMA + roflumilast or LABA + roflumilast
other possible treatments: SAMA or SAMA + SABA or theophylline
Group D:
first choice: ICS + LABA + LAMA or LAMA alone
alternative: ICS + LABA + LAMA or inhaled CS + LABA + roflumilast or LABA + LAMA or LAMA + Roflumilast
other possible treatments: SAMA or SAMA + SABA or theophylline, carbocyteine, N-acetylcysteine
What are inhaled beta 2 agonists for stable COPD?
LABAs (first choice option alone for group B patients, CI: severe hypersensitivity to milk proteins) salmeterol formoterol indacaterol olodaterol aformoterol SABA (first choice option prn alone for group A, prn for all groups) albuterol levalbuterol
What are inhaled anticholinergics for stable COPD
LAMA: (first choice option for groups B, C and D. use with caution in pts with narrow-angle glaucoma and men with BPH. caution or CI: severe hypersensitivity to milk proteins)
tiotropium
aclidinium
umeclidinium
SAMA: first choice prn for group A; “other” option group B-D
iprotropium
What are combination bronchodilators for stable COPD?
SAMA + SABA: iprotroprium + albuterol (combivent resimat): alternative choice for A; “other” options B-D
LAMA + LABA: umeclidinium + vilanterol (Anoro Ellipta): alternative choice for groups B and C. CI: severe hypersensitivity to milk proteins
Theophylline
low efficacy and side effects, not recommended unless other bronchodilators are unavailable or unaffordable
available in tablets, capsules & liquid
dose-dependent side effects: tremor, tachycardia, insomnia, nervousness, irritability, GI, seizures, cardiac arrhythmias
watch out for drug interactions
inhaled Corticosteroid pearls
decrease exacerbations, improve symptoms, lung function, and QOL (does not alter progression of disease)
add on therapy for patients at high risk for exacerbations or frequent exacerbations (1st choice option in combination with LABA for groups C & D)
not recommended as monotherapy
side effects: increased risk for pneumonia (?), increased thrush, bruising and hoarseness
risk for worsening symptoms if discontinued
combination ICS + LABA products
budesonide + formoterol (symbicort): FDA-approved for COPD
fluticasone + salmeterol (Advair diskus): 250/50 dose FDA-approved for patients w/COPD. CI: severe hypersensitivity to milk proteins
fluticasone furoate + vilanterol (Breo Ellipta): FDA-approved for COPS. CI: severe hypersensitivity to milk proteins
inhaled combinations (ICS + LABA) have been shown to be more efficacious than either agent alone.
Roflumilast
selective phosphodiesterase (PDE) - 4 inhibitor
decrease PDE4 –> decrease cAMP metabolism –> increase cAMP in lung cells
FDA indicated to reduce the risk of COPD exacerbations in patients w/severe COPD associated w/chronic bronchitis and a history of exacerbations
alternative choice for groups C and D patients per GOLD guidelines
500 mcg tablet po once daily
$270/month
CI: moderate to severe liver impairment (Childs Pugh B & C)
warnings: watch out for worsening insomnia, depression, anxiety, suicidal thoughts
adverse effects: diarrhea, weight loss, nausea, headache, back pain, insomnia, dizziness, psychiatric adverse effects
DI: do not use with potent CYP450 inducers, use cautiously with CYP3A4 and dual CYP1A2/3A4 inhibitors
daily antibiotic therapy & COPD
one large study of Azithromycin 250mg po daily vs placebo for 1 yr showed significant reduction in time to & rate of exacerbations BUT
not recommended in guidelines due to risk > benefits
(small increase risk for hearing loss, possible antibiotic resistance, small increase risk for cardiac death - fatal heat arrhythmia)
how do you monitor response to therapy in COPD?
repeat spirometry is not reliable options: patient reported symptoms/activity level CAT score 6 minute walk test QOL questionnaires other scoring tools
what are patient education points for COPD?
smoking cessation (mention it every time you see them)
purpose of medications
expected outcome (benefit) from medications
side effects
timing & techniques (MDI/DPI)
What is an acute exacerbation of COPD?
an acute event characterized by a worsening of the patient’s respiratory symptoms (dyspnea, cough and/or sputum) beyond normal day-to-day variation & leads to a change in medication
precipitating factors: respiratory infection, environmental exposure, non-adherence
What are the consquences of a COPD exacerbation?
negative impact on QOL impact on symptoms and lung function increased economic cost increased mortality accelerated lung function decline
how do you manage an acute exacerbation of COPD?
oxygen: titrate to improve patient’s hypoxemia w/target saturation of 88-92%
bronchodilators: SABA w/or without SAMA preferred
hospitalized/ED patients; administration by nebulizer tends to be easier
outpatient management: MDI + spacer is effective
antibiotics: considered in hospitalized or ED patients w/increased sputum purulence AND increased dyspnea or sputum volume
treat for 5-10 days
benefits: decreased treatment failure, decreased mortality (in ICU patients)
systemic corticosteroids:
recommended in all COPD patients w/exacerbation
prednisolone/predisone 40 mg po daily X 5 days (*** know this **)
benefits: shorten recovery time, improve lung function & arterial hypoxemia reduce risk of early relapse, treatment failure, & length of hospital stay
watch for SE: hyperglycemia, edema, psych (insomnia, psychosis, anxiety)
Management of acute exacerbations of COPD and VTE prophylaxis
COPD exacerbation = major risk factor for VTE
may use heparin, enoxaparin, dalteparin, fondaparinux… until hospital discharge
asthma statistics
1 out of 11 children (US) 1 out of 12 adults (US) females > males young > old black children > white children lower ed & income > higher ed & income
characteristics of asthma
chronic inflammatory disorder of the airway
mast cells, eosinophils, neutrophils, macrophages & epithelial cells play a role
inflammation leads to recurrent episodes of cough, wheezing, breathlessness, and chest tightness
widespread, variable, reversible airflow obstruction
bronchoconstriction
airway hyperresponsiveness
edema
how do you diagnose asthma?
symptoms
med history
physical exam (increased nasal secretion, mucosal swelling, use of accessory muscles, hyperexpansion of thorax, atopic dermatitis, eczema)
spirometry: FEV1/FVC reduced
positive bronchodilator reversibility test (after SABA - tells us airway obstruction is reversible - necessary for diagnosis of asthma)
when should we use spirometry with asthma?
initial assessment
after treatment has been started & symptoms have stabilized
loss of asthma control
every 1-2 years
what are the goals of asthma treatment?
reduce impairment (reduce symptoms, minimal need of rescue inhaler, few night-time awakenings, optimal lung function, maintain normal daily activities) reduce risk (prevent exacerbations/ need for hospitalization, prevent reduced lung growth in children/loss of lung function in adults, optimize medications & minimize adverse effects)
classification of asthma severity in 0-4 yrs old
Intermittent: symptoms 2 days/week but not daily, 1-2/month nighttime awakenings, > 2 days/week but not daily use of SABA, minor limitation of activity, >/=2 exacerbations in 6 months requiring oral systemic glucocorticoids OR >/= 4 wheezing episodes/per lasting >1 day and risk factors for persistent asthma
Moderate: daily symptoms, 3-4/month nighttime awakenings, daily SABA use, some limitation with activity - same exacerbation/risk as mild
Severe: symptoms throughout the day, >1 time/week nighttime awakenings, SABA several times/day, extremely limited activity, same risk as mild
classification of asthma severity in 5-11 y.o.
intermittent: symptoms 85%, FEV1 > 80%, 0-2 exacerbations requiring oral systemic glucocorticoids/yr
mild: symptoms > 2 days/week but not daily, 3-4/mo night time awakenings, >2 days/week SABA use but not daily, minor limitations with activities, FEV1/FVC > 80%, FEV1 > 80%, > 2 exacerbations in 1 year
moderate: daily symptoms, < 1/week but not nightly nighttime awakenings, daily SABA use, some limitations of activity, FEV1/FVC 75-80%, FEV1 60-80%, same risk as mild
severe: symptoms throughout the day, often 7 times per week nighttime awakenings, several times/day SABA use, extremely limited activity, FEV1/FVC < 75%, FEV1 < 60%, same risk as mild
classification of asthma severity in >/= 12 y.o.
intermittent: symptoms 80%, exacerbations requiring oral systemic glucocorticoids 0-2/yr
mild: > 2 days/week but not daily symptoms, 3-4/month nighttime awakenings, >2 days/week but not daily SABA use, minor limitations with activity, lung function FEV1/FVC normal, FEV1 > 80%, > 2 exacerbations in 1 year requiring oral systemic glucocorticoids
moderate: daily symptoms, < 1/week but not nightly nighttime awakenings, daily SABA use, some limitations with activity, FEV1/FVC reduced < 5%, FEV 60-80%, same risk as mild
severe: symptoms throughout the day, often 7 times/week nighttime awakenings, several times/daySABA use, extremely limited activity, FEV1/FVC reduced > 5%, FEV1 < 60%, same risk as mild
Step therapy
intermittent: step 1
mild persistent: step 2
moderate persistent: step 3 or 4
severe persistent: step 5 or 6
Step therapy for 0-4 y.o.
ALL have SABA prn
Step 1: SABA prn
Step 2: preferred: low dose ICS
alternative: montelukast or cromolyn
step 3: preferred: medium-dose ICS
step 4: preferred: medium dose ICS AND either montelukast or LABA
step 5: preferred: high-dose ICS and either montelukast or LABA
step 6: preferred: high dose ICS and either montelukast or LABA AND oral corticosteroids
step up if needed (first check adherence & environmental control) assess control, step down if possible (and asthma is well controlled at least 3 months)
patient education & environmental control at each step
step therapy for 5-11 y.o.
SABA for all
patient education & environmental control at each step
step 1: preferred SABA prn
step 2: preferred: low dose ICS
alternative: LTRA (leukotriene receptor antagonist: montelukast), Cromolyn, nedocromil, or theophylline
step 3: preferred: medium-dose ICS or low dose ICS + LABA, LTRA, or thephylline
step 4: preferred: medium-dose ICS + LABA, alternative: medium-dose ICS + either LTRA or theophylline
step 5: preferred: high-dose ICS + LABA, alternative: high-dose ICS + either LTRA or theophylline
step 6: preferred: high-dose ICS + LABA + oral corticosteroid, alternative: high-dose ICS + either LTRA or theophylline + oral corticosteroid
step up if needed (first check adherence & environmental control & comorbid conditions) assess control. step down if possible (and asthma is well controlled at least 3 months)
steps 2-4, consider SQ allergen immunotherapy for allergic patients
step therapy for >/= 12 y.o.
patient education and environmental control at each step
SABA prn for all patients
step 1: preferred SABA prn
step 2: preferred: low dose ICS, alternative: cromolyn, nedocromil, LTRA or theophylline
step 3: preferred: medium-dose ICS OR low-dose ICS + LABA, alternative: low-dose ICS+LTRA, theophylline or zileuton
step 4: preferred: medium-dose ICS + LABA, alternative: medium-dose ICS + LTRA, theophylline or zileuton
step 5: preferred: high dose ICS + LABA, and consider omalizumab or patients who have allergies
step 6: preferred: high-dose ICS + LABA + oral corticosteroid and consider omalizumab for patients who have allergies
step up if needed (first, check adherence and environmental control, and comorbid conditions) assess control. step down if possible (and asthma is well controlled at least 3 months)
steps 2-4: consider sq allergen immunotherapy for allergic patients
use of beta 2 agonists > 2 days/week for symptom control indicates inadequate control & the need to step up treatment
What are the categories of asthma medications?
Quick Relief:
SABA (short acting beta agonists)
short acting anticholinergic
systemic corticosteroids
Long Term Control Medications: Inhaled corticosteroids LABAs (long acting beta agonists) Cromolyn leukotriene modifiers methlxanthines immunomodulators systemic corticosteroids
Asthma medication terminology
MDI
HFA
DPI
MDI - meter dosed inhaler
HFA - hydrofluoroalkane (propellant that’s used to get medication out)
DPI- dry powder inhaler (discus)
spacer - attach it to MDI to help patient use it appropriately
nebulizer
SABAs
drug of choice for acute bronchospasm
sole treatment for intermittent asthma
therapy of choice for exercise induced bronchospasm (EIB)
albuterol HFA (proventil, ventolin, proair)
levalbuterol HFA (xopenex) (L-enantiomer of albuterol)
Albuterol nebulizer
levalbuterol nebulizer
Adverse effects: tachycardia, tremor, hypokalemia, hyperglycemia, inhaled route leads to few systemic side effects
therapeutic considerations:
not for long term daily use
increase in use or lack of effect indicates diminished control of asthma
inhalation route preferred (oral therapies are available)
all patients w/asthma should have SABA available
Anticholinergics
Role in therapy:
drug of choice for bronchospasm due to beta-blocker medication
alternative for patients intolerant to SABA
used in combination w/SABA during acute exacerbation
ipratropium HFA (atrovent)
Ipratropium nebulizer
Iprotropium/albuterol inhaler (combivent Respimat)
Ipratropium/albuterol nebulizer
Adverse effects: dry mouth & respiratory secretions, blurred vision (if sprayed in eyes), less cardiac stimulation than SABAs
Therapeutic considerations: increase in use or lack of effect indicates diminished control of asthma, not for long term daily use in asthma, does not work for exercise induced bronchospasm
Oral corticosteroids
Role in therapy: short courses “bursts” used to establish control with initiation of therapy or during exacerbation
may be used in severe persistent asthma (step 6 for every age group)
Methylprednisolone
prednisolone
prednisone
adverse effects: short term use: glucose abnormalities, increased appetite, fluid retention, weight gain, facial flushing, mood changes, hypertension, adrenal suppression, osteoporosis, skin thinning, growth suppression
Therapeutic considerations: burst should be continued until patient achieves 80% of peak expiratory flow or symptoms resolve, other equipotent doses of systemic corticosteroids may be used, different dosages for daily use, tapering with daily use, not with bursts
inhaled corticosteroids
role in therapy: drug of choice for persistent asthma long term prevention of symptoms, suppression, control and reversal of inflammation beclomethasone HFA Budesonide DPI Budesonide nebulizer Flunisolide Flunisolide HFA fluticasone HFA Fluticasone DPI mometasone DPI triamcinolone adverse effects: cough, dysphonia, oral thrush, at high doses, systemic side effects may occur Therapeutic considerations: reduce risk of thrush by use of spacer/holding chamber with MDI, rinse mouth after inhalation, Dexamethasone is not used as an ICS due to high absorption & long term suppressive side effects
Long acting beta agonists
role in therapy:
long term prevention of symptoms in addition to ICS
prevention of exercise induced bronchospasm
do NOT use for acute symptoms
potential for uncommon, severe, life threatening or fatal exacerbation when used as monotherapy in asthma
Salmeterol
Formoterol
adverse effects: tachycardia, tremor, hypokalemia, prolongation of QTc
Therapeutic considerations:
do not use for acute symptoms
Do not use as monotherapy
May provide more control when added to ICS compared to increasing dose of ICS
what are some combination medications available? (LABA + ICS)
fluticasone/salmeterol (Advair) DPI
Budesonide/formoterol (Symbiocort)
Mometasone/formoterol (Dulera)
Cromolyn
Role in therapy:
long term prevention of symptoms in mild persistent asthma as an alternative to ICS
preventive treatment prior to exposure to exercise or known allergen
Adverse effects: cough and irritation
Therapeutic considerations:
safety is primary advantage of cromolyn
Therapeutic response will typically occur in 2 weeks, but max benefit may not be seen in 4-6 weeks
dose of MDI cromolyn may be inadequate for asthma; nebulizer may be preferred
Leukotriene modifiers
Role in therapy:
alternative treatment for persistent asthma
may be used in exercise induced bronchospasm, aspirin-induced asthma, and allergic asthma
Leukotriene Receptor antagonists:
Montelukast
Zafirlukast
5-Lipoxygenase inhibitor:
Zileuton
adverse effects: Antagonists: headache | Inhibitor: GI upset, headache, hepatoxicity
Therapeutic considerations:
monitor liver function with zafirlukast and zileuton
Administer zafirlukast at least 1 hr before or 2 hrs after meals
be aware of drug interactions with zafirlukast & zileuton
also approved for allergic rhinitis
Methylxanthines
Theophylline
Role in therapy:
long term control & prevention of symptoms in mild persistent asthma (as an alternative to ICS) or as an adjunctive with ICS in moderate to severe asthma
have to calculate dose
adverse effects:
insomnia, gastric upset, aggravation of ulcer/gerd, increase in hyperreactivity in children
Toxicities: tachycardia, nausea, vomiting, tachyarrhythmias, central nervous system stimulation, headache, seizures, hematemesis, hyperglycemia, hypokalemia
Therapeutic considerations:
regular serum monitoring is necessary (narrow therapeutic window, severe toxicity)
steady-state concentrations = 5-15 mcg/mL
food affects absorption
many drug-drug/drug disease interactions
Immunomodulators
Role in therapy:
long term control and prevention of symptoms in adults (>/=12 yrs) who have moderate or severe persistent allergic asthma inadequately controlled with ICS
Omalizumab
only for > 12 y.o.
adverse effects: pain & bruising at injection sites, anaphylaxis
Therapeutic considerations:
monitor following injections due to potential for anaphylaxis
administer no more than 150 mg in one injection
refrigerate
tiotropium in asthma
long acting anticholinergic bronchodilator
widely used for COPD, but not included in asthma guidelines
reserve for poorly controlled asthma despite ICS/LABA
Assessing control of asthma 0-4 y.o.
well controlled: 2 days/week symptoms, >/= 1 time/month nighttime awakening, > 2 days/week SABA use, some limitations of activity, 2-3 /yr exacerbations requiring oral systemic glucocorticoids
very poorly controlled: symptoms throughout the day, >/= 1 time/week nighttime awakenings, several times/day SABA use, extremely limited activities, > 3/yr exacerbations requiring oral systemic glucocorticoids
assessing control of asthma 5-11 y.o.
well controlled: 80% lung function FEV1, >80% FEV1/FVC, 0-1/yr exacerbations requiring oral systemic glucocorticoids
Not well controlled: > 2 days/week; multiple times on /= 2 times/month nighttime awakenings, some limitations in activity, 60-80% lung function FEV1, FEV1/FVC 75-80%, >/=2/yr exacerbations requiring oral systemic glucocorticoids
very poorly controlled: symptoms throughout the day, nighttime awakenings >/= 2 times/week, SABA use several times/day, extremely limited activity, lung function < 60%, FEV1/FVC /= 2 /yr exacerbations requiring systemic glucocorticoids
