1. What is the severity of COPD associated with FEV1 ≥ 80% predicted?
    • Mild
    • Stage I
  2. What is the severit of COPD associated with FEV1 between 50-80% predicted?
    • Moderate
    • Stage II
  3. What is the severity of COPD associated with FEV1 between 30-50% predicted?
    • Severe
    • Stage III
  4. What is the severity of COPD associated with FEV1 < 30% predicted?
    • Very Severe
    • Stage IV
  5. What is the severity of COPD associated with FEV1 < 50% predicted plus chronic respiratory failure?
    • Very Severe
    • Stage IV
  6. How much of an increase in postbronchodilator FEV1 or FVC can occur before the disease is more characteristic of asthma than of COPD?
  7. Which PFT test is used to determine diagnosis of COPD?
    FEV1/FVC ratio
  8. What FEV1/FVC ratio confirms COPD?
    < 70%
  9. Which PFT test is used to determine staging of COPD?
  10. What would the qualitative measures of FEV1, FVC, FEV1/FVC, and TLC in an obstructive disease?
    • FEV1 = decreased
    • FVC = decreased or normal
    • FEV1/FVC = decreased
    • TLC = normal or increased
  11. What are the key indicators of COPD?
    • Cough (especially productive cough)
    • Sputum production
    • Chronic and progressive dyspnea
  12. What does FEV1 measure?
    How much is exhaled in the 1st second
  13. What does FVC measure?
    Total volume exhaled after maximal inhalation
  14. What 2 things are always done to treat COPD no matter the stage/severity?
    • Active reduction of risk factors: influenza vaccine
    • Add short-acting bronchodilator prn
  15. What is added to tx for Stage II/Moderate COPD?
    • Regular treatment with ≥ 1 long-acting bronchodilators
    • Rehabilitation
  16. What is added to tx for Stage III/Severe COPD?
    Inhaled corticosteroids if repeated exacerbations
  17. What is added to tx for Stage IV/Very Severe COPD?
    • Long-term oxygen if chronic resp. failure
    • Consider surgical tx
  18. What is the mainstay of treatment for COPD?
  19. What is the mainstay of treatment for asthma?
  20. What are the SABAs used for Mild COPD?
    • Albuterol (Proair, Proventil, Ventolin)
    • Perbuterol (Maxair)
    • Levalbuterol (Xoponex)
  21. What are the short-acting anticholinergics used for Mild COPD?
    Ipratropium (Atrovent MDI or neb)
  22. What is the short-acting bronchodilator combination used for Mild COPD?
    Albuterol/Ipratropium (Combivent, Duoneb)
  23. What are the SE of SABAs?
    • tachycardia
    • tremor
  24. What are the SE of inhaled anticholinergics?
    • Dry mouth
    • Nausea
    • Metallic taste
  25. What is the problem with LABAs in tx of COPD?
    • tolerance can develop to the efficacy
    • (bonus is that it develops to SE also)
  26. What are the LABAs used to tx Moderate COPD?
    • Salmeterol (Serevent)
    • Formoterol (Foradil DPI, Perforomist neb)
    • Arformoterol (Brovana neb)
  27. What are the Long-acting anticholinergics used to tx Moderate COPD?
    • Tiotropium (Spiriva DPI)
    • Ipratropium (Atrovent)
  28. What are the methylxanthines used to tx Moderate COPD?
  29. What is the MOA of theophylline in tx of Moderate COPD?
    bronchodilation by inhibition of PDE
  30. What are the SE of theophylline?
    • NV
    • Tachycardia/arrhythmias
    • HA
    • Insomnia
    • Seizures
  31. How often should pts on theophylline for COPD be re-assessed?
    6-12mo intervals
  32. What is the target serum concentration of theophylline for COPD?
    5-15 mcg/mL
  33. What are the DI of theophylline?
    • 1A2 substrate
    • tobacco
    • Anticonvulsants
    • Rifampin
    • Alcohol
  34. What is pulmonary rehabilitation?
    • exercise training
    • nutritional counseling
    • disease education
  35. What are the corticosteroids used in tx of Severe COPD?
    • Beclomethasone (QVAR)
    • Budesonide (Pulmicort flexhaler DPI, Pulmicort respules neb)
    • Ciclesonide (Alvesco)
    • Fluticasone (Flovent, Flovent diskus DPI)
    • Mometasone (Asmanex)
  36. What is the only corticosteroid available in a nebulizer formulation?
    Budesonide (Pulmicort respules)
  37. What are the corticosteroid combination products used in tx of Severe COPD?
    • Budesonide/Formoterol (Symbicort)
    • Fluticasone/Salmeterol (Advair diskus DPI, Advair)
    • Mometasone/Formoterol (Dulera)
  38. What are the SE of inhaled corticosteroids?
    • Hoarseness
    • Thrush
    • Cough
    • ↓ bone mineral density
    • ↑ fracture risk?
    • ↑ risk of pneumonia?
    • ↑ risk of atrial fibrillation?
  39. What role do inhaled corticosteroids play in tx of COPD?
    • Reduce frequency of exacerbations and improve health status
    • Response is less dramatic than in asthma
    • THEY DO NOT reduce mortality in COPD!
  40. What must be done to increase effectiveness of Advair diskus for tx of COPD?
    • you have to increase the dose d/t the limit on LABA/d
    • You can not increase the frequency!
  41. What role does Roflumilast (Daliresp) play in tx of COPD?
    decreases frequency of exacerbations
  42. What is the MOA of roflumilast for tx of COPD?
    PDE-4 inhibitor (expressed in inflammatory cells)
  43. What are the advantages of Roflumilast over Theophylline in tx of COPD?
    • It is more selective (PDE-4)
    • Weaker DI (1A2, 3A4)
    • not associated with CV or seizures
    • no need to monitor blood levels
  44. What are the SE of roflumilast?
    • ND
    • Anorexia
    • Suicidal thinking (rare, but requires med guide)
  45. What is the most common cause of a COPD exacerbation?
    respiratory tract infection
  46. What is the tx for mild exacerbation of COPD?
    increase dose of regular meds
  47. What is the tx for moderate exacerbation of COPD?
    Systemic corticosteroids +/- antibiotics
  48. What is the tx for severe exacerbation of COPD?
    • Hospitalization or evaluation in ER
    • O2 if O2 Sat < 90%
    • SABA +/- anticholinergic nebulizer or MDI w/spacer:
    • nebs q 20min (albuterol 2.5-5mg, ipratropium 0.5mg), then q 1-4h
    • Glucocorticoids for 7-10d:
    • PO preferred route
    • Consider adding theophylline if needed
    • Antibiotics:
    • Macrolides, anti-pneumococcal FQs, 2nd/3rd gen Ceph
  49. What are the SE associated with high doses or long use of glucocorticoids for tx of severe exacerbation of COPD?
    • hyperglycemia
    • psychosis
    • muscle atrophy
  50. When do you have to worry about tapering off of glucocorticoids?
    if used longer than 2wks
  51. When should discharge be considered for COPD severe exacerbation?
    • SABA required no more than q 4h
    • Pt can walk across the room
    • Pt is able to eat and sleep w/o frequent awakening by dyspnea
    • Pt has been clinically stable for 12-24h
    • Arterial blood gases have been stable for 12-24h
    • Pt/caregiver fully understands correct use of meds
    • Follup-up arrangements have been made
    • Pt/family/physician confident pt can manage successfully at home
  52. What meds should the pt be discharged on for severe exacerbation of COPD?
    • Finish up Steroid course
    • Short-acting bronchodilator prn
    • other meds as appropriate based on COPD stage most likely in
    • Finish up antibiotic course
  53. Can beta agonists still do their job if the pt is on BBL?
  54. What are the preferred BBL for COPD pts?
    • atenolol
    • bisoprolol
    • metoprolol
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