COPD

What causes airflow limitation in COPD

small airways disease (obstructive bronchiolitis) and parenchymal destruction (emphysema)

Characterics COPD

Reversible and irreversible

What are the reversible changes

1. presence of mucus, inflammatory cells, and mediators in bronchial secretions

2. Bronchial smooth muscle contraction in peripheral and central airways

3. Dynamic hyperinflation during exercise

The Irreversible changes?

1. Fibrosis and narrowing of airways

2. Reduced elastic recoil with loss of alveolar surface area

3. Destruction of the alveolar support with reduced patency of small airways

Risk factors of COPD?

Genetics/environmental/time (GETomics)

What are some gene factors?

1. age and gender

2. alpha-1 antitrypsin deficiency

3. asthma/bronchial hypersensitivity

4. impaired lung growth

What are some clinical indicators for diagnosing COPD

1. Dyspnea (worse over time/persistent/worse with exercise)

2. Recurrent wheeze

3. Chronic cough (intermittent and non- or productive)

4. Recurrent respiratory tract infections

5. History of risk factors

What can you see in a physical examination

Rarely diagnostic - physical signs are not present until significant damage has occured

Diagnostic exam?

FEV/FVC has to be less than 0.7 or 70%

Classification of GOLD 1

Mild, FEV1 greater than or equal to 80

Classification of GOLD 2

Moderate FEV1 is between 50% and 80%

Classification of GOLD 3

Severe- FEV1 is between 30% and 50%

Classification of GOLD 4

Very severe FEV1 is less than 30%

Assessment of symptoms

Modified Medical Research Council Questionnaire (mMRC)- (1-4)

COPD Assessment Test (CAAT) (1-40)

Exacerbation

Severe worsening of symptoms

Mild Exacerbation

Treated with short-acting bronchodilators only

Moderate

Treated with short-acting bronchodilators plus antibiotics and/or oral

corticosteroids

Severe

Requires hospitalization or visits the emergency room; may also

be associated with acute respiratory failure

Blood eosinophil count

Predicts the magnitude of the effects of inhaled corticosteroids

Which patient is most likely to benifits ICS regimens as a treatment with COPD

When blood eosinophil is ≥ 300 cells/ul. ICS containing regimens have a little to no effect at a blood eos count less than 100 cells/ul

When to use and not use ICS as a treatment

Use with you have high eos count and 1 or more exacerbations in the past year.

Not use if there is history of pneumonia, blood eos count of less than 100, and history of mycobacterial infection

Goals for Treatment of Stable COPD

Reduce symptoms and Reduce risk

Reduce symptoms

Relieve symptoms

Improve exercise tolerance

Improve health status

Reduce risk

Prevent disease progression

Prevent and treat exacerbations

Reduce mortality

Miscellaneous recommendations for treatment

Smoking cessation

Nicotine replacement

Antidepressants (bupropion/nortriptyline)

Varenicline (nicotinic acetylcholine receptor partial agonist)

What vaccinations can be useful in the treatment of COPD

Flu

Pneumonia

Covid

RSV

Shingles

Tdap

Pulmonary rehabilitation

Helps with the treatment of COPD by making patients comfortable and able to manage their symptoms, and be able to do light exercise

Oxygen therapy

Long-term oxygen therapy (>15 hours per day) for patients with chronic respiratory

failure increases survival

Who's indicated for oxygen therapy?

PaO2 ≤ 55 mmHg or SaO2 ≤ 88% with or without hypercapnia confirmed twice over

a three-week period

Who's indicated for oxygen therapy?

PaO2 between 55 mmHg and 60 mmHg or SaO2 of 88% if there is evidence of:

- Pulmonary hypertension

- Peripheral edema suggesting congestive heart failure

- Polycythemia (hematocrit >55%

Anticholinergic Drugs for COPD

Drugs in Ium like Ipratropium

Glycopyrrolate

Revefenacin

Beta-2 Agonists for COPD

Drugs ending in terol, like albuterol

Theophylline ~ side effects

Nausea/insomnia/ headache / heartburn/seizures/arrhythmia

B •adrenergics side effects

Sinus tachycardia

Tremor

Hypokalimia

Anticholinergics side effects

Dry mouth

Bitter metallic taste (itratropium)

Acute glaucoma

What is the major risk of regular inhaled corticosteroid (ICS) treatment in COPD?

Increase risk of pneumonia

How does ICS and LABA compare with either therapy alone in COPD?

Combination of both is more effective. Improve lung function, health status and reduce exacerbations

What is best inhaled therapy when it comes to treatment of COPD?

Triple therapy (LAMA+LABA+ICS)

Which COPD patients should treatment always include a ICS?

Patients with COPD and asthma

What blood eosinophil level is associated with increased pneumonia risk in COPD?

A blood eosinophil count less than 2%

What PDE-4 inhibitor improves lung function and reduces exacerbations in chronic bronchitis with severe COPD?

Roflumilast

Which antibiotics can reduce COPD exacerbations when used long term?

Azithromycin and erythromycin

For which COPD patients is azithromycin most often considered?

Smokers

Long term effect of antibiotics?

Antibiotic resistance and hearing impairment

Which mucolytics may reduce exacerbation risk in COPD patients and can all people with COPD take them?

One in market is N-acetylcysteine and not all patients with COPD is selected for that treatment.

When should we consider adding biologics in treatment patients with COPD?

when blood eosinophil is ≥ 300 cells/ul

Why uses bioligics?

Improve lung function, reduce exacerbation risk and improve quality of life

What biologics may be used in COPD patients with chronic bronchitis and with EOS ≥ 300 cells/ul despite triple therapy

Dupilumab

What biologics reduces COPD exacerbation with or without chronic bronchitis?

Mepolizumab

Mechanism of action for roflumilast?

PDE-4 inhibitor; inhibit breakdown of cAMP and ↓ inflammation

Does roflumilast have bronchodilator activity?

No

What are some side effects of roflumilast?

Nausea/Diarrhea

Deduce appetite (weight loss)

Abdominal pain

Sleep disturbances

Headache

Anxiety or depression

What is Ensifentrine (Ohtuvayre) MOA?

Dual inhibitor of phosphodiesterase 3 and 4. Anti-inflammatory

Does Ensifentrine have bronchodilator effect?

Yes and improve lung function and dyspnea. but inconsistent effects on quality of life

Adverse effecs of Ensifentrine

Hypertension

Diarrhea

Back pain

Depression and suicidal tendencies

Dupilumab mechanism of action

inhibitor of IL-4 and IL-13

What's the MOA for mepolizumab>

IL-5 inhibitor