Term
progressive disease
characterized by airflow limitation
NOT FULLY REVERSIBLE
abnormal inflammatory response of the lungs to noxious particles or gases
chronic bronchitis
emphysema |
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Definition
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Term
chronic bronchitis
"blue bloater" - clinical term
presence of excess mucus production
cough present on most days: at least 3 months in each of 2 consecutive years
emphysema
"pink puffer": pathologic term, incorrectly used clinically
abnormal enlargement of airspaces
destruction of bronchiole walls without fibrosis: destruction of gas exchange surfaces (alveoli) of the lung |
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Definition
| chronic bronchitis vs emphysema |
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Term
THE SINGLE MOST IMPORTANT CAUSE OF COPD IS CIGARETTE SMOKING: accounts for 85-90% of COPD cases
exposures:
environmental tobacco smoke
occupational dusts and chemicals
air pollution
host factors:
genetic predisposition (AAT)
airway hyperresponsiveness
impaired lung growth |
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Definition
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Term
smoking cessation is the ONLY treatment that can alter the course of the disease
all other treatments just provide symptomatic relief |
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Definition
| ONLY treatment of COPD that can alter the course of the disease |
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Term
rare cause of COPD (emphysema)
accounts for < 1% of COPD cases
genetic defect in the production of AAT enzyme
AAT protects the lungs and alveoli from destruction by elastase which is released by neutrophils
develop COPD at an early age (20-50 years old)
accelerated decline in lung function |
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Definition
| pathophysiology of alpha1-antitrypsin (AAT) deficiency |
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Term
chronic inflammatory changes: TNF-a, IL-8, LTB4
widespread pathologic changes: repeated injury and repair -> scarring
airflow limitation:
inflamed airways -> decreased FEV1
damaged parenchyma (lung tissue) -> poor gas exchange |
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Definition
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Term
mucus hypersecretion
ciliary dysfunction
airflow limitation
hyperinflation: can't exhale all the air they should, so lungs are inflated more than they should be
gas exchange abnormalities: hypoxemia develops
pulmonary hypertension: body sees there isn't enough oxygen and it reworks the pulmonary vasculature
systemic effects: trying to make up for lack of oxygenation by increasing RBCs |
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Definition
| physiologic abnormalities of COPD |
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Term
ASTHMA
bronchoconstriction and airway hyperresponsiveness -> REVERSIBLE AIRFLOW LIMITATION
COPD
small airway fibrosis and alveolar destruction -> NOT FULLY REVERSIBLE AIRFLOW LIMITATION |
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Definition
| pathophysiology of asthma vs COPD |
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Term
SYMPTOMS
***dyspnea
***chronic cough
***chronic sputum production
***EXPOSURE TO RISK FACTORS
tobacco smoke
AAT deficiency
occupational hazards
PHYSICAL EXAMINATION
cyanosis of mucosal membranes
barrel chest
increased resting respiratory rate
shallow breathing
pursed lips during expiration
use of accessory muscles |
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Definition
| clinical presentation of COPD |
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Term
spirometry with reversibility testing
radiograph of chest
arterial blood gas (not routine) |
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Definition
| diagnostic tests for COPD |
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Term
reversibility testing by spirometry
repeated at least annually to determine disease progression |
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Definition
| gold standard for diagnosing and monitoring of COPD |
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Term
Preparation:
patient should be clinically stable without respiratory infection
no inhaled short acting bronchodilators for 6 hours
no long acting B agonists for 12 hours
no sustained released theophylline for 24 hours
Process:
pre-bronchodilator FEV1 measured
bronchodilator administered via metered-dose inhaler or nebulizer: usual a beta-agonist, an anticholinergic, or the 2 combined
post-bronchodilator FEV1: 10-15 minutes after beta-agonist, 30-45 minutes after combination is given
Results:
an increase in FEV1 > 12% above the pre-bronchodilator FEV1 is considered significant (reversible, may not be COPD)
the presence of post-bronchodilator FEV1 < 80% predicted together with an FEV1/FVC < 70% confirms the presence of airflow limitation that is not fully reversible (COPD) |
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Definition
| preparation, process, and results of spirometry |
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Term
Cor Pulmonale:
right sided heart failure, secondary to pulmonary hypertension
treatment - long term oxygen therapy, diuretics
Polycythemia:
increased circulating red blood cell count, secondary to chronic hypoxemia
can result in mental status changes due to sludging
treatment - long term oxygen therapy, periodic phlebotomy (blood letting) |
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Definition
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Term
FEV1/FVC < 70%
FEV1 >/= 80%
with or without symptoms |
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Definition
COPD Classification
Stage 1 - Mild |
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Term
FEV1/FVC < 70%
50%
with or without symptoms |
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Definition
COPD Classification
Stage 2: Moderate |
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Term
FEV1/FVC < 70%
30% < FEV1 < 50%
with or without symptoms |
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Definition
COPD Classification
Stage 3: Severe |
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Term
FEV1/FVC < 70%
FEV1 < 30% OR FEV1 < 50% with presence of chronic respiratory failure or right heart failure |
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Definition
COPD Classification
Stage 4: Very Severe |
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Term
relieve symptoms
prevent disease progression
improve exercise tolerance
improve overall health status
prevent and treat exacerbations
prevent and treat complications
reduce morbidity and mortality |
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Definition
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Term
smoking cessation: ONLY intervention shown to slow progression of disease
pulmonary rehabilitation
immunizations
long-term oxygen therapy |
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Definition
| non-pharmacologic treatment of COPD |
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Term
exercise: aerobic and strength training
breath training: diaphragmatic breathing, pursed-lips breathing, breathing while bending forward
rehab with exercise 3-7 times per week shows long-term improvement in: activities of daily living, quality of life, exercise tolerance, dyspnea |
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Definition
| components of pulmonary rehabilitation for COPD patients |
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Term
influenza vaccine, inactivated: yearly
pneumococcal vaccine:
GOLD guidelines
patients > 65 years
patients < 65 years with FEV1 < 40% predicted
CDC guidelines
patients 2-64 years with chronic lung disease
all patients > 65 years
may repeat once at 65 years old if first vaccine was more than 5 years earlier |
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Definition
| immunization recommendation of COPD patients |
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Term
Stage 4: Very Severe COPD
resting PaO2 < 55
OR
right sided heart failure, polycythemia, or impaired neuropsychiatric function with PaO2 < 60
> 15 hours per day increases survival
nasal cannula
titrate to PaO2 > 60 or SaO2 > 90% |
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Definition
| indications for long-term oxygen therapy |
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Term
FEV1/FVC < 70%
FEV1 >/= 80% predicted
active reduction of risk factors
influenza vaccine
ADD short-acting bronchodilator (when needed) |
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Definition
| therapy for mild, Stage 1 COPD |
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Term
FEV1/FVC < 70%
50%
active reduction of risk factors
influenza vaccine
ADD short-acting bronchodilator (when needed)
ADD regular treatment with one or more long-acting bronchodilators (when needed)
ADD rehabilitation |
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Definition
| therapy for moderate, Stage 2 COPD |
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Term
FEV1/FVC < 70%
30% < FEV1 < 50% predicted
active reduction of risk factors
influenza vaccine
ADD short-acting bronchodilator (when needed)
ADD regular treatment with one or more long-acting bronchodilators (when needed)
ADD rehabilitation
ADD ICS if repeated exacerbations |
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Definition
| therapy for severe, Stage 3 COPD |
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Term
FEV1/FVC < 70%
FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure
active reduction of risk factors
influenza vaccine
ADD short-acting bronchodilator (when needed)
ADD regular treatment with one or more long-acting bronchodilators (when needed)
ADD rehabilitation
ADD ICS if repeated exacerbations
ADD long term oxygen if chronic respiratory failure
CONSIDER surgical treatments |
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Definition
| therapy for very severe, Stage 4 COPD |
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Term
bronchodilators: short and long acting B2 agonists, short and long acting anticholinergics, methylxanthines
corticosteroids: inhaled and systemic
combination therapy
AAT replacement therapy
PDE4 inhibitors
no medications for the treatment of COPD have been shown to modify the progressive decline in lung function or prolong survival |
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Definition
| pharmacologic treatment of COPD |
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Term
drugs of choice for initial treatment of COPD
short-acting B2 agonists and short-acting anticholinergics
increased exercise capacity
decreased air trapping in the lungs
relief of symptoms such as dyspnea |
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Definition
| benefits of short-acting bronchodilators |
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Term
MOA: relaxation of bronchial smooth muscle leading to bronchodilation
ADRs: sympathomimetics
increased BP
increased HR
CNS stimulation and tremor
hypokalemia
Albuterol duration = 4-6 hours |
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Definition
| MOA and ADRs of short-acting B2 agonists |
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Term
products: ipratropium
MOA: inhibits cholinergic receptors in bronchial smooth muscle resulting in bronchodilation
ADRs:
dry mouth
nausea
occasional metallic taste
use with caution in patients with glaucoma and BPH (?)
duration: 4-6 hours
slower onset of action:
15-20 minutes compared to < 5 minutes with albuterol |
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Definition
| MOA and ADRs of short-acting anticholinergics |
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Term
drugs of choice for moderate to severe COPD
long-acting beta agonists and long-acting anticholinergics
use in patients requiring 12 or more puffs per day of SABA or when short-acting therapies do not provide enough relief
continue using short-acting for PRN rescue
use for nocturnal dyspnea
benefits include:
improved symptoms
reduced exacerbation frequency
improved quality of life |
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Definition
| benefits of long-acting bronchodilators |
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Term
MOA: relaxation of bronchial smooth muscle -> bronchodilation
ADRs:
increased BP
increased HR
CNS stimulation and tremor
duration: 12 hours
salmeterol onset = 15-20 minutes
formoterol onset = < 5 minutes
arformoterol onset = 7-20 minutes
storage: formoterol - refrigerate before dispensing, room temperature after |
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Definition
| MOA and ADRs of long-acting B2 agonists |
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Term
1) peel back paper from blister pack
2) put capsule in inhaler chamber and twist mouthpiece closed
3) press both side buttons ONLY ONCE and release with inhaler held upright
4) place mouth on mouthpiece and tilt head back slightly, after fully exhaling. Breathe in fast, steadily, and deeply. |
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Definition
| how to use Foradil (formoterol) |
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Term
product: tiotropium
MOA: inhibits cholinergic receptors in bronchial smooth muscle resulting in bronchodilation
ADRs:
dry mouth
use caution in patients with glaucoma and BPH (?)
duration: 24 hours |
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Definition
| MOA and ADRs of long-acting anticholinergics |
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Term
tiotropium is superior in improving lung function compared to ipratropium and salmeterol
compared to ipratropium, tiotropium is superior in relieving symptoms, decreasing exacerbation frequency, and improving health status
first line in COPD with persistent symptoms
drawback = $$$
tiotropium as maintenance, use albuterol PRN |
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Definition
| tiotropium compared to ipratropium and salmeterol in COPD |
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Term
1) open handihaler and blister
2) insert Spiriva capsule into the inhaler
3) press the green piercing button to release medication
4) inhale the medication |
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Definition
| how to use Spiriva (tiotropium) |
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Term
products: theophylline, aminophylline
MOA: relaxation of bronchial smooth muscle leading to bronchodilation
alternative therapy for patients intolerant or unable to use inhaled bronchodilators
requires serum concentration monitoring: narrow therapeutic index
drug interactions:
smoking increases clearance
rarely used but synergistic with anticholinergics and beta-agonists
ADRs:
restlessness
insomnia
tachycardia
tremor |
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Definition
| MOA, ADRs, and place in therapy of methylxanthines |
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Term
products: fluticasone, flunisolide, mometasone, triamcinolone, budesonide, beclomethasone
use is controversial: no change in functional decline, however, does decrease frequency of exacerbations
used in severe COPD with frequent exacerbations
ADRs:
hoarseness, sore throat
oral candidiasis
dosing: BID
after starting reassess response in 6-8 weeks based on increased FEV1 or 15% or more, improvement in symptoms, and/or improvement in 6 minute walking distance
D/C if no substantial improvement
if lung function deteriorates or symptoms/exacerbations increase after D/C, may consider restarting therapy |
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Definition
| place in therapy, MOA, and ADRs of ICS |
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Term
risks out weigh benefits for stable COPD
long term ADRs:
osteoporosis
muscular atrophy
thinning of skin
cataracts
adrenal suppression and insufficiency
if used long term, lowest effective dose daily or every other day in the morning
can be used short term to treat exacerbations |
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Definition
| role of systemic corticosteroids in COPD and long term ADRs |
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Term
product: roflumilast
MOA:
no direct bronchodilatory activity
decreased inflammation by inhibiting cAMP breakdown
may improve FEV1 in patients treated with salmeterol or ipratropium
ADRs:
nausea
reduced appetite
abdominal pain
diarrhea
sleep disturbances
headache
significantly more patients receiving roflumilast withdrew from trails
worse in early treatment, potentially reduce with time
CAUTIONS: avoid with depression, cannot be given with theophylline
incidence of cancer in the roflumilast treatment group
place in therapy:
stage 3 or 4 COPD - may reduce exacerbations requiring treatment with glucocorticoids
adjunct to bronchodilators in severe to very severe COPD with frequent exacerbations
moderately improves FEV1 over baseline |
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Definition
| MOA, ADRs, and place in therapy of PDE4 inhbitors |
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Term
predetermine end-of-life decisions and advance directives
treatment of subjective symptoms of dyspnea vs reversal of hypoxia
bronchodilators and opioids are mainstay of palliative therapy:
oral morphine
nebulized morphine |
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Definition
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