Saturday, February 27, 2016

COPD: Tips for step 2 CK and rounds

Hello! I have a pulmonary rotation going on and I thought I'd shed light on management of COPD :D

During rotations, you may be asked what you want to do for the patient. I have written "Plan" for what you might want to answer to impress your attending. I've included a few common brand names too :)

Inhalers: Remember inhalers only improve symptoms and have no mortality benefit and do not affect the progression of the disease.

For all patients with COPD: A short-acting bronchodilator (eg, beta-agonist, anticholinergic agent) is prescribed for use as-needed for relief of intermittent increases in dyspnea.
Plan:
Albuterol PRN

COPDers in whom intermittent short-acting bronchodilators are insufficient to control symptoms or two or more exacerbations in the previous year: Add a regularly scheduled long-acting inhaled bronchodilator. The long-acting inhaled anticholinergic (muscarinic) agent (LAMA) is preferred to the twice daily long-acting beta agonists (LABAs).
Plan:
Albuterol PRN
Tiotropium OD (Spiriva)

Important for step 2 CK: Inhaled anti-cholinergics are the most effective in COPD.
(Contrary to asthma, where you start Inhaled steroids if symptoms aren't controlled by short acting bronchodilator like albuterol alone.)
Mnemonic: antiCholinergics are the Coolest in COPD.

For patients who continue to have respiratory symptoms or exercise limitations when using long-acting inhaled bronchodilator monotherapy, add a second long-acting bronchodilator from another class (LAMA or LABA), rather than adding an inhaled glucocorticoid. For patients who continue to have symptoms or have repeated exacerbations despite an optimal long-acting inhaled bronchodilator regimen, add an inhaled glucocorticoid (ICS). An inhaled glucocorticoid may be warranted earlier (ie, at the same time that the long-acting inhaled bronchodilator is initiated) if there are signs of inflammation or an asthmatic component to the COPD.
Personally, I have seen them prescribed together in clinical practice rather than one after the other.
Plan:
Albuterol PRN
Tiotropium OD
Fluticasone / Salmeterol BD (Adavir)
Or Budesonide / Formoterol BD (Symbicort)

Stuff that has a  mortality benefit:
Oxygen therapy
Smoking cessation
Vaccination (Influenza, pneumococcal)

Clinical pearl: Always ask your COPD patient when was their last flu shot. If your attending asks, you'll know it like a boss B)

When do you start O2? Start O2 when pO2 < 55, sat < 88%
(Silly question that I asked and answered myself: Why don't we start O2 right away if it's so awesomee? Because carrying an O2 cylinder around isn't always feasible lol.)

Other things to shine on rounds:
Know that COPD is a systemic disease, not just a lung disease - Depression, osteoporosis, weight loss, etc are also a part of the disease.
Read about BODE index.
Know about the anti-inflammatory effects of macrolides in COPD exacerbations.

That's all!
We rise by lifting others :)
-IkaN

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