Therafinal Copd

Front 1

Chronic Obstructive Pulmonary Disease

Back 1

chronic disease of the airways characterized by persistent airflow limitation that is:
1) progressive with no reversibility

Front 2

Causes of COPD

Back 2

Interaction of Environmental factors and host facotrs

Front 3

Environmental Factors that can cause/affect COPD

Back 3

1) particles inhaled by individual that leads to inflammation
2) Cigarette Smoke - most important modifiable
3) Occupational Dust/Chemicals - pollution

Front 4

Host Factors that can cause/affect COPD

Back 4

1) a1-antitrypsin (AAT) deficiency - early onset
2) airway hyperresponsiveness
3) insufficient lung growth

Front 5

Pathophysiology of COPD

Back 5

1) Inflammation - exposure to noxious particles
2) Oxidative Stress - oxidants damage proteins/lipids
3) Proteinases - released from inflammatory cells
4) Airways, alveoli, blood vessels affected - chronic inflammation leads to repeat injury and repair which leads to scarring AND increased mucus secretion

Front 6

Signs/Symptoms of COPD

Back 6

1) Dyspnea
2) Cough
3) Sputum production
4) Cyanosis of mucus membranes (progression)
5) "Barrel chest"
6) shallow breathing
7) increased respiratory rate

Front 7

Spirometry for diagnosis of COPD

Back 7

REQUIRED for diagnosis

FEV1/FVC < 70%

Front 8

4 aspects of COPD to be considered for assessment

Back 8

1) Symptoms
2) Spirometry
3) Exacerbation Risk
4) Presence of Co-morbidities

Front 9

Assess symptoms in COPD diagnosis

Back 9

use validated questionnaires
1) mMRC
2) CAT

Front 10

Assess Spirometry in COPD diagnosis

Back 10

performed after administration of Short acting bronchodilator

FEV1/FVC <70%

Front 11

GOLD Classification of Airflow Limitation: MILD (I)

Back 11

FEV1 > 80%

Front 12

GOLD Classification of Airflow Limitation: MODERATE (II)

Back 12

50% < FEV1 < 80%

Front 13

GOLD Classification of Airflow Limitation: SEVERE (III)

Back 13

30% < FEV1 < 50%

Front 14

GOLD Classification of Airflow Limitation: VERY SEVERE (IV)

Back 14

FEV1 < 30%

Front 15

Assess Exacerbation risk in COPD

Back 15

2+ exacerbations/year

Front 16

Common comorbidities with COPD

Back 16

1) CV disease
2) skeletal muscle dysfunction
3) metabolic syndrome

Front 17

Desired outcomes of COPD

Back 17

1) PREVENTION
2) minimize progression

Front 18

Goals of therapy of COPD

Back 18

1) relieve symptoms
2) improve exercise tolerance AND overall health status
3) Prevent disease progression

Front 19

Non-Pharm Therapy in COPD

Back 19

1) Education
2) Smoking cessation
3) Pulmonary Rehab (groups B-D)
4) Immunizations (annual flu & PPSV)
5) Long-term oxygen Therapy (resting PaO2 < 55 or SaO2 < 88%)

Front 20

Types of medications used in COPD

Back 20

1) Bronchodilators
2) Inhaled Corticosteroids
3) PDE-4 Inhibitors

Front 21

3 Classes of Bronchodilators for COPD

Back 21

1) Beta Agonists
2) Anticholinergics/Antimuscarinics
3) Methylxanthines

Front 22

MOA of Beta Agonists

Back 22

stimulate beta receptor -- increase cAMP -- smooth muscle relaxation -- antagonism of bronchoconstriction

Front 23

Beta Agonists used in COPD

Back 23

1) Albuterol - not FDA approved (SABA)
2) Levalbuterol - not FDA approved (SABA)
3) Arformoteral (Brovana) (LABA)
4) Formoterol (Foradil, Perforomist) (LABA)
5) Salmeterol (Serevent) (LABA)
6) Indacaterol (Arcapta, Neohaler) (LABA)

Front 24

Place in Therapy for Beta Agonists for COPD

Back 24

SABA - first line for Group A
LABA - Groups B-D

Front 25

MOA of anticholinergics/antimuscarinics for COPD

Back 25

inhibition of muscarinic cholinergic receptors -- bronchodilation

decrease mucus gland secretion

Front 26

Anticholinergics used in COPD

Back 26

1) Ipratropium (Atrovent) (SHORT)
2) Aclidinium (Tudorza, Pressair)
3) Tiotropium (Spiriva)

Front 27

Duration of Aclidinium and Spiriva

Back 27

A) 12 hours
B) 24 hours

Front 28

Place in Therapy of Anticholinergics for COPD

Back 28

Short Acting: initial therapy for Grp A
Long Acting: for Group B-D

Front 29

MOA of Methylxanthines

Back 29

inhibit PDE -- increased cAMP
Inhibit Calcium Ion influx to smooth muscle
Prostaglandin antagonism

Front 30

Place in Therapy of Methylxanthines for COPD

Back 30

1) intolerant or unable to use inhaled bronchodilators
2) limited role due to drug interactions and variability in dosing

Front 31

MOA of inhaled corticosteroids for COPD

Back 31

Reduce capillary permeability to decrease mucus

inhibit release of proteolytic enzymes

inhibit prostaglandins

HELP WITH INFLAMMATION

Front 32

Place in Therapy of Inhaled Corticosteroids in COPD

Back 32

*Not well established*
Recommended in severe - very severe disease and frequent exacerbations (Groups C and D)

Front 33

Combination production with Long-Acting bronchodilator and ICS for COPD

Back 33

Fluticasone/Vilanterol (Breo, Ellipta)

Front 34

MOA of PDE 4 inhibitor for COPD

Back 34

selectivity inhibit PDE type 4 -- increase cAMP -- decreased inflammation

Front 35

PDE 4 inhibitor used in COPD

Back 35

Roflumilast (Daliresp)

Front 36

Dosing of Roflumilast (Daliresp) for COPD

Back 36

500mcg once daily with or without food

Front 37

ADRs of Roflumilast (Daliresp)

Back 37

1) GI (N/V/D)
2) Weight loss (~2kg)
3) Psychiatric (insomnia, anxiety, depression, suicidal)

Front 38

Drug interactions with Roflumilast (Daliresp)

Back 38

*Metabolized by CYP3A4*

decrease levels (rifampin, phenytoin) - inducers
increase levels (erythromycin, ketoconazole) - inhibitors

Front 39

Place in therapy of Roflumilast (Daliresp) in COPD

Back 39

reduce risk of exacerbations in severe - very severe COPD associated with chronic bronchitis and a history of exacerbations

Front 40

Recommended First Choice Therapy for Group A

Back 40

Short acting anticholinergic PRN

OR

Short acting beta agonist PRN

Front 41

Recommended First Choice Therapy for Group B

Back 41

Long-Acting Anticholinergic

OR

Long-Acting Beta Agonist

Front 42

Recommended First Choice Therapy for Group C

Back 42

Inhaled corticosteroid + long-acting beta agonist

OR

Inhaled corticosteroid + long-acting anticholinergic

Front 43

Recommended First Choice Therapy for Group D

Back 43

Inhaled Corticosteroid + Long Acting Beta Agonist and/or long-acting anticholinergic

Front 44

Other Pharmacotherapy for COPD

Back 44

1) alpha1-antitrypsin replacement therapy
2) Antibiotics
3) Expectorants and mucolytics (WATER is best)
4) Narcotics

Front 45

Dietary Supplements for COPD

Back 45

1) Vitamins E,C, and beta carotene

Front 46

Surgical Interventions in COPD

Back 46

1) Bullectomy - removal of large air spaces
2) Lung Volume Reduction Surgery - remove parts of lung to reduce hyperinflation
3) Lung Transplantation - FEV1 < 20% and pulmonary HTN/ cor pulmonale AND exacerbations

Front 47

COPD exacerbation

Back 47

acute event characterized by a worsening of the patient's respiratory symptoms that is beyond normal day-to-day variations and leads to a change in medication

Front 48

COPD exacerbations are caused by

Back 48

1) Respiratory tract infections (viral or bacterial)
2) Air pollution
3) unknown

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Symptoms and Signs of COPD exacerbation

Back 49

1) increased sputum volume
2) worsening dyspnea
3) Chest tightness
4) Increased need for bronchodilators
5) Fever
6) wheezing
7) use of accessory muscles
8) Deteriorated mental status

Front 50

Cardinal Symptoms of COPD exacerbation

Back 50

1) Worsening Dyspnea
2) Increased sputum volume
3) increased sputum purulence

Front 51

Mild COPD exacerbation

Back 51

1 cardinal symptom PLUS at least one of the folowing:
1) URTI within 5 days
2) Unexplained fever
3) increased wheezing
4) increased cough
5) increased RR or HR >20% above baseline

Front 52

Moderate COPD Exacerbation

Back 52

2 cardinal symptoms

Front 53

Severe COPD Exacerbation

Back 53

3 cardinal symptoms

Front 54

Indications for Hospital Assessment/Admission in COPD Exacerbation

Back 54

1) marked increase in intensity of symptoms
2) Severe underlying COPD
3) Onset of new physical signs (cyanosis, edema)
4) Failure of exacerbation to respond to therapy
5) Older age

Front 55

Indications for ICU admission in COPD exacerbation

Back 55

1) Severe dyspnea that responds inadequately to initial emergency therapy
2) Changes in mental status
3) Worsening of hypoxemia and/or severe/worsening respiratory acidosis
4) need for invasive mechanical ventilation

Front 56

Non-Pharm Treatment of COPD Exacerbation

Back 56

1) Supplemental Oxygen Therapy - saturation > 88-92%
2) Non-invasive mechanical ventilation

Front 57

Pharm Therapy for COPD exacerbation

Back 57

1) Bronchodilators- increased doses and frequency (SABA preferred)
2) Corticosteroids - oral therapy preferred
3) Antimicrobials - 3 cardinal symptoms present, 2 cardinal symptoms and one is increased sputum purulence, mechanical ventilation

Front 58

Antibiotics used for uncomplicated COPD exacerbations

Back 58

1) Macrolides (azithromycin, clarithromycin)
2) 2nd or 3rd gen cephalosporins
3) Doxycycline

Front 59

Cor Pulmonale

Back 59

Right-sided heart failure secondary to pulmonary HTN

Treatment includes long-term oxygen therapy and diuretics along with COPD management

Front 60

Polycythemia

Back 60

Increased number of RBCs secondary to chronic hypoxemia (HCT >55%)

Treated with oxygen therapy or periodic phlebotomy

Front 61

Respiratory Syncytial Virus

Back 61

Single stranded RNA in Pneumovirus

Type A(severe), Type B(milder)

Highly contagious!!!!!

Front 62

Presentation of RSV in adults/adolescents

Back 62

common cold with significant sinus drainage

Front 63

Presentation of RSV in children

Back 63

1) starts as URTI
2) <2 years old = progress to LRTI

Front 64

HIGH RISK FACTORS for RSV

Back 64

1) <2yrs old with chronic lung disease (BPD)
2) <2yrs old with congenital heart disease (CHF, pulmonary HTN)
3) born before 35weeks w/ congenital abnormalities of airways or neuromuscular disease
4) premies born <28 weeks and are <12 months old at start of RSV season
5) premies born between 29-32 weeks and are <6 months old at the start of season
6) Premies born between 32-35 weeks and are <3 months old at start of season and have 1 of the following: daycare, sibling less than 5 yrs old

Front 65

Signs and Symptoms of RSV

Back 65

*Non-Specific*
1) low grade fever (<100.5, most wont have)
2) irritability (cranky, crying)
3) Lethargy
4) Poor feeding (young patients)
5) Rhinorrhea and congestion
6) Cough, dyspnea, wheezing in LRTI

Front 66

Treatment of RSV

Back 66

1) SUPPORTIVE CARE - MAINSTAY OF THERAPY

Front 67

Bronchodilators used in RSV

Back 67

1) widely used in the past but not proven to be effective
2) clinically still used to see if patients benefit
3) most have viral trigger for a reactie airway disease (similar to asthma)
4) used to treat RAD not the RSV

Front 68

Inhaled Hypertonic Saline (3%) for RSV

Back 68

1) thins secretions by drawing fluid to it

2) produces bronchospasms as an adverse effect

3) using this may lead to need for prophylactic albuterol q6h

Front 69

Ribavirin for RSV

Back 69

*ONLY DRUG WITH FDA INDICATION FOR RSV*
1) must be started within 72 hours of onset of infection
2) 6g/day via neb over 12-18 hours for 3-14 days
3) TERATOGENIC

Front 70

Prophylaxis of RSV

Back 70

*HIGHEST RISK ONLY -- 6 risk factors*
1) Synagis (Palivizumab) - monoclonal antibody; 15mg/kg IM monthly over 5 months
2) Numax (motavizumab) - monoclonal antibody with higher affinity for RSV fusion proteins

Front 71

3 forms of Croup

Back 71

1) Viral - not life threatening
2) Epiglottitis - life-threatening
3) Bacterial Tracheitis - life threatening

Front 72

Viral Croup

Back 72

Most common

affects younger children in fall and early winter

Inflammation of entire airway exists, but edema of SUBGLOTTIC space!

Front 73

Signs/Symptoms of Viral Croup

Back 73

Prodrome: URTI
1) barking like cough and inspiratory stridor
2) fever is absent or low grade
3) Severe--stridor at rest, air hunger, cyanosis

Front 74

Treatment of Viral Croup

Back 74

MILD: managed at home and oral rehydration

Stridor Present: oxygen, Racemic Epinephrine 2.25% (DO NOT USE ALBUTEROL)

Dexamethasone

Front 75

Dose of Dexamethasone for Viral Croup

Back 75

0.6mg/kg IM for 1 dose only!!!

Front 76

Eppiglottitis

Back 76

*TRUE MEDICAL EMERGENCY*
epiglottis and other supraglottic structures swell and obstruct the airway

Cause: H. Influenza type B

Front 77

Signs/Symptoms of Epiglottitis

Back 77

*Sudden Onset*
1) fever
2) dysphagia
3) drooling
4) muffled voices
5) inspiratory retractions
6) Sniffing-Dog Position

Front 78

Treatment of Epiglottitis

Back 78

1) endotracheal intubation performed immediately
2) Antibiotic (gram + cocci and beta lactam) -- Cefuroxime

Front 79

Bacterial Tracheitis

Back 79

bacterial superinfection of the mucosa effected by viral croup resulting in inflammatory edema, purulent secretions and pseudomembranes

Cause: Staph aureus

Front 80

Signs/Symptoms of Bacterial Tracheitis

Back 80

1) early infection mimics viral croup
2) then high fever, toxic look, progressive airway obstruction
3) sudden respiratory arrest or progressive respiratory failure (risk is high)

Front 81

Treatment for Bacterial Tracheititis

Back 81

1) intubation is necessary in most cases
2) antibiotic (cover Staph aureus and H influenzae)

Front 82

TRADITIONAL: Antibiotic used in bacterial tracheitits

Back 82

Cefotaxime

Front 83

Antibiotic used in bacterial tracheititis in community acquired MRSA in highly prevalent

Back 83

Clindamycin

Front 84

Antibiotic used in bacterial tracheititis in patient is highly toxic or has multple organ involvement

Back 84

Vanco

Front 85

Shut the hell up Ellie---don't make fun of my spelling mistakes!

Back 85

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