Patient Recommended Tx Assessment Escalation

Group

A A bronchodilator Sx controlled→ Continue initial tx

SAMA or SAMA PRN Sx not well controlled→ Try a different class of
LABA or LAMA bronchodilator as monotx

B LAMA or LABA Persistent sx→ LAMA + LABA

C LAMA (preferred because has a greater impact on Further exacerbations→ LAMA + LABA or LABA + ICS
exacerbation rates)

D LAMA + LABA or LABA + ICS Persistent sx and further LAMA + LABA + ICS
exacerbations→

CHAPTER 36 COPD
● Spirometry is required to assess lung function and
make a dx for COPD
○ Post bronchodilator FEV1/FVC<0.70
confirms a dx of COPD
○ Gold 1: mild; FEV1 >80%
○ Gold 2: moderate; FEV1 50-80%
○ Gold 3: severe; FEV1 30-50%
○ Gold 4: very severe; FEV1 <30%
● mMRC dyspnea scale: assess breathlessness and
scores range from 0 (only breathless with exercise)
to 4 (too breathless to leave the house/do normal
daily activities)
● CAT score: assesses all sx; scores range from 0-40%;
higher scores→ worse sx
● >2 exacerbations/year→ frequent exacerbators
● Combined Assessment: sx assessment and risk of
exacerbations drive tx options
● Non-Drug Tx:
○ Smoking cessation is the only method to
slow the progression of COPD
○ Annual flu vaccine and pneumococcal
vaccinations dec the risk of hospitalizations
○ Assess inhaler technique and adherence to
improve outcomes
○ Long term oxygen tx for patients with
severe resting hypoxemia inc survival
● Drug tx: only help with sx and prevent
complications
○ Each tx is personalized based on combined
assessment
○ First line: bronchodilator
○ SABAs & SABAs added PRN
○ If regular use is required, LAMAs or LABAs
should be used
○ Combining different bronchodilators from
different classes may improve efficacy and
dec SE
○ Long term monotx with PO or ICS is not
recommended, but ICS may be added to
LABA tx or LAMA/LABA tx in moderate-
severe COPD
■ ICS may cause pneumonia, but
overall improves sx, lung ftn, QoL,
and reduces exacerbation
frequency
○ PDE-4 inhibitors are used in most severe
cases
○ Theophylline can only be used if no other
options
● Exacerbations: treated with a SABA with/without a
SAMA + an IV/PO systemic steroid
○ If there is inc sputum purulence, inc sputum
volume, inc dyspnea, or mechanical
ventilation i s needed, abx should be used
for 5-10 days
● Muscarinic Antagonists/Anticholinergics: block
constricting action of Ach at M3 muscarinic
receptors in BSM
○ SE: dry mouth, URTI, cough, bitter taste
○ Avoid spraying in eyes
○ Do not swallow the capsules in DPIs
● SAMAs:
○ Ipratropium bromide:
■ Atrovent HFA (17 mcg/inh)
● MDI: 2 inh QID
● Neb: 0.5 mg TID-QID
■ Combivent Respimat (20 mcg
ipra/100 mg alb/inh)
● MDI: 1 inh QID
■ Combivent Respimat Neb (0.5 mg
ip/2.5 mg alb/3 mL)
● Neb: 3 mL QID
● LAMAs:
○ Aclidinium (Tudorza PressAir): 400 mcg/inh
■ DPI: 1 inh BID
○ Glycopyrrolate: 15.6 mcg/inh
■ DPI: 1 capsule BID
○ Tiotropium:
■ Spiriva Handihaler (18 mcg capsule)
1 capsule QD (requires 2 puffs)
■ Spiriva Respimat (2.5 mcg/inh) MDI:
2 inh QD
○ Umeclidinium (Incruse Ellipta): 62.5
mcg/inh
■ DPI: 1 inh QD
● Long acting beta-2 agonists: LABAs should be used
as monotx in COPD only
○ CI: status asthmaticus, acute episodes of
asthma or COPD, monotx in tx of asthma
○ SE: nervousness, tremor, tachycardia,
palpitations, cough, hyperglycemia, dec K
○ Do not swallow the capsules by mouth
○ Salmeterol: (serevent Diskus) 50 mcg/inh
■ DPI: 1 inh BID
○ Formoterol: (Perforomist) 20 mcg/2 mL neb
soln
■ Neb: 20 mcg BID
○ Indacaterol (Arcapta Neohaler) 75 mcg
capsule
■ DPI: 1 capsule daily
○ Olodaterol (Striverdi Respimat)
■ MDI: 2 inh daily
● Phosphodiesterase Inhibitor: Inhibit PDE-4 to inc
cAMP levels leading to dec lung inflammation
○ Should always be used in combo with at
least one long acting bronchodilator
○ Reserved for very severe COPD, chronic
bronchitis, and hx of exacerbation
○ Roflumilast: (Daliresp) 500 mcg PO QD
■ CI: moderate to severe hepatic
impairment
■ SE: diarrhea, weight loss
■ Major 3A4 and 1A2 substrate
● Respimat:
○ Turn the blear base until it clicks
○ Turn head away and breathe out slowly,
fully
○ Take a slow deep breath and press the dose
release button as you breathe in slowly
○ Hold your breath as long as possible, up to
10 sec
○ Discard 3 months after cartridge is inserted
○ Priming:
■ Turn it until you hear a click
■ Point towards the floor and push
the dose release button
■ Repeat until a spray is visible
■ When a spray is visible, repeat 3x
■ If not used in >3 days prime again
by releasing one spray to the
ground
■ If not used for >21 days, prime like
initial use
○ Clean with a damp cloth or tissue weekly.
● Handihaler:
○ Remove the capsule and insert into the
chamber
○ Close the mouthpiece firmly until you hear
a click
○ Press the green button once until it is flat
against the base then release. Do not shake
○ Turn head away and breathe out fully
○ Breathe in deeply and fully. You should feel
it vibrate
○ Hold breath for a few seconds then breathe
normally
 ○ To get full dose, you must inhale twice from ○ Breathe out
each capsule. Repeat last two steps ○ The chamber should be empty. If not, inhale
breathing out fully again and breathing in again
deeply and fully through the inhaler. ○ Remove capsule by tipping it out
○ Tip out the used capsule after two ○ Clean with a dry towel
inhalations into a trashcan.
○ Clean by running under warm water and
pushing green button to rinse piercing
needle and chamber under water.
○ Make sure any powder build up is gone.
○ Let air dry for 24 hours before use.
● Tudorza Pressair:
○ Hold inhaler with mouthpiece facing you
and the green button face up. Before
putting in your mouth, press the green
button all the way down then release.
○ Check the control window. Green means
go.
○ Breathe out completely away from the
inhaler
○ Breathe in until you hear a click sound and
keep breathing in to get a full dose
○ Hold your breath for as long as you can
○ Breathe out slowly through your nose
○ Check the control window. Red means you
got the full fose.
○ Clean by wiping with a dry paper towel
● Ellipta:
○ Slide the cover down until you hear a click.
○ Turn your face away and breathe out fully.
○ Take one long, deep, steady breath through
your mouth
○ Do not block the air vent with your fingers
○ Hold breath for 3-4 sec or as long as
comfortable
○ Breathe out slowly and gently
○ Rinse mouth out if ICS
○ Clean with dry tissue before you close the
cover.
● Neohaler:
○ Remove a capsule and place in the chamber
○ Close the inhaler until you hear a click
○ Hold inhaler upright. Push both buttons
down until you hear a click.
○ Release buttons and breathe out fully, away
from inhaler.
○ Hold inhaler with buttons to the side in your
mouth. Breathe in rapidly and deeply until
you hear a whirring sound