Week 2: COPD Flashcards

Question

stepwise approach to dx and initial treatment of ACO via GINA and GOLD guidelines

Answer 1

1. dx airway disease yes:go to step 2 no: onsider other disease first 2. syndromic dx of asthma, COPD, or ACO using chart, if pt has 3 or mroe of either asthma or COPD, there is a strong likilood that is the correct dx. 3. perform spirometry 4. commence initial treatment: notes: no LABA monotherapy in asthma pats. no ICS monotherapy in COPD. *ket: if ACO, initiate ICS or ICS bronchdilator combo.

Answer 2

determine the laevel of airflow limitation determine impact on patients health status determine risk for furture events (exacerbations, hospitalization, death) to guide therapy

Answer 3

Used for initial assessment of copd 1.Assess degree of airflow limitation 2. assess symptoms 3. assess risk of exacerbations

Answer 4

Gold 1: Mild: FEV1 >/=80% predicted Gold 2: Moderate: 50%

Answer 5

1. Modified British medical research council (mMRC) questionaire *measures breathlessness predicts future mortality, and relates to other measures of health status mMRC0-4 2.COPD Assessment Test (CAT *comprehensive assesment of symptoms

Answer 6

COPD exacerbations defined as acute worsening of respiratory symptoms that result in additional therapy. ( mild: (treated with SABAs only) moderate: treated with SABAs plus abx or oral corticosteroids severe: pt requires hospitalization or visits to ED. severe exacerbations may also be associated w. acut respiratory failure *note: blood eosinophil count may alsopredict exacerbation rates in pts treated w. LABA w.o ics

Answer 7

HIGH RISK: 2 or more exacerbations in the last year OR 1 or more exacerbation that led to hospitalization NOT HIGH RISK no exacerbations in the last year or 1 exacerbation in the last year that did not lead to hospitalization

Answer 8

CD AB left:(moderate or severe exacerbation hx) I. >/2 exacerbations or >/1 exacerbation that led to hospitalization II. 0-1 exacerbation not leading to hospitalization bottom: assessment of symtpoms mMRC >/1 or CAT<10: mMrc>/2 OR cat>/10

Answer 9

copd pts at risk for cv disease osteoporosis respiratory infections anxiety and depreesion diabetes lung cancer bronchiectasis thes comorbid ocnditions may influenc mortaility and hospitalizations and should be looked for routinely and treated appropriately

Answer 10

reduce symtoms reduce disease progreesion, risk, exacerbatoins, and mortaility

Answer 11

reduce symtoms reduce disease progreesion, risk, exacerbatoins, and mortaility

Answer 12

assess severity of airflow limitation base don fev1 assess symptoms/ exacerbations and stae (group ABCD) use initial pharm treatment algorithm to select theraoy based on group ABCD

Answer 13

Group A: A bronchodilator (can be short or long acting, for ex short acting in pts w. occasional dyspnea) Group b: A long acting bronchdilator (LABA OR LAMA)(no preference of one over other gorup C: LAMA Group D: LAMA or LAMA+LABA* or ICS+LABA** *CONSIDER IF cat score>20 *consider if eos>/300 also note: rescue inhalers are recommended too. +SABA, SAMA, OR SABA/SAMA(preffered over either alone for improving FEV1 and symptoms) combo

Answer 14

1. if response to initial treatment is appropriate,maintain it. 2. if not.. a) consider predominant treatable trait to target (dyspnea or exacerbations) b)place pt in a box corresponding to current treatment and follow indications. c)assess response, adjust and review these recommendations do not depend on the ABCD assessment at dx.

Answer 15

!!!DYSPNEA!!! if on...... LABA OR LAMA v LABA+LAMA v consider switching inhaler device or molescules investigate or treat other causes of dyspnea if on... LABA+ICS v LABA+LAMA+ICS notes:consider ICS if eos>/300 or >/= 100 AND 2 moderate exacerbations/1 hospitalization also consider ICS deescalation or switch if pneumonia , inapropriate original indication, or lack of response to ICS

Answer 16

!!EXACERBATIONS!!! LABA or LAMA v v LABA+LAMA LABA +ICS v v v v v > *LABA +LAMA+ICS*< v v v v> > > > > > > > >>>>v<<<<<<<<<<<< v v <<<<<<<<<<<<<<<<<>>>>>>>>>>>>>>>> V v Roflumilast if Azithromycin FEV1<50% & in former chornic bronchitis smokers notes:consider ICS if eos>/300 or >/= 100 AND 2 moderate exacerbations/1 hospitalization also consider ICS deescalation or switch if pneumonia , inapropriate original indication, or lack of response to ICS

Answer 17

based on .. therapy cost/formulary pt response delivery device

Answer 18

mainstay of COPD therapy increase fev1 and or change spirometric values alter smooth muscle tone; improvements in expiratory flow reflect widening of the airways (rather than elastic recoil) improve emptying of lunfs, decrease hyperinflation improve exercise performance dose response curves are relatively flat (toxicity is dose related-

Answer 19

for use inselect pts w. copd relationship btw eos count in ICS effects GOLD uses theeshold >/300 or >100+exacerbations) to predict probability of treatment beenfit ics increases risk of pneumonia asthma hx or features of asthma present? ics combo therapy indicated

Answer 20

pharm therapy slow decline of fev1 saba/sama combo superior than either alone lama has greater reduction in exacerbations vs laba laba/lama reduce SS and exac, inc. outcomes, and red. hospitalizations better than when used alone

Answer 21

ABX: infectious exacerbations , also macrolides can decrease exacerbation rate mucolytics, antioxidants (guafenisin, carbocysteine, NAC reduce exacerbations and modestly improve health status antitussives: regular use not recommended, due to cough having protective role in copd

Answer 22

A)smoking cessation: greatest capacity to influence natural history of copd B)vaccinations: *influenza dec. lower respiratory tract infections pneumococcal vaccination dec lower resp. tract infections tdap in those not vaccinated to rpevent pertussis covid 19 C)pulmonary rehab D) long term oxygen therapy: in pts. with severe resting chornic hypoxemia, long term oxygen therapy (15 hrs/dau) improves survivial. *given when pao2< 55 mmhg or sao2 <88% or *pao2>55 but <60mmhg (>7.3 pka but <8kpa) given to bring sao2

Answer 23

annual spirometry testing ask pts to mointor any changes in their symptoms(ie sleep, exercise ability, sob) CAT or mMRC smoking status med side effects adherence disease progression and development of complications

Answer 24

acute worsening of respiratory symptoms that results in additional therapy or medications

Answer 25

increased airway inflammation increased mucus production marked gas trapping increased eosinophils in significant number of patients pts w. longstanding copd retain co2, causing chronic respiratory acidosis. drive to breath is hypoxia. if overoxygenated, c an cause repsiratory depression, thats why o2 goal is 88-92%

Answer 26

increased dyspnea increased sputum purulence (change in color) and volume increased cough and wheeze Lasts about 7-10 days

Answer 27

in order 1. viral *rhinoviruses 2.bacterial 3.fungal 4.other *pollution *ambient temp *fine particulate matter exposure

Answer 28

severity treatment mild SABDs only moderate SABDs+abx+/-oral cortico, severe requires hospitalization or ED visit +/- severe acute resp failure

Answer 29

hx: compare SS to baseline, severity of symptoms, subjective signs, smoking, O2 physical exam: vitals, conciousness , temp(fever, taCHYPNEA, tachycardia, o2 stat resp exam: wheezing, coughing, decreased breath sounds Labs possbile ABG WBC K+, Mg (dependent on bronchodilator used), glucose (stoeroids vit D. if severe definciency (<10 ng/ml or 25 nM...supplement dx: sputum sample, gram stain/culture, chest xray

Answer 30

O2 sat: <90 goal sao2: 88-92% ventilation: noninvensive mechanical ventilatioin(NIV) intubation and mechanical ventilation

Answer 31

1)bronchodilators: Albuterol(A)(preffered), Ipratropium(I), A/I combo, *A or I MDI1 puff inh Q1h 2-3 doses then 2 puffs Inh q 24-hrs 2)corticosteroids: predinosone 40 mg or equiv for 5 days abx: treart for 5-7 days if moderately ill w. 3 cardinal signs or have 2 cardinal symptoms w. one being sputum purulence oxygen supplementation: if sao2<90%.titrate to goal of 88-92% home medications: adjust as needed

Answer 32

dyspnea increased sputum volume increased sputum purulence

Answer 33

organisms needing coverage: Hemophilus influenzae, stereptococcus pneumoniae, moraxella catarrhalis options Aminopenicillin/clavulanic acid (augmentin) 875 mg po BID or Unasyn 3gmIV q6h (renal elimination) for 5-7 days *note. augmentin and unasyn must be renally dosed macrolide-azithromycin 500 mg po dailyx3 days or 500 mgx1, then 250 mg days 2-5 days (can do 3 days due to long half life of upto 3 days) a tetracycline-doxycycline 100 mg PO BID for 5-7 days if risk for pseudamonas: cefepime, piperacillin/tazobactam, levofloxacin, carbapnem (hospotal antibiogram)

Answer 34

smokkind cessation immunizations (influenza, pneumococcoal, tdap (pertussis), covid 10 dvt prophylaxis

Answer 35

IV/PO theophylline chronic suppressive abx

Answer 36

copd control: o2 sat, clinical symptoms, HR physical exam (wheezing, accessory muscle use, cyanosis medication efficacy/ toxicity control of copd, as above stroids : monitor WBC, glucose (daily), consider short acting insulin if needed abx: wbc, neutrophils, temp, cultures, Scr,Crcl,eGFR (if renal elimination) bronchodilators: HR, frequency of use(ATC v. PRN)