Term
| What is the major cause of COPD? |
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Definition
Cigarette smoke - not the only cause
**Noxious stimuli to the lungs |
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Term
| What is a major difference between COPD and asthma? |
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Definition
COPD is not reversible!
- productive cough
- No allergies
- Coughing throughout the day
- Not present in youth
- Most prevalent in white women |
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Term
| What 5 components define COPD? |
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Definition
- Preventable
- Treatable
- Airflow limitation
- Chronic inflammation
- Progressive |
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Term
| What are the old components of COPD? |
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Definition
- Emphysema - destruction of alveoli
- Chronic bronchitis - Primary productive cough |
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Term
| What genetic factor can cause COPD? |
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Definition
| alpha-1 antitrypsin deficiency. Missing elastic factor - remodeling occurs at all times |
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Term
| What is the main mechanisms of COPD? |
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Definition
- Small airway fibrosis leads to air trapping and airway limitation that is measurable by spirometry
- Chronic inflammation due to NEUTROPHILS, CD8 cells, and macrophages
- Oxidative stress
- Proteases break down elastin - irreversible |
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Term
| What cells are involved in asthma pathophysiology? |
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Definition
| Eosinophils, CD4 cells, and mast cells |
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Term
| What kind of acid/base disorder is present in COPD? |
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Definition
Respiratory acidosis due to decline in respiration.
** Low FEV1 and gas exchange |
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Term
| How does mucous production affect COPD? |
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Definition
| Not in all patients - increased goblet cells and stimulation by EGFR --> incr mucous production |
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Term
| When does pulmonary hypertension occur? |
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Definition
In late COPD
Vasoconstriction of pulmonary arteries, SM hyperplasia, and loss of capillary bed --> can lead to right ventricle heart failure - swelling of the hands and feet, JVD |
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Term
| What do COPD exacerbations look like? |
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Definition
- Increased neutrophils
- Increased mediators
- Increased air trapping
**Increased dyspnea and hypoxemia |
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Term
| What are the signs and symptoms of COPD? |
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Definition
- DYSPNEA - the cardinal symptom
- Chronic cough - can be productive
- Chronic sputum production
- wheeze, chest tightness |
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Term
| What comorbidities are seen with COPD? |
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Definition
- Weight loss, Skeletal muscle dysfunction
- CV, metabolic, depression, lung cancer |
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Term
|
Definition
Questionnaires - mMRC of 2+ indicates significant symptoms
Spirometry - FEV1/FVC ratio < 0.7
Gold grade |
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Term
| How are COPD patients classified into GOLD grade based on FEV1? |
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Definition
- Stage 1/mild - FEV1>= 80%
- Stage 2/moderate - FEV between 50 and 80
- Stage 3/Severe - FEV between 30 and 50
- Stage 4/Very severe - FEV less than 30, or <50 w/ chronic respiratory failure |
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Term
| How is COPD exacerbation risk assessed? |
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Definition
Square chart:
Left side - mMRC 0-1 or CAT <10, patient is Grade A or C. Patient moves to grade C w/ 3-4 exacerbations
- Right side - mMRC >= 2, CAT >= 10. Patient is grade B (0,1 exacerbation) or grade D (2+ exacerbations) |
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Term
| What are physical exam findings associated w/ COPD? |
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Definition
- Cyanosis
- Barrel chest
- Increased RR
- Pursed-lip breathing
- use of accessory muscles
- Lower extremity edema |
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Term
| What is the best non-pharmacologic Tx for COPD? |
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Definition
| STOP SMOKING! Prevents airflow limitation and improves mortality. |
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Term
| How is pack year history calculated? |
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Definition
| Pack year history = #of packs/day * # of years smoked |
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Term
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Definition
- NO medications modify long term lung fxn decline
- NO medications improve mortality |
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Term
| What bronchodilators are used for COPD? |
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Definition
- Beta agonists - SABA or LABA
- Anticholinergics - Tiotropium or Ipratropium
- Methylxanthines - Theophylline |
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Term
| How do bronchodilators work on COPD? |
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Definition
- Decrease hyperinflation to improve symptoms and exercise tolerance
- Reduction in exacerbations
- Toxicity is dose dependent |
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Term
| How do B2 agonists work for COPD? |
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Definition
- Increased cAMP --> bronchodilation
- Asthma > COPD
- Use proper inhaler technique
- AE: tachycardia, tremor, hypokalemia |
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Term
| What beta agonists are available for COPD Tx? |
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Definition
SABAs:
- Albuterol/Ventolin
- Levalbuterol/Xopenex
- Pirbuterol/Maxair
LABAs:
- Salmeterol/Serevent
- Formoterol/Foradil and perforomist
- Arformoterol/Brovana |
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Term
| What medications is an ULTRA-long action beta2 agonist? |
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Definition
Indacaterol/Arcapta
Once daily - not for asthma use |
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Term
| How do anticholinergics work for COPD? |
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Definition
Inhibition of Ach at muscarinic receptors --> inhibit bronchoconstriction. Lasts longer than beta agonists
AE: DRY MOUTH, bitter, blurry vision, urinary retention |
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Term
| What anticholinergics are available for COPD? |
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Definition
Short:
- Ipratropium/Atrovent - do not use w/ peanut allergy!
Long:
- Tiotropium/Spiriva
- Aclidinium/Tudorza
**Tudorza inhaler - push down button, green = ready to use. Inhale, goes from green to red |
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Term
| What is the MoA of methylxanthines in COPD? |
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Definition
non-selective PDE inhibitor --> increases cAMP --> bronchodilation
**Inhaled agents are preferred. AE: tremor, arrhythmia, seizure, HA, GI |
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Term
| How do glucocorticoids work in COPD? |
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Definition
- Decrease mucous, inhibit release of enzymes from leukocytes, inhibit PGs
- Asthma > COPD
- For patients with FEV < 60% |
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Term
| What drug is a PDE4 inhibitor for COPD? |
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Definition
Roflumilast/Daliresp
Increases cAMP by inhibiting PDE4, reduces inflammation. Do not dose w/ theophylline due to CYP induction
AE: Nausea, diarrhea, weight loss |
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Term
| What vaccinations should a COPD patient get? |
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Definition
- Flu shot
- Pneumonia vaccine |
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Term
| How are Group A COPD patients treated? |
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Definition
| short acting agents prn - Albuterol or ipratropium |
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Term
| How are Group B COPD patients treated? |
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Definition
- Long acting agents are FIRST LINE:
LABAs - Salmeterol, formoterol, arformoterol
Long acting cholinergics: Tiotropium, aclidinium |
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Term
| How are Group C COPD patients treated? |
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Definition
Combo of ICS + LABA OR long acting cholinergics are FIRST LINE:
- Advair - fluticasone + salmeterol
- Spiriva |
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Term
| How are Group D COPD patients treated? |
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Definition
Same as group C: Combo of ICS + LABA OR long acting cholinergics are FIRST LINE:
- Advair - fluticasone + salmeterol
- Spiriva
**Can use triple therapy - Advair + Spiriva |
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Term
| What is non-pharmacologic Tx for COPD? |
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Definition
- Pulmonary rehab that focuses on exercise training, nutrition, and education
- O2 in stage 4. PaO2 cut off is <55 |
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Term
| What studies exist about COPD meds? |
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Definition
- UPLIFT - Spiriva decreases exacerbations
- POET-COPD - Tiotropium > Salmeterol
- TORCH - Advair > components or placebo |
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Term
| What is the most common risk factor for an acute COPD exacerbation? |
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Definition
| upper respiratory tract infection |
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Term
| How are COPD exacerbations classified? |
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Definition
Accessory muscle use
Chest wall movement
Cyanosis
Edema
Hemodynamic instability
Right sided HF
Reduced alertness |
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Term
| How are systemic glucocorticoids dosed for an acute COPD exacerbation? |
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Definition
| 30-40 mg of prednisolone for 1-2 weeks |
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Term
| When should antibiotics be used for a COPD inpatient? |
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Definition
Increase in 2-3 of:
Dyspnea
Cough
Sputum production
OR Mechanical ventilation |
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Term
| What comorbidities are seen with COPD? |
|
Definition
- CV - HF, afib
- Osteoporosis - associated w/ emphysema, avoid triamcinolone
- Depression/Anxiety - treat per usual
- Metabolic syndrome/Diabetes |
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