COPD - Med/High Priority

Question 1

What is COPD?

Answer 1

progressive, partially reversible airflow limitation
-inflammation throughout central and peripheral airways, lung parenchyma, and pulmonary vasculature resulting in mucus hypersecretion and/or lung changes

Question 2

What is the pathophysiological hallmark of COPD?

Answer 2

expiratory flow limitation

Question 3

What are the risk factors for COPD?

Answer 3

smoking (leading cause)
air pollution/biomass cooking and heating
long term dust & chemical exposure (occupation)
genetics (A1AT deficiency)
age > 35 yrs
childhood infections
tuberculosis-associated COPD
HIV-associated COPD
premature birth weight and LBW
recurrent LRTIs

Question 4

What are common comorbidities seen in COPD?

Answer 4

cardiovascular disease
metabolic syndrome
skeletal muscle dysfunction
GERD
renal insufficiency
sleep apnea
depression
anxiety
osteoporosis
lung cancer

Question 5

Which drugs may exacerbate, mimic disease, or limit response to COPD therapy?

Answer 5

beta-blockers
ACEI (dry cough unrelated to COPD)

Question 6

What are the signs and symptoms of COPD?

Answer 6

signs:
-reductions in FEV1/FVC
-hypoxia and hypercapnia
-physiologic changes to chronic hypoxia (polycythemia, pulmonary HTN, cor pulmonale)
symptoms:
-chronic cough and sputum production
-recurrent respiratory infections
-exertional SOB
-exercise limitations

Question 7

What is the spirometry diagnostic criteria for COPD?

Answer 7

FEV1/FVC < 0.7 post-bronchodilator

Question 8

What are the different severities of COPD based on FEV1?

Answer 8

mild: FEV1 >= 80%
moderate: FEV1 50-80%
severe: FEV1 30-50%
very severe: FEV1 < 30%

Question 9

How do asthma and COPD differ in their onset?

Answer 9

asthma: usually under 40 yrs old
COPD: usually over 35 yrs old

Question 10

How do asthma and COPD differ in terms of smoking history?

Answer 10

asthma: no correlation
COPD: usually 10+ yrs of smoking

Question 11

How do asthma and COPD differ in terms of clinical symptoms?

Answer 11

asthma:
-SOB, chest tightness, wheezing and coughing attacks worsened by respiratory viruses
-intermittent in nature and variable based on trigger exposure
-sputum: rarely
COPD:
-SOB, fatigue, productive cough, chest tightness, and wt loss/muscle loss
-persistent symptoms and worsens with exertion
-sputum: frequently

Question 12

How do asthma and COPD differ in terms of disease course?

Answer 12

asthma: stable with exacerbations
COPD: progressively worsening with increasing frequency & severity of exacerbations

Question 13

How do asthma and COPD differ in terms of pathology?

Answer 13

asthma:
-genetics and environments causes leading to increased contractibility of the respiratory smooth muscles
-pulmonary constriction associated with triggers
COPD:
-accumulation of damage/scar tissue from prolonged exposure to inhaled chemicals
-leads to reduced elasticity of the lungs due to scarring (emphysema) and hypersecretion of phlegm (chronic bronchitis)

Question 14

Differentiate the different severities of COPD based on the mMRC dyspnea scale.

Answer 14

grade 0:
-SOB with strenuous exercise
grade 1:
-SOB when walking up hill or hurrying on level
grade 2:
-walks slower than peers or stopping for breath when walking at usual pace
grade 3:
-stopping for breath after walking 100m or for a few min
grade 4:
-SOB while performing ADLs

Question 15

What is the CAT?

Answer 15

COPD Assessment Test
-8 questions assessment of common COPD sx and side effects
-5 point scale for each question
-total score ranges from 0-40
-higher score indicates greater impact on health

Question 16

Differentiate COPD severity A, B, and E.

Answer 16

E: most severe
- >=2 exacerbations in past yr (no hospital) or >=1 exacerbation in past yr leading to hospital admission
B:
-0-1 exacerbation in past yr (no hospital admission)
-mMRC >=2 or CAT >=10
A:
-0-1 exacerbation in past yr (no hospital admission)
-mMRC 0-1 or CAT < 10

Question 17

What are the goals of therapy for COPD?

Answer 17

prevent disease progression by providing smoking cessation support
reduce frequency and severity of exacerbations
alleviate dyspnea
improve exercise tolerance and daily activity
treat exacerbations and complications of the disease
improve health status and concomitant disease burden
reduce mortality related to CV complications of COPD

Question 18

What are the non-pharmacological measures for COPD?

Answer 18

vaccination
smoking cessation
home O2
symptom self-management

Question 19

Which vaccinations are recommended for pts with COPD?

Answer 19

annual influnenza
pneumococcal
COVID-19
Tdap
RSV
Shingles

Question 20

What is a contraindication to home O2?

Answer 20

current smoking

Question 21

When might home O2 be used in COPD?

Answer 21

severe hypoxia at rest
-improves survival

Question 22

Describe the COPD treatment algorithm.

Answer 22

E: LAMA + LABA
-consider LABA+LAMA+ICS if serum eos >= 300
B: LAMA + LABA and short-acting bronchodilator prn
A: LABA or LAMA and short-acting bronchodilator prn

Question 23

When is ICS use strongly favoured in COPD?

Answer 23

history of hospitalization(s) for COPD
-despite appropriate long-acting bronchodilator therapy
>=2 moderate COPD exacerbations in past year
-despite appropriate long-acting bronchodilator therapy
blood eosinophils >= 300 cells/uL
history of or concurrent asthma

Question 24

When is ICS use favoured in COPD?

Answer 24

1 moderate COPD exacerbation/yr
-despite appropriate long-acting bronchodilator therapy
blood eosinophils >= 100 to < 300 cells/uL

Question 25

When is ICS use not favoured in COPD?

Answer 25

repeated pneumonia blood eosinophils < 100 cells/uL history of mycobacterial infection

Question 26

When is roflumilast added in COPD?

Answer 26

advanced disease (with exacerbations) when pt is: -on LABA + LAMA and eosinophils < 100 -on LABA + LAMA + ICS regardless of eosinophils -if FEV < 50% and chronic bronchitis

Question 27

When is azithromycin added in COPD?

Answer 27

on LABA + LAMA and eosinophils < 100 on LABA + LAMA + ICS regardless of eosinophils *preferrable in former smokers*

Question 28

What must be checked before adding azithromycin in COPD?

Answer 28

QT interval MAC status ensure pt is not a current smoker

Question 29

What is the role of duplimumab in COPD?

Answer 29

pts already on triple therapy with eosinophils >= 300 and chronic bronchitis symptoms -pts with above criteria had fewer exacerbations, better lung function, and improved overall health

Question 30

Which agents should not be used in COPD?

Answer 30

ICS monotherapy (increased mortality) theophylline (modest sx improvement, multiple DDI + AE) chronic systemic corticosteroids antitussives (codeine and DM) mucolytics (guaifenesin)

Question 31

What is AECOPD?

Answer 31

acute worsening of dyspnea, sputum purulence and/or sputum production leading to an increased use of maintenance medications and/or addition of other medications

Question 32

Why are we so concerned about AECOPD?

Answer 32

leads to increased: -medical visits -hospitalization -reduced lung function -mortality

Question 33

What causes AECOPD?

Answer 33

viral infection bacterial infection environmental factors

Question 34

What should we always assess when a pt presents with AECOPD?

Answer 34

inhaler technique precipitants smoking status

Question 35

What is the most common infectious agent in AECOPD?

Answer 35

viruses

Question 36

When are antibiotics indicated in AECOPD?

Answer 36

if the exacerbation has 2-3 of the following: -increased dyspnea -increased sputum volume -increased sputum purulence if on mechanical ventilation if positive bacterial sputum culture

Question 37

How is AECOPD managed?

Answer 37

mild: -SABA +/- SAMA moderate: -SABA +/- SAMA -+/- antibiotics -+/- short course po corticosteroid severe (ED visit/hospitalization/ICU admission): -respiratory support/O2 -SABA +/- SAMA -antibiotics -corticosteroids (IV or po)

Question 38

What are the probable bacterial pathogens in AECOPD?

Answer 38

simple: -S. pneumoniae -H. influenzae -M. catarrhalis complicated: -same as simple plus K. pneumoniae, P. aeruginosa, beta-lactam resistant pathogens

Question 39

What are the preferred antibiotics for simple AECOPD?

Answer 39

amoxicillin doxycycline azithromycin clarithromycin TMP/SMX

Question 40

What are the preferred antibiotics for complicated AECOPD?

Answer 40

in order of preference: -levofloxacin, ciprofloxacin or moxifloxacin -amoxicillin-clavulanate

Question 41

Differentiate simple and complicated AECOPD.

Answer 41

simple: -smokers -FEV1 > 50% -<= 3 exacerbations/year complicated: simple + at least one of -FEV1 < 50% ->=4 exacerbations/year -ischemic heart disease -use of home oxygen -chronic po corticosteroids

Question 42

How long is duration of therapy for AECOPD?

Answer 42

5-7 days (<= 5 days for outpatient treatment)