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COPD Clinical

Terms in this set (58)

For a MDI, inhalations should be
Slow and deep
For a DPI, inhalations should be
Rapid and deep
COPD is defined as a
Chronic, partially reversible persistent airflow limitation/obstruction associated with an abnormal inflammatory response to stimuli
Emphysema is anatomically defined as
Destruction and enlargement of the lung alveoli and parenchyma
Chronic bronchitis is clinically defined as
A condition with chronic cough and phlegm due to small airways disease
In emphysema, endothelial and epithelial cell death and dis-repair lead to
Air space enlargement, impaired gas diffusion, and air trapping on expiration
In chronic bronchitis, what cells are responsible for secretions?
Goblet cells
Chronic bronchitis and emphysema (together or alone) can lead to
Airway obstruction
Air trapping
Dyspnea
Frequent infections
What are 3 environmental exposure risk factors for COPD?
Tobacco smoke
Occupational dusts and chemicals
Air pollution
What are 3 host risk factors that may lead to COPD?
Genetic predisposition (AAT deficiency)
Airway hyper responsiveness
Impaired lung growth
Which of the following accurately describes COPD?

A. Acute, fully reversible airflow limitation that may occur with or without an inflammatory response to a stimulus

B. Acute, partially reversible airflow limitation that occurs as an allergic response to a stimulus

C. Chronic, fully reversible airflow limitation that occurs without a stimulus

D. Chronic, partially reversible airflow limitation that occurs with an inflammatory response to a stimulus
D. Chronic, partially reversible airflow limitation that occurs with an inflammatory response to a stimulus
What is needed for a formal diagnosis of COPD?
Spirometry
What percent ratio of FEV1:FVC confirms a diagnosis of COPD?
<70%
For GOLD 1, what is the FEV1 (%) predicted?
> or equal tho 80
For GOLD 2, what is the range of FEV1 (%) predicted?
50-79%
For GOLD 3, what is the range of FEV1 (%) predicted?
30-49
For GOLD 4, what is the range of FEV1 (%) predicted?
<30
Which of the following symptoms warrant a COPD work-up? Select ALL that apply

A. Shortness of breath that has worsened over the past 6 months and is worse during exercise

B. Cough lasting over 3 months on most days

C. Rhinorrhea after exposure to grass pollen

D. Yellow-green sputum production for the past 2 months
A, B, D
What are the two methods of predicting frequent exacerbations?
Predicted risk of future exacerbations based on spirometry

Review of exacerbation history over previous 12 months-
> or equal to 2 exacerbations
> or equal to 1 exacerbation requiring hospitalization
A patient newly diagnosed with COPD presents with FEV1 of 63% predicted, mMRC of 1 and a history of 1 exacerbation (with hospitalization) in the past 12 months. How should this patient be classified based on the GOLD combined assessment?

A. GOLD Grade 2, Group B

B. GOLD Grade 3, Group A

C. GOLD Grade 1, Group C

D. GOLD Grade 2, Group C

E. GOLD Grade 1, Group D
D
What is the correct scheduling for pneumococcal vaccine in COPD patients?
Administer PCV13 first, followed by PSV23 1 year later
What are 3 types of bronchodilator medications?
Beta 2 agonists
Muscarinic antagonists/Anticholinergics
Theophylline
What are 3 types of anti-inflammatory agents used in COPD?
ICS
Systemic CS
Phosphodiesterase-4 inhibitors (Roflumilast)
What are the side effects of Beta-2 agonists?
Tremor, sinus tachycardia, cough, headache, hypokalemia, insomnia
What is the MOA of muscarinic antagonists/anticholinergics
Inhibition of bronchoconstriction action of ACh at muscarinic receptors in bronchial smooth muscles

M1 and M3 receptors facilitate release of ACh (preferred blockade)
M2 receptors cause feedback inhibition
What are the side effects of muscarinic antagonist/anticholinergics?
Can't pee
Can't see
Can't spit
Can't shit
What are side effects of ICSs?
Oral candidiasis, dysphasia, skinbruising/dermal thinning, increased pneumonia risk, adrenal insufficiency, osteoporosis
T/F inhaled corticosteroids are an appropriate mono therapy for COPD?
False
What are the side effects of theophylline?
Atrial and ventricular arrhythmias, grand mal seizures

N/V, HA, insomnia, tachycardia
What enzymes metabolize theophylline?
CYP450 1A2 and 3A4
Cimetidine, Macrolides (erythromycin and clarithromycin), quinolone, CHF, liver dysfunction, and viral illness can lead to (decreased/increased) clearance of theophylline
Decreased
Carbemazepine, phenobarbital, phenytoin, rifampin, and smoking can lead to (decreased/increased) clearance of theophylline
Increased
What is roflumilast?
Phosphodiesterase-4 inhibitor, reduces lung inflammation
What are the side effects of Roflumilast?
Weight loss, mood changes (suicidality), liver injury

Diarrhea, nausea, decreased appetite, insomnia, HA, depression
Roflumilast is contraindicated for
Child-Pugh B or C hepatic impairment
PDE-4 inhibitors should be reserved for
Severe to very severe COPD with chronic bronchitis and exacerbation history optimized on LAMA+LABA+ICS
Long-term treatment with a Zithromax in reduces......
Exacerbation rate per year, but increases bacterial resistance
Azithromycin should be considered in
Former smokers with ccontinued exacerbations in Group D optimized on LAMA+LABA+ICS regimen
What are the side effects of systemic corticosteroids?
Hyperglycemia, insomnia, immunosuppressive, adrenal insufficiency, myopathies

Skin bruising/dermal thinning, osteoporosis
Treatment with systemic corticosteroids should be reserved for treatment of
Acute exacerbations-should not be long term for COPD
What is the preferred initial treatment for patients in GOLD Group A
SABA or SAMA prn +/- LAMA or LABA
What is the preferred initial treatment for patients in GOLD Group B
LAMA or LABA
What is the preferred initial treatment for patients in GOLD Group C
LAMA
What is the preferred initial treatment for patients in GOLD Group D
LAMA + LABA
What is the escalation of treatment following symptom persistence or exacerbation for patients in GOLD Group A
Try a different class of bronchodilator as monotherapy
What is the escalation of treatment following symptom persistence or exacerbation for patients in GOLD Group B
LAMA + LABA
What is the escalation of treatment following symptom persistence or exacerbation for patients in GOLD Group C?
LAMA + LABA
What is the escalation of treatment following symptom persistence or exacerbation for patients in GOLD Group D
LAMA + LABA + ICS
A patient is newly diagnosed with GOLD Grade 3, Group B COPD. He is currently not on any medication with no PMH or drug allergies. Choose the most appropriate pharmacological regimen for this patient based on the information provided

A. Fluticasone + Umeclidinium + Vilanterol

B. Levalbuterol PRN + Mometasone

C. Olodaterol + Tiotropium

D. Albuterol PRN + Tiotropium

E. Albuterol PRN
D. Albuterol PRN + Tiotropium
The same patient presents to your clinic and reports he was discharged from the hospital following an exacerbation last month despite compliance to the previously chosen regimen. Choose the most appropriate pharmacological ADDITION to this patients current regimen

A. Vilanterol + Beclomethasone

B. Ipatriopium PRN

C. Mometasone

D. Olodaterol

E. Umeclidinium
D. Olodaterol
What are the 3 cardinal symptoms of a COPD exacerbation?
A change in 2 of the following are considered an exacerbation:
Worsening Dyspnea
Increase in sputum volume
Increase in sputum purulence
What are the four steps in treatment of a COPD exacerbation?
1. Add or increase doses/frequency of short acting bronchodilator (Combine SABA + SAMA)

2. Ensure initiation, continuation, or step-up in current inhaler regimen using GOLD Combined Assessment chart

3. Consider treatment with systemic corticosteroids

4. Consider antibiotics if increased sputum purulence + increased sputum volume and/or increased dyspnea
What are 3 antibiotics used for treatment of COPD Exacerbations?
Azithromycin-500mg QD x 3 days or 500mg on day 1, then 250 mg QD for 4 days

Doxycycline-100mg PO q 12 h x 7 days

Amox/Clav 875/125 P.O. q 12 h x 7 days
What are side effects associated with azithromycin?
QTc interval, diarrhea, N/V
What are side effects of Doxycycline?
Photo sensitivity, tooth discoloration, diarrhea, N/V
What are side effects of Amox/Clav
Diarrhea, N/V
Required renal dose adjustment
Early onset (<40 yo), symptoms worse with triggers, symptoms was and wane, family history often present, night time symptoms are common, and obstruction reversible post-bronchodilator are all symptoms of
Asthma
Later onset (>40 yo), history of exposure to tobacco smoke or other exposures, slowly progressing symptoms, obstruction non-reversible post-bronchodilator, chronic, productive cough common, and weak response to steroid therapy are all signs of
COPD
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