Short acting beta agonists (time and suffix)
Rescue med (bronchodilation within 2 mins). Work 4-6 hrs; "terol". Albulterol, Levalbuterol
Long acting beta agonists
12-24 hrs; start working after 10-20mins. Ex. Salmeterol. Suffix is "terol".
Inhaled Anticholinergics
Produce "a little" bronchodilation. Work by preventing bronchoconstriction. Examples: Ipratropium (Atrovent), tiotropium (Spiriva), aclidinium (Tudorza Pressair), Umeclidinium (Incruse Ellipta), Glycopyrrolate (Seebri Neohaler).
May cause constipation. Wo
Anti-cholinergic side effects
Memory impairment, confusion, hallucinations, dry mouth, blurry vision, urinary retention, constipation, tachycardia, - avoid with acute angle glaucoma.
"Oh this drug, it makes me pink, sometimes, I can't think or even blink - I can't see, I can't pee, I
Inhaled Corticosteroids
Best in COPDers with FEV1 <60% predicted. Works by reducing inflammation.
Examples: fluticasone, mometasone, budesonide. Best in combo with bronchodilators (usually LABA).
LABA plus LAAC
Olodaterol/Tiotroprium (Stiolto Respimat) and Vilanterol/Umeclidium (Anoro Ellipta). New research shows these work really well but are expensive.
Treatment of asthmatic exacerbation (impending respiratory failure)
Adrenaline injection. Oxygen 4-5 lpm. Albuterol nebs, parenteral steroids, antihistamines (diphenhydramine), and H2 blocker (cimetidine).
Physical exam of Treatment of asthmatic exacerbation (impending respiratory failure) will reveal
Cyanosis and "quiet" lungs with no wheezing or breath sounds. Accessory muscle use.
Normal lower lobe sounds
vesicular breath sounds (soft and low)
Normal upper lobe sounds
Bronchial breath sounds (louder)
Normal egophony
eee"
Louder over large bronchi; lower lobes are softer "eee
Abnormal egophony
bah
tactile fremitus
palpable vibration - have pt say "99" or "one, two, three
Normal tactile fremitus results
Stronger vibrations are palpable on the upper lobes and softer vibrations on lower lobes (abnormal findings are reversed and/or asymmetrical)
whispered pectoriloquy - lung consolidation
Whispered words heard on the lower lobes of the lungs
whispered pectoriloquy normal
voice louder and easy to understand in upper lobes; muffled in lower lobes
whispered pectoriloquy abnormal
clear voice sounds in the lower lobes or muffled sounds on the upper lobes
Percussion findings - COPD/emphysema
Tympany or hyperresonance
Percussion findings - consolidation, pleural effusion (fluid or tumor) or solid organ
Dull tone
Respiratory diseases with obstructive dysfunction (reduction in airflow rates)
Asthma, COPD (chronic bronchitis and emphysema), bronchiectasis, others
Respiratory diseases with restrictive dysfunction (reduction of lung volume due to decreased lung compliance)
Pulmonary fibrosis, pleural disease, diaphragm obstruction, others.
COPD includes
Both emphysema and chronic bronchitis. (Some pts may also have an asthma component.)
COPD is characterized by
The loss of elastic recoil of the lungs and alveolar damage - takes decades
Chronic bronchitis
Coughing with excessive mucus production for at least 3 or more months for a minimum of 2 or more consecutive years
Emphysema
Permanent alveolar damage and loss of elastic recoil result in chronic hyperinflation of the lungs. Expiratory respiratory phase is markedly prolonged.
Risk factors for COPD
Smoking, occupational exposure, Alpha-1 trypsin deficiency (damage happens earlier in these individuals)
Objective findings COPD
Percussion: Hyperresonance. Tactile fremitus and egophony are decreased. Flattened diaphragms with hyperinflation (and bullae sometimes present) on xray.
Objective findings COPD - Emphysema component
Increased anterior-posterior diameter, decreased breath and heart sounds, use of accessory muscles, pursed-lip breathing, weight loss.
Objective findings COPD - Chronic bronchitis component
Productive cough, wheezing, and coarse crackles.
SABA (examples and use cautions with...)
Short-acting beta-agonists; albuterol, levalbuterol, or metaproterenol. Use with caution in pts with HTN, angina, hyperthyroidism.
Inhaled anticholinergics (examples and use caution with)
Atrovent, Spiriva. Avoid if pt has narrow-angled glaucoma, BPH, or bladder neck obstruction.
Vaccines for COPD
Annual influenza; pneumococcal (PPSV23/Pneumovax) and (PCV13/Prevnar) - administer 12 months apart.
Meds for COPD category A/GOLD 1-2
Short acting B2 agonist (SABA) PRN alone or in combo SABA with short-acting anticholinergic.
COPD category A/GOLD 1-2
Minimally symptomatic, low risk of exacerbation
COPD category B/GOLD 1-2
More symptomatic, low risk of exacerbation
Meds COPD category B/GOLD 1-2
Long-acting B2 agonist (LABA) OR long-acting anticholinergic (newer name is long-acting muscarinic agent - LAMA) with SABA for rescue PRN.
COPD category C/GOLD 3-4
Minimally symptomatic (but high risk of exacerbation)
Meds COPD category C/GOLD 3-4
High-risk; refer to pulmonologist.
LABA
long acting beta agonist; Salmeterol or formoterol.
Short acting anticholinergics
Ipratropium (Atrovent)
LAMA
Long acting anticholinergics/long acting muscarinic antagonist: Tiotropium (Spiriva), umeclidinium powder (Ellipta).
If symptoms of COPD are not improved with single agent...
Combined use of SABAs or LABAs and short-acting anticholinergics OR LAMAs may be considered.
Recommended treatment for COPD pts with severe airflow limitation (GOLD 3-4 category) with frequent exacerbations
Refer to specialist. Long-term therapy with ICS plus LABA.
Daliresp
Phosphodiesterase-4 inhibitor (Roflumilast) - used for severed COPD. May increase risk of suicide. **Drug interactions.
Acute causes of cough
(<3weeks) Acute resp. infection (bronchitis, sinusitis, PND), COPD/asthma exacerbation, pneumonia, PE.
Chronic causes of cough
(>8weeks) Asthma, GERD, Infection (pertussis, atypical pneumonia), ACE inhibitors (dry cough 1-3 weeks after starting), chronic bronchitis, bronchiectasis (chronic cough, viscid sputum, bronchial wall thickening on CT), lung CA
Pertusis
highly contagious, reportable!, one of the few times acute bronchitis is treated with abx
abx for pertussis
Macrolide; ex: Azithtomycin 500mg day 1, 250mg days 2-5
S. pnuemoniae
pneumococcal pneumonia - most common cause of pnemonia death
Atypical pneumonia
Most common causes of pneumonia .
Mycoplasma Pneumoniae, Chlamydia Pneumoniae, Legionella Pnumophila
Mostly Seen in Adolescent or Young Adults
Cause Bilateral, Diffuse Infiltrates on CXR
DRSP presentation
Look sick; abrupt onset fever, chills, cough, pain in side or chest, colored sputum (older pts exhibit fewer symptoms)
Atypical pneumonia presentation
Low grade fever, cough, chills, HA, malaise, rash, joint aches, arrhythmias
Atypical pneumonia treatment
Macrolides or doxycyclines
If DRSP is suspected, treat with...
Respiratory quinolone (gemifloxacin, levofloxacin, moxifloxacin)
OR
Beta lactam (PCN or Ceph) PLUS macrolide or doxy
Pneumonia vaccine for adults 19-64 years who are at increased risk of pneumococcal disease (asthma, COPD, CV dx, etc)
PPSV23
Pneumonia vaccine for all adults 65 and older or adults 19-64 with asplenia, immunocompromising conditions, CSF leak, cochlear implants
PCV13, then PPSV23 (in 1 year)
PPSV23
Pneumovax
PCV13
Prevnar
Key indicators of COPD
1) Dyspnea
2) Chronic cough
3) Chronic Sputum Production (3 or more months in 2 yrs)
4) History of Exposure to Risk Factors such as Tobacco
COPD dyspnea
-progressively worsens over time, increases w/ exercise, persists on a daily basis & feels to the patient like an "increased effort to breathe", "heaviness/gasping
COPD chronic cough
Initially may be intermittent, may be unproductive, then present every day throughout the day
Diagnosis of COPD
SPIROMETRY REQUIRED FOR DX. FEV1:FVC ratio of <70% with less than 12% reversibility; SOB, chronic cough, sputum and exposure.
Differential diagnosis for COPD
COPD, HF, Asthma, TB
COPD - mid life onset, slow progression, hx of exposure.
HF - dilated heart, pulmonary edema on xray, no airflow limitation.
Asthma - early in life onset usually. Wide variation of symptoms day to day which may worsen in early AM or e
COPD GOLD 1
(Based on post-bronchodilator FEV1)
Mild FEV1 >- 80% predicted
COPD GOLD 2
Moderate. 50% <- FEV1, <80% predicted
COPD GOLD 3
Severe. 30% <- FEV1, <50% predicted
COPD GOLD 4
Very Severe FEV1 < 30% predicted
FVC
forced vital capacity - volume of air forcibly exhaled from the point of max inspirations
FEV1
forced expiratory volume in 1 second
FVC/FEV1
RATIO (age, gender, height, race taken into account with reference values)
Beta agonists
Albuterol/RESCUE MED