COPD and Asthma- Heemer

What are the 2 phenotypes of COPD?

• chronic bronchitis

• emphysema

What are the complications of COPD?

• hypoxemia

• hypercapnia

• secondary pulmonary HTN

What risk factor is the leading cause of COPD?

SMOKING CIGS

a deficiency in what enzyme can lead to COPD?

a1-antitrypsin (AAT)

What are the subjective and objective signs and symptoms of COPD?

subjective: chronic cough, sputum production, dyspnea

objective- cyanosis, increased RR, barrel chest, spirometry tests

What test is used to diagnose COPD?

spirometry

A FEV1/FVC ratio <_____% indicates COPD.

<70%

How is COPD classified by spirometry?

a. GOLD classification

b. WHO functional classification

c. ABE assessment tool

d. CAT COPD assessment tool

a

What are the 4 GOLD classifications for COPD?

What is some non-pharm tx for COPD?

• smoking cessation

• vaccination

• pulmonary rehab

• long-term oxygen therapy

• surgery

What is the only intervention proven to affect long-term decline in FEV1 and slow progression of COPD?

smoking cessation

When is oxygen therapy indicated in COPD?

• PaO2 ≤ 55 mmHg or SaO2 <88%

  or

• PaO2 >55 mmHg but <60 mmHg w/ RHF

What 2 classes of meds are COPD specific and not for use in asthma?

• PDE-4 inhibitors

  • roflumilast

• a1-antitrypsin replacement therapy

  • pooled human AAT

Oxygen therapy has evidence of improved survival in…

pts. w/ chronic hypoxemia

Studies have shown correlation between ___________________counts and the effect of ICS on COPD.

eosinophils

ICS shouldn’t be used if your eosinophil blood count is <_______ cells/uL.

ICS shouldn’t be used if your eosionophil blood count is <100 cells/uL.

ICS CAN BE used if your eosinophil blood count is >________ cells/uL.

ICS CAN BE used if your eosinophil blood count is >300 cells/uL.

The ABE assessment tool is used to assess pts. with COPD. The 3 main components of the assessment tool are:

• mMRC

• CAT

• Exacerbation history

Explain the mMRC component of the ABE assessment tool:

• basically, assesses dyspnea on a scale of 0-4

  • ex: 0 would be dyspnea w exercise and 4 would be dyspnea all the time

    • you check off the box that applies to you

    • placed in the A/B category based off the box you check off

Explain the CAT component of the ABE assessment tool:

• basically, a COPD symptom test

  • assesses different symptoms on a scale of 0-5

  • placed in A/B category based off the score

Explain the Exacerbation history component of the ABE assessment tool:

• based off frequency and severity of exacerbations

• basically, if you have 2 or more exacerbations or 1 or more exacerbations leading to hospitalization= E category

  • if you have 0 or 1 moderate exacerbations no hospitalization in either A or B category depending on mMRC and CAT

Exacerbations are classified as mild, moderate, or severe. What do each of these mean?

mild- tx with SABA

moderate- tx with SABA plus antibiotics/steroids

severe- ER visit or hospitalization

What non-pharm tx is essential and recommended if you are in group A of the ABE assessment tool?

essential- smoking cessation

recom- physical activity

What non-pharm tx is essential and recommended if you are in group B and E of the ABE assessment tool?

essential- smoking cessation, pulmonary rehab

recom- physical activity

What is the initial pharm tx for Groups A, B, and E ?

In addition to the initial pharm tx, what should be prescribed to all groups for immediate symptom relief?

rescue SABA

If initial tx fails and I wanted to do triple therapy with a LABA+LAMA+ICS, what must I first consider?

eosinophil count

• MUST be >300

If my triple therapy doesn’t work and I want to use a COPD specific medication, what would I choose?

Roflumilast

When would I use antibiotics in COPD?

given to pts. w/ 2 or more cardinal symptoms:

• increase in sputum purulence AND

• Increase in sputum production AND/OR

• worsening of dyspnea

Practice:

If I had an increase in sputum purulence and worsening dyspnea would I need an antibiotic? how long would I take that antibiotic if necessary?

yes—> take for 5-7 days

Practice:

A pt. has a CAT score of 7, mMRC of 1, and 0 moderate exacerbations in the last year. What group would the patient be placed in the ABE assessment tool?

A

Practice:

A pt. has a CAT score of 10, mMRC of 1, and 3 moderate exacerbations in the last year. What group would the patient be placed in the ABE assessment tool?

E

What factor leads to 60-80% of susceptibility to have asthma?

genetics

What is a KEY indicator of asthma?

wheezing

You have assessed the patient’s control of their asthma, but before making changes to a patient’s asthma medication regimen, what 3 additional things should be assessed?

• patient education

  • adherence, inhaler technique

• control of environment

  • reduce exposure to allergens

• manage comorbidities

How is asthma classified in ppl ≥12 years of age?

• intermittent

• mild

• moderate

• severe

For intermittent classification answer the following:

• symptoms (how many days/week)

• nighttime awakenings (how often)

• using a SABA for symptom control (how often)

• interference with normal activity (none—> fully limited)

• symptoms

  • ≤2 days/week

• nighttime awakenings

  • ≤2x/month

• using a SABA for symptom control

  • ≤2 days/week

• interference with normal activity

  • none

For mild persistent classification answer the following:

• symptoms

• nighttime awakenings

• using a SABA for symptom control

• interference with normal activity

• symptoms

  • >2 days/week but not daily

• nighttime awakenings

  • 3-4x/month

• using a SABA for symptom control

  • >2 days/week but not daily

• interference with normal activity

  • minor limitation

For moderate persistent classification answer the following:

• symptoms

• nighttime awakenings

• using a SABA for symptom control

• interference with normal activity

• symptoms

  • daily

• nighttime awakenings

  • >1x/week but not nightly

• using a SABA for symptom control

  • daily

• interference with normal activity

  • some limitation

For severe persistent classification answer the following:

• symptoms

• nighttime awakenings

• using a SABA for symptom control

• interference with normal activity

• symptoms

  • throughout the day

• nighttime awakenings

  • often 7x/week

• using a SABA for symptom control

  • several times per day

• interference with normal activity

  • extremely limited

What is the recommended step for initiating tx in intermittent, mild, moderate, severe?

• intermittent- step 1

• mild- step 2

• moderate- step 3 and consider short course of systemic corticosteroids

• severe- step 4 or 5 and consider short course of systemic corticosteroids

What are the PREFERRED tx options in steps 1-6?

step 1- PRN SABA

step 2- ICS and PRN SABA or PRN ICS and SABA

step 3- daily and PRN combo of low dose ICS and formoterol

step 4- daily and PRN combo of medium dose ICS and formoterol

step 5- daily medium-high dose ICS-LABA-LAMA and PRN SABA

step 6- daily high-dose ICS-LABA+ oral systemic corticosteroids and PRN SABA

What device can be used to assess asthma control?

peak flow meter

If asthma is controlled for ____ months we can step dose.

3

What classifies if our asthma is well controlled, not well controlled, or very poorly controlled?

How is exercise induced bronchospasm diagnosed?

exercise challenge