The flashcards below were created by user
robinlhx
on FreezingBlue Flashcards.
-
what should COPD do?
- -they should have influenza caccine(one per year) and a pneumococcal vaccin(one per lifetime).
- -if you got your first does of pneumococcal vaccine more than 5 years when you reach your age 65, you should get your second dose at 65.
-
Two types of COPD
- -Brochitis
- -wet, lot's of mucus
- -more infection
- -usually die of pneumonia
- - go to hospital more often
- -Emphysema
- -don;t usually get sick, but once you sick, then death!!
- -dry, people live longer with this type.
-
COPD Definition
COPD is a disease state chgaracteruzed by airflow limitation that is not fuly reversible, associate inflammatory response.
-
diffences between Asthma vs. COPD
-onset
-symptoms
-history
-type of airflow limitation
- Asthma
- -onset early in life
- -symptoms vary day to day
- -allergy, rhinititis, eczema also present
- -family history
- -Largely reversible airflow limitation
- COPD
- -onset in midlife (really slow)
- -symptoms slowly progressive
- -long smkoing history
- -dyspnea on exertion
- -largely Irreversible airflow limitation
-
facts about COPD
- -COPD is now the Third leading casuse of death.
- -for all age group > 55 yrs old
-
Risk factors for COPD
- -Genes
- -Exposure to particles
- -tobacco smoke
- -occupatiobnal dust
- -indoor air pollution from heating and cooking with biomass
- -outdoor air pollution
- -lung growth and delopment
- -oxidative stress
- -gender
- -age
- -repiratory infections
- -socioeconimic status
- -comorbidities
-
Etiology/ Risk factors
- -cigratte smoking
- -genetic factors
- -----emphysema-a1-antutrypsin deficiency, it makes you possibly have COPD in early life instead of midlife
- ----very high risk!!! take the test on it!!
- -low birthweight
-
Pathogenesis of COPD
- -chronic inflammtion throughout the aiways, parenchymam, and pulmonary vasculature
- -Oxidative stress -------cigrette smoking
- ---blue berry is good shit of anti-oxidants
-
pathophysiology progression of COPD
- -mucus hypersecretion
- -ciliary dysfunction
- -Airflow limitation ---(hallmark of physiologic change-key to diagnosis)
- -pulmonary hyperinflation
- -gas exchange abnormalities (turning blue/pink)(
- pulmonary hypertension
- -cor pulmonale (right heart failure due to lung problem)
-
Smoking and lung fucntion
- -tabacco smkong will lead to serve lung faliure
- -it is always better than try to quit off on several times than those who never try to quit. your lung function still improving~!!!
- -COPD is caused majority by Smoking ( 90-95%)
-
COPD Diagnosis
- -symptoms of cough
- -sputum prodcution (change color, green/grey)
- -dyspnea or
- -history of exposure of risk factors for the diease
- -have problem with expiration
-
other diagnostic tests
- -Arterial blood gas
- -should be consider for all pt with FEV1<40% of standards
- -Bronchodilator REversiblity Test
- -Glucocorticosteroid REversiblity Test ( use inhaled steroid for 6 weks. if improve 15% -----> COPD)
- -Chest X-ray
- -a1-antitrypsin deficiency screening
- ---yong age of onset
- ---strong family history
-
Classification of Severity of Airflow inCOPD: FEV1/FVC < 0.70
-COPD: FEV1/FVC < 0.70 (diagnostic)
- Gold 1 Mild
- FEV1 ≥ 80% predicated
- Gold 2 Moderate
- 50% ≤ FEV1 < 80% predicated
- Gold 3 Severe
- 30% ≤ FEV1 < 50% predicated
- Gold 4 Very Severe
- FEV1 < 30% predicted
-
Assessing Symptoms (different questionnaires)
- COPD Assessment Test (CAT)
- Modified Medical Research Council (MMRC)
- Dyspnea Scale
-
combined Assessment
- A (low risk, low symptoms)
- -- Gold 1-2
- -- ≤ 1 exacerbation per year
- --MMRC 0-1
- -- CAT < 10
- B (low risk, more symptoms)
- -- Gold 1-2
- -- ≤ 1 exacerbation per year
- -- MMRC ≥ 2
- --CAT > 10
- C (high risk, less symptoms)
- --Gold 3-4
- -- ≥ 2 exacerbations per year
- -- MMRC 0-1
- -- CAT < 10
- D (high risk, more symptoms)
- -- Gold 3-4
- -- ≥ 2 exacerbations per year
- -- MMRC ≥ 2
- -- CAT > 10
-
Chronic Bronchitis
----Pathophysiology
- -Normal V (ventilation) is 4 L of air per minute.
- -Normal Q (perfusion) is 5L of blood perminute.
- -When the V/Q is < 0.8, there is a VQmismatch caused by poor ventilation.
- -Impairs ventilation (V) more than perfusion (Q),leading to V/Q mismatch and hypoxemia.
- -Cor Pulmonale
-
Chronic Bronchitis
--------Clinical Presentation
- Frequent respiratory tract infections
- The “Blue Bloater” presentation
- Tend to be overweight
- Present with increasingly productive cough
- Dyspnea is common
- Hypercarbia (“CO2 retainers”)
- “Barrel Chested” appearance
- Have frequent hospitalizations for acuteexacerbations
-
Emphysema
--------Pathophysiology
- Destruction of the walls within the acinus
- Surface area for gas exchange is lost
- Ventilation (V) and perfusion (Q) both lost,leading to maintenance of V/Q match
- No Cor Pulmonale
-
Emphysema
Clinical Presentation
- “Pink Puffer”
- Older than the chronic bronchitic
- Chief complaint is dyspnea without cough
- “Pursed lip” breathing is common.
- Acute exacerbations are less common.
- Respiratory failure and intubation isoften a “terminal event”
-
Differences between Emphysema and Chronic Bronchitis
-
Risk Factor Reduction
- Smoking cessation is the single mosteffective-and cost-effective- intervention toreduce the risk of developing COPD andstop its progression (Evidence A).
- Reducing the risk from indoor and outdoor airpollution is feasible
-
Goals of Therapy of COPD
- Relieve symptoms
- Improve lung function
- Improve exercise tolerance
- Prevent and treat complications
- Exacerbations and hospitalizations
- Improve quality of life
- Prevent disease progression
- Increase life expectancy
- Accomplish in a cost effective manner
-
Manage Stable COPD
- The principal Bronchodilator treatments are:
- ß- agonists,
- anticholinergics,
- methylxanthines --------used singally or in combination
- long-actingbronchodilatorsis good to add in treatment with short-actingbronchodilators
- addition of regular treatment with inhaledglucocorticosteroids to bronchodilator treatmentis appropriate for symptomatic COPD patientswith an FEV1 < 50% predicted
- All COPD patients benefit from exercisetraining programs!!!
Don't use systemic Glucocorticosteroid for LONG TERM!!!
-
Non-Pharmacologic Therapy
- Pulmonary Rehabilitation-------Exercise
- Oxygen Therapy (> 15hours per day)
- Lung Volume Reduction Surgery
-
Pharmacologic Therapy
- Bronchodilators:
- ß2-agonists (short acting and long acting)
- Anticholinergics
- Methylxanthines - Theophylline
- Non-Bronchodilators:
- Corticosteroids
- Antibiotics
- Future therapies
-
Bronchodilators
- --Bronchodilators (anti-cholinergics and ß2-agonists) are first-line treatmentfor symptomatic COPD and should be maximized before moving to othermedications.--Combination of Bronchodilators are better than single one.
- --------increase efficacy and decrese Side Effect
- Metered dose or dry powder inhalers are preferred over wet nebulizers for stable COPD
-
Inhaled Bronchodilators
Drug type and Name
- Anticholinergic
- ipratropium (Atrovent®)
- Tiotropium (Spiriva®)
- Aclindium Bromide (Tudorza®)
- Short acting ß-2 agonists
- albuterol, salbutamol (Ventolin®, Proventil®)
- metaproterenol (Alupent®, Tornalate®)
- Long acting ß-2 agonists
- salmeterol (Serevent®)
- formoterol (Foradil®)
-
Anticholinergics
Mech. and Side Effects
- blocks the acetylcholine
- OFF LABEL USE for Asthma
- Produce bronchodilation only in the presenceof cholinergic-mediated bronchospasm.
- Side Effect:
- --dry mouth,
- --urinaryretention,
- --blurred vision,
- --constipation,
- --dysgeusia
-
Anticholinergics
Ipratropium (Atrovent) MDI
- MDI 1-2 puffs up to 3-4 times daily
- Nebulizer 3-4 times daily
-
Anticholinergics
Tiotropium (Spiriva) Handihaler
- Adults/elderly: 18 mcg/day via oral inhalation.
- One capsule via Handihaler once daily
- don't know if it is safe for kids
-
Aclidinium Bromide:
Tudorza Pressair ®
- should be discard
- -----when the device lock or
- -----45 days after removing fromthe sealed pouch
- Breathe in quickly and deeply through the mouth (b/c its dry powder)
- When done, wipe mouthpiece with a DRY tissue or paper towel.
-
Arformoterol Inhalation Solution:
Brovana®
- long-acting beta2-agonist bronchodilator (LABA)
- 15 mcg BID
- Nebulizer only
- -------it is the Only LABA in liquid form
-
Anticholinergic Combinations
Albuterol + Ipratropium (Combivent® MDI)
ADR / Contraindication
- Albuterol + Ipratropium (Combivent® MDI)
- 1 inhalation QID
- ADR
- -- Infections of ear, nose, throat
- -- Runny nose
- -- Cough
- -- Shortness of breath
- Contraindication to Soybean and Peanut (b/c has CFC as propellant)
-
Anticholinergic Combinations
Albuterol + Ipratropium (Combivent® MDI)
Precaution
- Narrow angle glaucoma
- Prostate/urinary problems
- Heart conditions
- Seizures
- Thyroid
- Low potassium levels
- Kidney dx
- Liver dx
-
Anticholinergic Combinations
Albuterol + Ipratropium (Combivent® Respimat)
ADR / Contraindication / Precaution
- 1 inhalation QID
- Dosing indicator
- No shaking or spacer required
- Uses NO propellan (so No contraindication on soy or peanut)
- ADRInfections of ear, nose, throat
- Runny nose
- Cough
- Shortness of breath
- Precaution: same as Albuterol + Ipratropium (Combivent® MDI)
-
Inhaled Corticosteroids
- Fluticasone (Flovent®)
- Flunisolide (Aerobid®)
- Budenoside (Pulmicort®)
- Beclomethasone (Vanceril®, Beclovent®)
- Triamcinolone (Asmacort®)
- Mometasone (Asmanex® )
-
Inhaled Corticosteroids
- Decreases frequency of exacerbations BUT
- --------------- Increased risk of pneumonia.
- Not for monotherapy
- Combination with LABA
- Combination with LABA + Spiriva
-
Roflumilast (Daliresp)
- Use for Severe COPD (FEV1<50%)
- Reduces the risk of exacerbations
- First drug in new category
- ------ Phosphosdiesterase 4 inhibitor(PDE4 )
- it will Decrese Sputum (Chronic Bronchitis)
- 500 mg tablet QD with or without food.
- No dosage adjustment
- Not pregnancy nor nursing mothers
- No liver dysfunction
-
Theophylline Info
- Third-line role in COPD
- May be helpful when patients have poor responseto combination of β2-agonists and anticholinergics
- Narrow therapeutic index
- Sustanied release ------use at night
-
Systemic Corticosteroids Info
- Chronic treatment with systemic glucocorticosteroids should be avoided
- too much side effects
-
Treatments Guideline
- A (low risk, low symptoms)
- SABA or SAAC
- LAAC or LABA or SABA + SAAC
- Theophylline
- B((low risk, high symptoms)
- LAAC or LABA
- LAAC & LABA
- SABA &/or SAAC
- C(High risk, Low symptoms)
- LABA + ICS or LAAC
- LAAC + LABA
- PDE-4 Inhibitor or SABA &/or SAAC
- D(High risk, high symptoms)
- LABA + ICS or LAAC
- LAAC + ICS or LABA + ICS + LAAC or LABA + ICS +PDE-4 or LAAC + LABA or LAAC + PDE-4
- SABA &/or SAAC
- Theophylline
-
Oxygen Therapy
- Reduces mortality and improves quality of life.
- Indicated if either of following are present:
- --Resting PaO2 < 55 mm Hg (partial pressure of O2 inthe blood…from ABG)
- OR
- SaO2 < 88% (oxygen saturation..pulse oximetry)
- PaO2 between 55 and 60 mm Hg or SaO2 < 88% if there is evidence of pulmonary hypertension,peripheral edema, or polycythemia (Hct > 55%).
- Not indicated for lesser severity ofdisease
- Nocturnal O2 therapy not beneficial
-
Other Pharmacologic Treatments
Antibiotic
Mucolytics
Antioxidant agents
Immunoregulators
- Antibiotics. Acute exacerbations only
- Others: No Benefits
-
Cor Pulmonale
- Diuretics are mainstay of therapy
- Oxygen therapy
- Digoxin is NOT indicated
-
Miscellaneous Therapy
- α1-Antitrypsin replacement therapy
- Anti-Tussives -------- Contraindicated
- Respiratory Stimulants-------- Not Recommended
-
Manage Exacerbations
- Most common cause of exacerbations are infections of tracheobronchial tree and airpollution.
- Bronchodilators and systemic steroids areeffective for COPD exacerbations.
- antibiotics are helpful in selectpatients.
-
COPD Exacerbation
Differential Diagnosis
- Pneumonia
- CHF
- Pneumothorax
- Pleural Effusion
- Pulmonary Embolism
- Arrhythmia
-
Exacerbation Classification and Clinical Presentation
- Severity based upon these 3 symptoms
- (1)increased dyspnea,
- (2) increased sputum purulence
- (3) increased sputum volume:
-
Three types of Exaecrbation
Type 1 (Mild) – 1 out of 3 symptoms + at least one of the following:
- URI in past 5 days:
- Fever without other cause
- Increased wheezing
- Increased cough, or
- 20% increase in RR or HR.
- Type 2 (Moderate) – 2 out of 3 symptoms
- Type 3 (Severe) – All 3 symptoms
-
Severe Acute Exacerbations Treatment
- Systemic Corticosteroids (10-14 days max)
- ----Inhaled steroid not appropriate
- Bronchodilators
- Oxygen Therapy
- Noninvasive Positive Pressure Ventilation(NPPV)
- Intubation/Mechanical Ventilation if indicated.
- Antibiotics (Widely prescribed during the treatment ofacute exacerbations.)
- Nutrition Support
-
Organisms of greatest concern of acute exacerbation
- S.pneumoniae,
- H. Influenzae,
- M.Catarrhalis.
-
antibiotic use in Atcute Exacerbation
- Complicated COPD:
- Amoxicillin
- Clavulanate
- Fluoroquinolone
- Simple COPD:
- Doxycycline
- Macrolide
- Cephalosporin
|
|