Chronic Obstructive Pulmonary Disease (COPD)

role of roflumilast in treating COPD

1) add-on to triple therapy for people with COPD who have had at least 1 exacerbation in the past year 2) add-on before or with the addition of ICS/LABA in patients with frequent or severe exacerbations

does this list of side effects match up with LABA or LAMAs? "dry mouth, metallic taste, mydriasis and glaucoma if released into eye; urinary retention"

LAMA (LABAs list of side effects involves tremors and palpitations and hypokalemia)

which of the following has a slower onset of action but a longer duration of action? - SABA - SAMA

SAMA (duration of action up to 8 hours vs 4-6 hours)

probable pathogens for AECOPD patients with <4 exacerbations in the past year

h. influenzae moraxella catarrhalis streptococcus pneumoniae

cardinal symptoms of COPD

shortness of breath and activity limitation

which of the following is not a precipitating factor or trigger for COPD? - tobacco smoking - frequent pneumonia - heavy exposure to occupational dusts and chemicals - air pollution

frequent pneumonia

when is an alpha1 antitrypsin level indicated in patients undergoing COPD assessment?

if patient <65 years old of age presents with COPD, 20 years or more pack-year smoking history of a strong family hx of COPD

Which of the following pharmacological options is useful in the management of COPD? - antitussives - expectorants - vasodilators - oxygen therapy

oxygen therapy has demonstrated increased survival in patients with arterial hypoxemia or chronic respiratory failure

what are oscillating positive expiratory pressure (OCEP) devices?

they may provide some improvement in lung function efficacy of OCEP devices in reducing COPD exacerbation severity and improving lung function has been supported by some small studies

is there any benefit from combining a SAMA with a SABA? (i.e., ipratropium/salbutamol)

yes this combination produces greater and more sustained improvement in FEV1 and a greater degree of bronchodilation with a lower or similar incidence of AE compared with either drug alone

can ICS/LABA and LAMA therapy be combined together? (triple therapy)

yes, the combination of ICS/LABA plus tiotropium improves bronchodilation and lung deflation, reduces freq and severity of exacerbations, improves health and reduces hospitalization reserve this for patients with severe COPD and repeated exacerbations

benefits of combining LAMA and LABA compared to monotherapy

- bronchodilation maximized - improvement of FEV1 - reduction of symptoms and exacerbation rates

scales that help to assess degree of shortness of breath and disability

1) modified medical research council's dyspnea scale (mMRC) 2) COPD assessment test (CAT)

what is defined as "frequent exacerbations" in a COPD patient?

2 or more moderate exacerbations OR 1 or more exacerbation requiring hospitalization

If a patient has smoked for 10 pack years, this means that he or she could have smoked: - 0.25 of a pack per day for 80 years - 1 pack per day for 15 years - 2 packs per day for 5 years - 3 packs per day for 3 years

2 packs per day for 5 years

how is COPD diagnosed?

2 things 1) baseline postbronchodilator FEV1 <80% of the predicted value 2) decreased FEV1/FVC (lower than the lower limit of normal)

tapering is unnecessary for oral corticosteroid courses that least less than ________weeks

2 weeks

corticosteroids (prednisone 30-40 mg/day) given within _____days of an acute exacerbation will help reduce the risk of further exacerbations

30 days administration beyond 30 days is not recommended

onset of action/brochodilation of formoterol

<3 minutes (12 hour duration of action)

which of the following statements is true regarding the use of Ellipta devices? - a disadvantage of Ellipta devices is that they do not include a dose counter - ellipta devices are ideal for patients who low inspiratory capacity - ellipta devices have an expiry date of 6 weeks after their removal from the pouches - ellipta devices require assembly and insertion of the canister to prepare it for usage

Ellipta devices have an expiry date of 6 weeks after their removal from the pouches

LAMAs and risk for cardiovascular events

Found with ipratropium and tiotropium in retrospective studies The FDA and others have extensively reviewed available data and have concluded there is no increased risk of stroke, MI or death associated with tiotropium DPI Ipratropium appears to be associated with an increase in CV events

which of the following statements regarding the use of Genuair devices is FALSE? - Genuair devices are not suited for patients with poor cognition or dexterity issues - Genuair devices require forceful inhalation and are thus not suited for patients with severe COPD - Genuair devices have a colour coded window on top of their mouthpiece - The Genuair device is only used in patients with COPD and only 2 meds use this device

Genuair devices are not suited for patients with poor cognition or dexterity issues Untrue because it does not involve multiple steps, thus its suitable for these patients

Which of the following statements is FALSE regarding the use of HandiHalers? - if rattling occurs to the capsule, this indicates that the dose was inhaled correctly - it is an ideal device for patients with poor dexterity issues (e.g., in parkinson's disease) - a second breath may be taken to ensure that the full dose is inhaled - there is only one medication that is available as a HandiHaler and that is tiotropium

It is an ideal device for patients with poor dexterity issues (e.g., in Parkinson's disease) HandiHalers are not appropriate devices for patients with poor dexterity and cognition due to the several steps that are involved

Patient currently on SABD PRN and LAMA/LABA combination inhaler. The patient still has frequent exacerbations and the physician asks you what would be the best next step to step up therapy

LAMA + ICS/LABA OR ICS/LAMA/LABA

Patients with COPD are all started on a SABD PRN (regardless of case severity) what else is appropriate to initiate in a patient who has only 1 exacerbation in the past year that was resolved without antibiotics or steroids?

LAMA or LABA (no need for LAMA/LABA since zero serious exacerbations requiring steroids or antibiotics in the past year)

when selecting a combination bronchodilator therapy, which of the following options is preferred to maximize bronchodilation and reduce incidence of acute exacerbations and hospitalizations? - LAMA/LABA - ICS/LABA

LAMA/LABA

Patients with COPD are all started on a SABD PRN (regardless of case severity) what else is appropriate to initiate in a patient who has been hospitalized once in the past year ?

LAMA/LABA combination

when comparing LAMAs with LABAs, __________ appears to be more effective in reducing the incidence of exacerbations and hospitalizations

LAMAs ALL LAMAs have bee found to reduce the rate of AECOPD leading to hospitalization

which of the following is NOT a characteristic feature of COPD? - good response to inhaled corticosteroids - gas trapping and impaired gas exchange - overproduction of mucus - blockage in pulmonary microvasculature

good response to inhaled corticosteroids COPD does not respond adequately to inhaled corticosteroids, and thus, they are only used as adjuncts in the late stages of the disease

what type of drug is roflumilast?

a PDE4 inhibitor

which of the following LAMAs are dosed twice daily? (as opposed to once daily) - tiotropium - ipratropium - glycopyrronium - aclidinium - umeclidinium

aclidinium (400 mcg twice daily) the rest of the choices are once daily LAMAs

Which of the following is correct regarding the use of blood eosinophil counts as a measure of COPD prognosis? - blood eosinophil counts should be conducted in moderate-severe COPD patients to determine their exacerbation risk - increased efficacy of ICS may be observed in patients with low eosinophil counts - higher eosinophil counts have been associated with increased exacerbations in patients with a history of exacerbations - blood eosinophil counts should be conducted in all COPD patients to determine their exacerbation risk

higher eosinophil counts have been associated with increased exacerbations in patients with a history of exacerbations

which of the following is NOT an AE associated with the overuse of inhaled beta2-agonists? - tremors - hoarseness - tachycardia - nervousness

hoarseness this is an AE of ICS, esp with inappropriate technique

which of the following genetic mutations has been proven to be implicated in the development of COPD? - CFTR gene mutation - Alpha-1 antitrypsin deficiency - Alpha-1 antichymotrypsin deficiency - ORMDL polymorphism

alpha-1 antitrypsin deficiency

During COPD assessment, elevated eosinophils (>300 cells/mcL in blood or >3% in sputum) which may be a marker for overlapping symptoms of ______________and COPD

asthma

which of the following statements is INCORRECT with respect to the difference between asthma and COPD? - asthma flare-ups are triggered by inhaled allergens while COPD is only triggered by smoking - asthma is characterized by reversible lung obstruction vs COPD which is slowly progressive - wheezing is typically associated with asthma vs chronic cough and sputum production in COPD - ICS are reserved for severe COPD vs used as first-line maintenance in asthma

asthma flare-ups are triggered by inhaled allergens while COPD is only triggered by smoking

which antibiotic therapy for AECOPD is the shortest in duration - amoxi/clav - azithromycin - levofloxacin - doxycycline

azithromycin is the shortest duration (3 days) amoxi/clav is 5-10, doxy 5-7 and levo 5 days

As per the Modified medical research council (mMRC) dyspnea scale, which of the following is most likely to lead to a classification of very severe COPD? - stopping for breath every few minutes while walking on level ground - being unable to walk up a slight gradient without becoming breathless - becoming breathless while getting dressed and undressed - experiencing shortness of breath during strenuous exercise

becoming breathless while getting dressed and undressed becoming breathless during a simple task such as dressing is indicative of mMRC grade 4 (very severe COPD)

which of the following factors is NOT associated with poor prognosis after a COPD-related hospitalization - advanced age - occurrence of exaberations - body mass index (BMI) or 22 - comorbid CV disease

body mass index BMI or 22 a BMI of <19 is independently associated with poor clinical prognosis following hospitalization for a COPD exacerbation

which therapy choice leads to a GREATER IMPROVEMENT In lung function? - doubling the dose of SABA (salbutamol) - doubling the dose of SAMA (ipratropium) - combining SABA/SAMA

combining SABA/SAMA

Physician asks you how to dose azithromycin therapy for helping a COPD patient experience less frequent exacerbations. is pulsed dosing supported by evidence?

current evidence does not support pulsed antibiotic therapy for prevention of exacerbations; however intermittent prophylactic therapy (3x/week) clinically reduced exacerbations in COPD patients

which of the patients is LEAST likely to receive benefit from macrolide intermittent prophylactic therapy for acute exacerbations? - older patient with milder COPD - current smokers who are on optimized bronchodilator and ICS therapy

current smokers appear to receive no benefit from long-term azithromycin use of azithromycin in current smokers should be carefully considered

probable pathogens for AECOPD patients with 4 or more exacerbations in the past year (or failure of narrower antibiotics, antibiotic use in the past 3 months

enterobacteriaceae pseudomonas spp.

true or false: nebulize delivery of medication is superior to DPIs or SMIs (soft mist inhalers)

false, DPIs or SMIs provides optimal drug delivery and should be encouraged over nebulizers

which factor is associated with increased exacerbations or frequent exacerbations? female or male gender

female gender

which of the following statements regarding allergen immunotherapy is true? - immunotherapy can be initiated in pregnancy if the mother is in her third trimester - sublingual tablets have been designed to treat allergies to ragweed, bee pollen and house dust mites - immunotherapy provides lasting remission of allergy symptoms through allergen desensitization and production of antibodies - it should be considered in patients with moderate-severe allergic rhinitis who have low-FEV1 (<70% of predicted)

immunotherapy provides lasting remission of allergy symptoms through allergen it is a viable option in patients with moderate-severe allergic rhinitis, provided that their FEV1 >70% predicted

what did the TORCH study find?

increased mortality with ICS monotherapy the main role of ICS in COPD is in combination with LABA in moderate to severe disease

which of the following is NOT a risk associated with starting ICS therapy in patients with COPD? - increased risk of contracting or reactivating Tb - increased risk of pneumonia - increased risk of tremors and palpitations

increased risk of tremor and palpitations

which of the following is NOT an indication for hospitalization due to a COPD exacerbation select one: - increased shortness of breath for 2 days - peripheral edema or cyanosis - use of accessory inspiratory muscles - presence of comorbid CHF

increased shortness of breath for 2 days this warrants a physician's examination to investigate the possibility of an exacerbation and reassess therapy

Atrovent

ipratropium bromide

Combivent Respimat

ipratropium bromide and salbutamol

which of the following is NOT an agent used in AECOPD in a patient with less than 4 exacerbations in the past year and no previous using of antibiotics in the past 3 months - amoxicillin 5-7 days - doxycycline 5-7 days - Septra 5-7 days - levofloxacin 5 days

levofloxacin 5 days Levofloxacin is a preferred agent for AECOPD patients with 4 or more exacerbations per year or recent antibiotic use

all of the following substances are known to exacerbate asthma symptoms EXCEPT: - ibuprofen - propranolol - lisinopril - sulfites

lisinopril NSAIDs are known to aggravate asthma symptoms

Role of antibiotics to prevent exacerbations

long term macrolide therapy can help reduce # of patients experiencing exacerbation and frequency

All of the following are factors associated with exacerbations and increased mortality with COPD, EXCEPT - male gender - advanced age - low FEV1 - high number of comorbidities - low physical activity

male gender female gender is a risk factor

Role of vitamin D supplementation in COPD

may be helpful for reducing the risk of exacerbations ONLY In patients with low baseline vitamin D levels vitamin D3 120,000 units q2months

role of theophylline in treating COPD

may be used in patients with severe symptoms of COPD despite use of triple therapy

55 year old male exhibiting symptoms of COPD exacerbation Symptoms relieved with increased doses of salbutamol and ipratropium, inhaled through an aerochamber How would you classify his exacerbation, according to the 2018 GOLD assessment of exacerbation severity? - mild - moderate - severe - very severe

mild the exacerbation did not involve the use of antibiotics or oral corticosteroids, thus it is not considered moderate

which of the following agents is NOT an appropriate add on to a COPD patient on triple inhaler therapy who still has frequent exacerbations - roflumilast - theophylline - n-acetylcysteine - montelukast

montelukast (only has a role in asthma and allergies)

which of the following is considered and oral mucolytic add on? - Roflumilast - n-acetylcysteine - theophylline

n- acetylcysteine Roflumilast is PDE4 inhibitor that can also be considered as an add on (all three in the flip side of this card are good add ons to consider if the patient is still not controlled on triple therapy)

which of the following may enhance vasodilation of nitroglycerin? - roflumilast - theophylline - n- acetylcysteine

n-acetylcysteine (NAC)

Side effects of theophylline

nausea, vomiting, abdominal cramps, headache, nervousness, tremor, insomnia, tachycardia

role of ORAL beta2-agonists in COPD

no role in the routine management of COPD offer few advantages and are associated with an increased incidence of side effects

is there an advantage to using IV vs oral corticosteroids in AECOPD?

no, there is no advantage to using IV corticosteroids

do SABAs and SAMAs have effects on reducing exacerbations rates and dyspnea and hospitalizations?

no, this effect is found in long-acting bronchodilators only

which of the following statements is INCORRECT with regards to the management of COPD exacerbations? - antibiotics are indicated in patients with increased sputum purulence and dyspnea - oral corticosteroid maintenance therapy should be provided to patients with severe COPD - if indicated, a broad spectrum antibiotic should be provided to a patient with ischemic heart disease (IHD) - inhaled salbutamol and ipratropium given every 4-6 hours are recommended to improve dyspnea

oral corticosteroid maintenance therapy should be provided to patients with severe COPD there is no role for oral corticosteroid maintenance therapy due to the high AE profile associated with chronic use

which of these co-morbidities does NOT occur frequently with COPD? - lung cancer - metabolic syndrome - anxiety - osteooarthritis

osteoarthritis it has not been found to frequently co-exist with COPD

Which of the following is NOT an indication to perform spirometry? - smokers 35 years of age or older - occupational exposure to respiratory irritants - patients with recurrent chest infection - patients with congestive heart failure and persistent cough

patients with congestive heart failure and persistent cough this is likely indicative of decompensated HF and thus other lab investigations are to be performed

Which of the following is NOT an appropriate non-pharm measure for patients with COPD? - smoking cessation is the best way to improve COPD prognosis - physical activity is discouraged due to reduced lung function - influenza vaccinationns are recommended annually - patients should take measures to avoid airborne pollution and dust

physical activity is discouraged due to reduced lung function

what is the greatest predictor of future exacerbations? patient's current disease severity or prior history of exacerbations

prior history of exacerbations

Is exacerbation occurs despite triple therapy, what is the next best option to try before opting for an oral therapy like roflumilast?

pulmonary rehabilitation

which of the following would you recommend to a COPD patient in order to increase exercise capacity - psychotherapy - ambulatory oxygen therapy - acupuncture - pulmonary rehabilitation

pulmonary rehabilitation has been proven to reduce dyspnea and optimize functional status in GOLD groups B and C

Which of the following statements is FALSE regarding the efficacy of ICS for the treatment of COPD? - in stable COPD patients who are using ICS/LABA + LAMA, ICS withdrawal may be considered - regular use of ICS has not been associated with pneumonia in COPD patients - Adding an ICS/LABA to LAMA has limited effectiveness but may be useful in reducing symptoms - ICS monotherapy has not been found to be beneficial in improving COPD outcomes

regular use of ICS has not been associated with pneumonia in COPD patients

which of the following medications should be used carefully in patients with mood instability? - roflumilast - theophylline

roflumilast theophylline should be used carefully in the elderly

which of the following has a faster onset of action? - salbutamol - ipratropium

salbutamol the role of ipratropium monotherapy is limited because it is less effective than tiotropium and has a slower onset of action than salbutamol

which of the following is NOT an agent used in AECOPD if the patient has had 4 or more exacerbations in the past year? - levofloxacin - amoxi/clav - septra - cefuroxime

septra is used if the patient has <4 exacerbation in the past year

5 day course of prednisone prescribed for patient due to asthma attack. All of the following are key counselling points to review EXCEPT: - prednisone is generally considered safe for use during breastfeeding - prednisone should be taken early in the day to avoid insomnia - patient should follow up with her family physician regarding prednisone tapering - she should take prednisone with food

she should follow up with her family physician regarding prednisone tapering corticosteroid tapering is not required for a treatment duration of 5 days

late clinical findings of COPD

signs of hyperinflation, hypoxemia and pulmonary hypertension

________________________is the gold standard for diagnosis and risk stratification of COPD

spirometry

what did the WISDOM study find about tapering inhaled corticosteroid therapy in the context of current triple therapy (ICS/LABA/LAMA)?

tapering fluticasone over a 12 week period (in patients taking salmeterol and tiotropium) lead to no difference in time to first exacerbation, symptoms or QoL between dual therapy vs triple therapy patients

what did the FLAME study find about the effectiveness of ICS/LABA vs LABA/LAMA in delaying time to first exacerbation and decreasing the rate of exacerbations and incidence of pneumonia

they found that the LAMA/LABA combination was more superior to ICS/LABA

which of the following statements regarding soft mist inhalers (Respimate device) is INCORRECT? - they require priming until a fine mist is released then 3 more sprays if first time use - they require high inspiratory effort and volume, making them not ideal for the elderly - their base automatically locks when there are not actuations left for inhalation - steps for daily use involve turning, opening and pressing (TOP technique)

they require high inspiratory effort and volume, making them not ideal for the elderly they were designed for deeper lung deposition of inhaled particles and thus low inspiratory effort is required

which of the first-line agent for managing persistent symptoms and moderate to severe airflow obstruction? - glycopyrronium - tiotropium - umeclidinium - aclidinium

tiotropium

how is dyspnea due to AECOPD treated?

treat dyspnea with a SABA and ipratropium

true or false: Acute exacerbations are the most frequent cause of medical visits, hospital admissions and death among COPD patients.

true

true or false: COPD exacerbations become more frequent and more severe as a patient's disease worsens

true

true or false: DPIs do not present with problems with hand-breath coordination seen with pMDIs.

true

true or false: SABA PRN should be recommended in all stages of COPD disease severity for immediate symptom relief

true

true or false: both roflumilast and theophylline both have drug interactions with strong CYP450 inducers

true

true or false: cold weather is associated with an increase in the number of patients experiencing acute exacerbations

true

true or false: prior to initiating ICS, it is best to assess inhaler technique and ensure optimal bronchodilation using LAMA/LABA

true

true or false: there is no role for oral corticosteroids maintenance therapy for patients with COPD

true oral corticosteroids are strictly only used short term during AECOPD

true or false: all stages of COPD can potentially benefit from pulmonary rehabilitation

true After an acute exacerbation, recommend initiation of pulmonary rehabilitation within 4 weeks to reduce the chances of further exacerbations

True or false: recommend pneumococcal vaccination to all patients with COPD who have no CIs

true patients with COPD are at increased risk of hospitalization and mortality from pneumonia

true or false: routine use of antibiotics in AECOPD is not recommended

true , this is because of inconsistent study results in nonsevere exacerbations and concerns about increasing prevalence of antimicrobial resistance

true or false: Two-thirds of exacerbations are related to acute respiratory infections

true, 1/3 of them have no clear cause

true or false: spirometry should be done in all smokers 35 years or older

true, also in past smokers with a 20 year or more pack year

true or false: oxygen therapy reduces the risk of death in select patients (severe hypoxemia)

true, long term oxygen therapy may prolong life by 6-7 years continuously administered oxygen provides the greatest survival benefit

true or false: severe COPD patients gain additional benefit from a short course of systemic corticosteroids (in AECOPD hospitalization)

true, oral corticosteroids (5 day course) improves lung function and shorten length of hospital stay in all patients

true or false: physical activity will help prevent decreased mobility and increased dyspnea

tue patients with a lower activity level at 1 month of hospital discharge are more likely to be readmitted in the following year

65 year old male smokes 1 pack/day recently diagnosed with COPD after an AECOPD that lead to him being hospitalized Finished prednisone and antibiotics CAT score 8 according to his ABCD group which of the following maintenance therapies is the most appropriate? - salbutamol (SABA) 100 mcg inahler: 2-4 puffs q4h PRN (max 8) - formoterol (LABA) 6 mcg inhaler: 1 puff BID -budesonide/formoterol (ICS) 200/6 mcg inhaler: 1 puff BID - umeclidinium (LAAC) 62.5 mcg inhaler: 1 puff once daily

umeclidiium (LAAC) 62.5 mcg inhaler: 1 puff once daily preferred agent due to its efficacy in reducing COPD exacerbations

advantages of formoterol over salmeterol as LABA therapy?

unlike salmeterol, formoterol has the advantage of rapid onset of bronchodilation in addition to 12 hour duration of action

_________________are the most common infectious agents in AECOPD

viruses