COPD

Question 1

COPD

Answer 1

preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation usually caused by significant exposure to noxious particles or gases

Question 2

Risk factors for COPD

Answer 2

-smoking
-occupational dust and chemicals
-indoor/outdoor pollution
-genes
-infections
-socio-economic status
-aging population

Question 3

Clinical Presentation of COPD

Answer 3

-Dyspnea
-Cough (often first sx of COPD) - intermittent or persistent; productive or unproductive
-Chronic sputum production
-Wheezing
-Comorbidities

Question 4

Diagnosis of COPD

Answer 4

-Spirometry: FEV1/FVC < 0.70

Question 5

Bronchodilators

Answer 5

-Inc FEV1 or change other spirometric variables
-Widening of the airways
-Improve emptying of the lungs

Question 6

Beta agonists

Answer 6

-relax airway smooth muscles by stimulating beta 2 adrenergic receptors, which inc cyclic AMP and antagonizes bronchoconstriction - bronchodialation
-AE: tremor, hypokalemia, tachycardia, tacyphylaxis
-SABA: albuterol, levalbuterol
-LABA: Salmeterol, Formoterol, Olodaterol, Aformoterol, Indacaterol

Question 7

Muscarinic antagonists

Answer 7

-block bronchoconstrictor effects of acetylcholine on the M3 muscarinic receptors expressed in the airway smooth muscle
-SAMAs have slightly longer duration than SABAs
-poor systemic absorption
-AE: dry mouth (anticholinergic), tiotropium may cause metallic taste, cough, nausea, blurred vision, glaucoma
-SAMA: Ipratropium bromide
-LAMA: Tiotropium (Spiriva), Aclidinium, Umeclidinium (incruse ellipta)

Question 8

short acting bronchodilator combos

Answer 8

-prn for symptoms or scheduled
-SABA + SAMA
-improve efficacy and equal or lesser SE
-Albuterol/Ipratropium MDI
-Albuterol/Ipratropium neb

Question 9

Long acting bronchodilator combos

Answer 9

-Stiolto
-Anoro Ellipta

Question 10

ICS/LABA combo

Answer 10

-Fluticasone furoate/vilanterol (Breo)
-Fluticasone propionate/salmeterol (Advair, Wixela)
-Budesonide/fomoterol (Symbicort)
-mometasone/formoterol (Dulera)

Question 11

Triple therapy inhaler

Answer 11

-Fluticasone furoate/umeclidinium/vilanterol (Trelegy Ellipta)
-Budesonide/glycopyrrolate/formoterol (Breztri aerosphere)

Question 12

Oral steroids

Answer 12

-used for exacerbations not for chronic management

Question 13

Roflumilast (Daliresp)

Answer 13

-PDE4 inhibitors reduce inflammation by inhibiting the breakdown of intracellular cAMP
-AE: nausea, diarrhea, weight loss, sleep disturbances, HA, worsen depression
-do not use with Theophylline

Question 14

Assessment of COPD (ABCD assessment tool)

Answer 14

-need spirometric value of < 0.7 (FEV1/FVC)
-then grade severity based on gold guidelines, then assess symptoms/risk of exacerbations by using A,B,C,D grouping

Question 15

GOLD 1 (mild)

Answer 15

> /= 80%

Question 16

GOLD 2 (moderate)

Answer 16

50-79%

Question 17

GOLD 3 (severe)

Answer 17

30-49%

Question 18

GOLD 4 (very severe)

Answer 18

< 30%

Question 19

Group A

Answer 19

-mMRC 0-1
-CAT < 10
-0 or 1 exacerbation, not leading to hospital admission

Question 20

Group B

Answer 20

-mMRC >/= 2
-CAT >/= 10
-0 or 1 exacerbation not leading to hospitalization

Question 21

Group C

Answer 21

-mMRC 0-1
-CAT < 10
- >/= 2 or >/= 1 leading to hospitalization

Question 22

Group D

Answer 22

-mMRC >/= 2
-CAT >/= 10
- >/= 2 or >/= 1 leading to hospitalization

Question 23

mMRC

Answer 23

-measure of breathlessness
-scale 0-4
-predicts future mortality risk

Question 24

CAT

Answer 24

comprehensive assessment of symptoms not just breathlessness

Question 25

ICS

Answer 25

don't want to use in COPD patients unless they have features of asthma or inc eosinophil count

Question 26

Group A

Answer 26

-bronchodilator -long acting (LAMA or LABA) are preferred unless patient has occasional dyspnea

Question 27

Group B

Answer 27

long acting bronchodilator (LAMA or LABA)

Question 28

Group C

Answer 28

LAMA

Question 29

Group D

Answer 29

-LAMA or -LAMA + LABA or (if highly symptomatic CAT >20) -ICS + LABA (if eos >/= 300)

Question 30

Adjusting therapy

Answer 30

-use follow up pharmacological treatment algorithm -either dyspnea pathway or exacerbation pathway

Question 31

Dyspnea

Answer 31

-LABA or LAMA -> LABA + LAMA -if eos is >300 or eos >100 and > 2 moderate exacerbations/ 1 hospitalization switch to LABA + ICS or triple therapy

Question 32

Exacerbations

Answer 32

-LABA or LAMA -> LABA + LAMA -if eos is >300 or eos >100 and > 2 moderate exacerbations/ 1 hospitalization switch to LABA + ICS -if eos > 100 switch to triple therapy if eos < 100 switch to roflumilast or azithromycin (former smokers)

Question 33

long term oxygen therapy

Answer 33

in patients with severe resting chronic hypoxemia, long term oxygen therapy (>15 hours per day) improves survival

Question 34

Asthma-COPD Overlap

Answer 34

-Step 1: does the patient have chronic airway disease? -Step 2: if the patient has over 3 features of either asthma or COPD then it is likely the right diagnosis -Step 3: spirometry (< 0.7 ratio) -Step 4: initial therapy (start treatment as for asthma with low or moderate ICS; usually add LABA &/or LAMA or continue if already prescribed

Question 35

Acute COPD exacerbation

Answer 35

-sx: increased dyspnea, increased sputum purulence and volume increased cough and wheeze -goal O2: 88-92% -causes: main: viral; 2nd: bacterial and pollution; last: fungal

Question 36

Acute exacerbation classification

Answer 36

-mild: Short acting bronchodilators only (ex. albuterol) -moderate: Short acting bronchodilators + abx +/- steroids -severe: hospitalization or ED visit +/- severe acute respiratory failure

Question 37

Acute exacerbation nonpharm

Answer 37

-O2 < 90% saturation (target 88-92) -ventilation (NIV for severe respiratory acidosis (pH < 7.35 and PaCO2 > 45), severe dyspnea, persistent hypoxemia -Intubation and mechanical ventilation: life threatening hypoxemia, etc.

Question 38

(Acute) bronchodilators

Answer 38

-albuterol or ipratropium

Question 39

(Acute) steroids

Answer 39

-Prednisone 40 mg po daily -treat for 5 days -use oral unless pt cannot tolerate -no taper required unless over 14 days

Question 40

(Acute) abx

Answer 40

-treat for 5-7 days -3 cardinal signs: increased dyspnea, increased sputum vol and purulence -2 cardinal signs: one needs to be inc sputum purulence -Augmentin 875 mg po or Unasyn 3 gm IV Q6h (renal dosing) -Azithromycin 500 mg po daily x 3 days or 500 mg x 1 then 250 mg days 2-5 -doxycycline 100 mg po BID -Risk for pseudomonas: Cefepime, Pop/tazo, levofloxacin, carbapenem

Question 41

(Acute) monitoring

Answer 41

-steroids: WBC, glucose -abx: WBC w/ neutrophils, temp, cultures, SCr, CrCl, eGFR (if renal elimination) -bronchodilators: HR, frequency of use