Transcript COPD - South Carolina Society of Health

COPD Primer
Julie Sease, Pharm D, BCPS
Clinical Assistant Professor
South Carolina College of Pharmacy
Test Your Knowledge
1.
What are the 2 main subsets of COPD?
2.
What national guidelines are used to dictate management
of COPD patients?
3.
What is the primary non-pharmacological management
strategy for COPD?
4.
Name 2 inhaled anticholinergics commonly used in the
management of COPD.
5.
What FEV1/FVC percentage defines COPD?
6.
At what FEV1 percentage are inhaled corticosteroids
indicated in COPD management?
Objectives

Describe the etiology and epidemiology of chronic
bronchitis and emphysema

Discuss non-pharmacologic treatments and
preventive medicine strategies for COPD

Summarize pharmacologic treatment options for
COPD including the most recent additions

Review current guidelines to understand proper use
of medications used to treat COPD

Provide recommendations for the treatment of
patients with COPD
COPD

http://webtech.kennesaw.edu/joannregruto/images/lungs.gif
COPD=
Chronic Obstructive Pulmonary Disease
– Characterized by progressive airflow limitation
that is not fully reversible
– Associated with an abnormal inflammatory
response of the lungs to noxious substances
(ex: tobacco smoke)
Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease
(GOLD) 2007. Available from: http://www.goldcopd.org; accessed February 2008.
Main Subsets of COPD

Chronic Bronchitis (CB)

Emphysema (EP)
Images from www.deborah.org/consumer/clubs/art/copd1.gif
Epidemiology

Up to one quarter of patients age 40 and
older may have airflow limitation indicative
of Stage I COPD or higher

4th leading cause of morbidity & mortality in the US

Economic impact = $32 billion in 2002
Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease
(GOLD) 2007. Available from: http://www.goldcopd.org; accessed February 2008.
Etiology:
Risk Factors
– Genes
– Exposures



Smoking (#1)
Occupational dusts and
chemicals
Heating/cooking with
biomass in poorly
vented dwellings
– Lung growth and
development
– Oxidative stress
– Gender
http://en.wikipedia.org/wiki/Cigarette_smoking
–
–
–
–
–
Age
Respiratory infections
Socioeconomic status
Nutrition
Comorbidities
Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease
(GOLD) 2007. Available from: http://www.goldcopd.org; accessed February 2008.
Clinical Presentation:
CB










Blue Bloater (CO2
retention)
Low PaO2
Smoking History
Chronic cough/sputum
production
Overweight
Cyanosis of lips/mucus
membranes
Clubbing of fingers
http://www.forumbpco.be/Media/gen_images/bluebloater.jpg
Sleep apnea
Cor pulmonale
Polycythemia
Clinical Presentation:
EP

http://www.forumbpco.be/
Media/gen_images/pinkpuff
er.jpg









Pink Puffer
 dyspnea—even at rest
Tachypnea
Flushed face
Thin
Pursed breathing
Use of accessory
muscles to breath
Hyperinflation of diaphragm
Barrel chest
Polycythemia
http://www.after50health.com/images/image041.jpg
Diagnosis:
Pulmonary Function Tests
– Spirometry

Forced Expiratory Volume in 1 second (FEV1)

Forced Vital Capacity (FVC)

FEV1/FVC
– COPD = FEV1/FVC = <70%
Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease
(GOLD) 2007. Available from: http://www.goldcopd.org; accessed February 2008.
Diagnosis:
Pulmonary Function Tests

Reversibility
– FEV1 measured pre-bronchodilator
– Beta agonist, anticholinergic, or both given to
patient
– FEV1 measured post-bronchodilator
– Increase in FEV1 >200 mL and 12% above prebronchodilator is considered a significant
increase = reversibility
Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease
(GOLD) 2007. Available from: http://www.goldcopd.org; accessed February 2008.
Comparisons
Asthma
Reversibility
Sputum Production
Alveolar Damage
CB
EP
Classification of COPD
Stage I: Mild
FEV1/FVC < 70%
FEV1 >/= 80%
Stage II: Moderate
FEV1/FVC < 70%
50% < FEV1 < 80%
Stage III: Severe
FEV1/FVC < 70%
30% < FEV1 < 50%
Stage IV: Very Severe
FEV1/FVC < 70%
FEV1 < 30% or < 50% with presence of chronic
respiratory failure
Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease
(GOLD) 2007. Available from: http://www.goldcopd.org; accessed February 2008.
Goals of Therapy







Relieve symptoms
Prevent disease progression
Improve exercise tolerance
Improve health status
Prevent and treat complications
Prevent and treat exacerbations
Reduce mortality
punkindoodledesigns.com/footballGoal.jpg
Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease
(GOLD) 2007. Available from: http://www.goldcopd.org; accessed February 2008.
COPD Complications







Acute respiratory failure
Cachexia: loss of fat free mass
Skeletal muscle wasting: apoptosis, disuse
atrophy
Osteoporosis
Depression
Normochromic normocytic anemia
Increased risk of cardiovascular disease:
associated with CRP
Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease
(GOLD) 2007. Available from: http://www.goldcopd.org; accessed February 2008.
Non-Pharmacological
Therapy

Pulmonary rehabilitation

Immunizations

Long term oxygen therapy
– PaO2 < 55 mmHg
– SaO2 <88%
– Pulmonary HTN, Cor Pulmonale, Polycythemia (Hct >55%)

Nutritional support

Surgery (bullectomy, lung volume reduction, transplant)

SMOKING CESSATION
Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease
(GOLD) 2007. Available from: http://www.goldcopd.org; accessed February 2008.
Smoking Cessation





Ask
Advise
Assess
Assist
Arrange
The Tobacco Use and Dependence Clinical Practice Guideline Panel, Staff, and Consortium Representatives. A clinical
practice guideline for treating tobacco use and dependence. JAMA 2000;283:24-254.
Smoking Cessation:
Assistance

Bupropion SR (Zyban)

Nicotine (gum, inhaler, spray, patches)

Varenicline (Chantix)
Drug Therapy
Bronchodilators


Anticholinergics
– Ipratropium (Atrovent®, Combivent®)
– Tiotropium (Spiriva®)
2 Agonists
– Short-acting:
 Albuterol (Proventil®, Ventolin®, Combivent®)
 Levalbuterol (Xopenex HFA®)
 Pirbuterol (Maxair®)
 Terbutaline (Brethine®)
– Long-acting:
 Formoterol (Foradil®)
 Salmeterol (Serevent®, Advair®)
Anticholinergics

Mechanism of action:
– Blocks acetylcholine at parasympathetic
sites in bronchial smooth muscle =
bronchodilation

Also…
– Dries secretions
Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease
(GOLD) 2007. Available from: http://www.goldcopd.org; accessed February 2008.
Anticholinergics

Ipratropium: 18 mcg/puff
– Dose: 2 puffs every 6 hours
Possible to titrate up to 24 doses/24h
 Available as metered dose inhaler and
nebulizer solution

Anticholinergics

Tiotropium (Spiriva®)
18 mcg/capsule
– Long-acting agent



www.pharmaceutical-technology.com/projects/ro...
Onset within 30 minutes
Peak = 3 hours
Duration of effect = 24 hours
– Dose: 1 capsule daily (Handihaler)
http://www.yle.fi/akuutti/kuvat3/keuhkoaht_3.jpg
Tiotropium (Spiriva®)

Tiotropium vs. Placebo
– 1 year in duration, placebo controlled,
double-blind trial
– Tiotropium added to standard therapy
– Tiotropium improved FEV1 an average of
12% to 22% over placebo
Casaburi R, Mahler DA, Jones PW, et al. A long-term evaluation of once daily inhaled tiotropium in
chronic obstructive pulmonary disease. Eur Resp J 2002;19:217-224.
Tiotropium (Spiriva®)

Tiotropium vs. Ipratropium
– 1 year in duration, multicenter, double blind trial
– Once daily tiotropium vs. ipratropium four times
daily
– Tiotropium significantly improved lung function,
selected quality of life scores, decreased
dyspnea, and fewer exacerbations
Vincken W, van Noord JA, Greefhorst APM, et al. Improved health outcomes in patients with COPD during
one year treatment with tiotropium. Eur Resp J 2002;19:209-216.
Tiotropium (Spiriva®)

Tiotropium vs. Salmeterol vs. Placebo
– Randomized, controlled trial
– Tiotropium produced
Greater improvements in trough FEV1
 Greater improvements in dyspnea scores
 Greater improvements in quality of life scores

Donohue JF, van Noord JA, Bateman Ed, et al. A 6-month placebo-controlled study comparing lung function
and health status changes in COPD patients treated with tiotropium or salmeterol. Chest 2002;122:47-55.
2 Agonists

Mechanism of Action:
– Stimulate cyclic adenosine monophosphate
(cAMP) which mediates relaxation of bronchial
smooth muscle leading to bronchodilation

Adverse Effects:
– Tremor, palpitations, nervousness, tachycardia,
hypokalemia
– Lessened by appropriate dose and inhaled route
Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease
(GOLD) 2007. Available from: http://www.goldcopd.org; accessed February 2008.
2 Agonists (Short-Acting)

Albuterol (90 mcg/puff)
– Short onset of effect so drug of choice for acute
relief of symptoms
– Prescribed commonly on a scheduled basis to
prevent or reduce symptoms in COPD
– Dose: 2 puffs four times daily

Maximum albuterol dose = 12 puffs/day
– Metered dose inhalation & nebulizer solution
2 Agonists (Long-Acting)


Salmeterol (50 mcg)
Formoterol (12 mcg)
– Dose 1 inhalation every 12 hours
(SCHEDULED basis)
www.rch.org.au/.../images/Foradil.jpg
– Provide bronchodilation throughout the
dosing interval
Combination
Bronchodilator Therapy

Anticholinergic + 2 agonist
– Ipratropium + Albuterol
(Combivent®)
– Greater efficacy than either drug
alone
http://www.sk.lung.ca/drugs/images/respiratory/img000082b.jpg
– Dose: 2 puffs 4 times per day
(SCHEDULED more effective than
PRN in moderate and severe COPD)
Combivent Inhalation Aerosol Study Group. In chronic obstructive pulmonary disease, a combination of
ipratropium and albuterol is more effective than either agent alone. Chest 1994;105:1411-1419.
Corticosteroids

Mometasone (Asmanex®)
– 220 mcg/inhalation
– 1-2 inhalations at bedtime

Flunisolide (Aerobid®)
– 250 mcg/puff
– 1-4 puffs twice daily

https://online.epocrates.com/u/1094121/Asmanex+Twisthaler/Pill+Pictures
Fluticasone propionate (Flovent®)
– 44 mcg/puff (2 puffs twice daily)
– 220 mcg/puff 1-2 puffs twice daily



Beclomethasone dipropionatem (Vanceril®)
Budesonide (Pulmicort®)
Triamcinolone acetonide (Azmacort®)
Corticosteroids

Mechanism of Action:
– Reduce capillary permeability to decrease mucus
– Inhibit release of proteolytic enzymes from leukocytes
– Inhibit prostaglandins

Controversial: 2 appropriate situations
– Acute exacerbation (IV or oral)
– Long term inhalation therapy for chronic stable COPD

Adverse Effects:
– Inhaled: hoarseness, candida, skin bruising, decreased
bone density
Bourdet SV and Williams DM. Chronic Obstructive Pulmonary Disease. In: Dipiro JT, Talbert RL, Yee GC, et al., eds.
Pharmacotherapy: A Pathophysiologic Approach, 6th ed. McGraw-Hill Companies Inc., 2005: 537-556.
Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease
(GOLD) 2007. Available from: http://www.goldcopd.org; accessed February 2008.
Combination Therapy:
Long-acting 2 Agonist + Corticosteroid
– Salmeterol + Fluticasone (Advair®)
100/50 mcg BID
 250/50 mcg BID
 500/50 mcg BID

– Formoterol + Budesonide
(Symbicort®)
4.5/80 mcg 2 inhalations BID
 4.5/160 mcg 2 inhalations BID

Additional Bronchodilators:
Methylxanthines


Theophylline (Theodur®; PO)
Aminophylline (IV)
– Mechanisms of action:
Inhibit phophodiesterase increasing cAMP
 Inhibit calcium ion influx into smooth muscle
 Antagonize prostaglandins
 Simulate endogenous catecholamines
 Antagonize adenosine receptors
 Inhibit mast cell and leukocyte mediators

Bourdet SV and Williams DM. Chronic Obstructive Pulmonary Disease. In: Dipiro JT, Talbert RL, Yee GC, et al., eds.
Pharmacotherapy: A Pathophysiologic Approach, 6th ed. McGraw-Hill Companies Inc., 2005: 537-556.
Additional Bronchodilators:
Methylxanthines

Theophylline dosing:
– 200 mg twice daily (sustained action products
more prevalent in use - do not switch)
– Titrate to therapeutic effect and blood levels
(trough 8-15 mg/dL)
– Usual dose = 400-900 mg daily
– Once stable, monitor blood concentration 1-2
times per year
Bourdet SV and Williams DM. Chronic Obstructive Pulmonary Disease. In: Dipiro JT, Talbert RL, Yee GC, et al., eds.
Pharmacotherapy: A Pathophysiologic Approach, 6th ed. McGraw-Hill Companies Inc., 2005: 537-556.
Additional Bronchodilators:
Methylxanthines

Caution:
–

Metabolic Inducers and Inhibitors
Adverse Effects:
–
–
–
–
GI (Dyspepsia/Nausea/Vomiting/Diarrhea)
CNS (Headache/Dizziness; Seizures (toxic))
CV (Tachycardia; Arrhythmias (toxic))
Monitor LFTs, cardiac function
Bourdet SV and Williams DM. Chronic Obstructive Pulmonary Disease. In: Dipiro JT, Talbert RL, Yee GC, et al., eds.
Pharmacotherapy: A Pathophysiologic Approach, 6th ed. McGraw-Hill Companies Inc., 2005: 537-556.
Helpful Hints


Opened mouth technique
– Better yet…spacer
Check mouthpiece prior
to inhalation
– Prime metered dose
inhalers

Rinse mouth after steroid use to avoid thrush

Inhale short-acting bronchodilator first

Remember to keep scheduled doses scheduled-not
PRN
GOLD Guidelines
Global Initiative for Chronic
Obstructive
Lung
Disease
Stage I: Mild
Classification
Information
 FEV1 ≥ 80%
 FEV1/FVC < 70%
 With/without
symptoms
Recommended
Treatment

Short-acting
bronchodilator as
needed (albuterol or
ipratropium)
Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease
(GOLD) 2007. Available from: http://www.goldcopd.org; accessed February 2008.
Stage II: Moderate
Classification
Information
 FEV1/FVC < 70%
 FEV1 50-80%
 With or without
chronic symptoms
Recommended
Treatment
 Scheduled 1+
bronchodilators:
albuterol/ipratropium or
tiotropium
+/salmeterol or
formoterol
 Rehabilitation
Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease
(GOLD) 2007. Available from: http://www.goldcopd.org; accessed February 2008.
Stage III: Severe
Classification
Information
 FEV1/FVC < 70%
 FEV1 30-50%
 With or without
chronic symptoms
Recommended
Treatment
 Scheduled 1+
bronchodilators:
albuterol/ipratropium or
tiotropium
+/salmeterol or
formoterol
Inhaled corticosteroid
Rehabilitation
Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease
(GOLD) 2007. Available from: http://www.goldcopd.org; accessed February 2008.
Stage IV: Very Severe
Classification
Information
 FEV1/FVC < 70%
 FEV1 < 30%
or
 FEV1 < 50% with
respiratory failure or
clinical signs of heart
failure
Recommended
Treatment
 Scheduled 1+
bronchodilators:
albuterol/ipratropium or
tiotropium
+/salmeterol or
formoterol
 Inhaled corticosteroid
 Long term oxygen therapy
 Rehabilitation
 Consider surgery
Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease
(GOLD) 2007. Available from: http://www.goldcopd.org; accessed February 2008.
Other Drug
Considerations

Antibiotic prophylaxis:
–

Expectorants/Mucolytics:
–
–

Regular use should be avoided
Alpha-1 antitrypsin augmentation therapy
–

No proven benefit except in patients no on inhaled steroids
Antitussives
–

No proven benefit
Water likely to do just as much good
Antioxidants
–

No benefit + resistance
Young patients with deficiency only
Nebulized opioids
–
? Benefit; possible seroious adverse effects
Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease
(GOLD) 2007. Available from: http://www.goldcopd.org; accessed February 2008.
Case 1

CR is a 70 year old man
who presents with the following symptoms:
– Dyspnea
– Chronic cough for past 3 months (similar
symptoms/duration of symptoms have been
occurring for past 3 years)
– Significant amounts of clear sputum produced
which he continuously expectorates
– 30 year history of cigarette smoking (2 ppd);
worked x 30 years in the textile industry
Case 1

What is wrong with CR?
– What disease states do his symptoms
correlate with?
– What tests should be ordered to confirm
a diagnosis of COPD?
Case 1

Spirometry results for CR:
– Prior to bronchodilator:


FEV1/FVC = 60%
FEV1 = 70%
– Post bronchodilator:



FEV1/FVC = 65%
FEV1 = 75%
Does CR have COPD?
Case 1

What class?
a.
b.
c.
d.
Mild
Moderate
Severe
Very Severe
Stage II: Moderate
Classification Information
FEV1/FVC < 70%
FEV1 50-80%
With or without
chronic symptoms
Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease
(GOLD) 2007. Available from: http://www.goldcopd.org; accessed February 2008.
Case 1

Recommend therapy for CR
– First non-pharmacologic therapy
Non-Pharmacological
Therapy

Pulmonary rehabilitation

Immunizations

Long term oxygen therapy
– PaO2 < 55 mmHg
– SaO2 <88%
– Pulmonary HTN, Cor Pulmonale, Polycythemia (Hct >55%)

Nutritional support

Surgery (bullectomy, lung volume reduction, transplant)

SMOKING CESSATION
Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease
(GOLD) 2007. Available from: http://www.goldcopd.org; accessed February 2008.
Case 1

Now recommend pharmacological therapy
for CR:
a. Albuterol 2 puffs as needed 4-6 times per day
b. Ipratropium 2 puffs as needed 4-6 times per
day
c. Albuterol/ipratropium 2 puffs 4 times per day
+ albuterol as needed up to an additional 4
puffs per day
d. Albuterol/ipratropium 2 puffs 4 times per day
+ mometasone 220 mcg/night
Case 1
Moderate:
Scheduled 1+ bronchodilators
-also remember short-acting PRN
therapy
Case 1

CR is prescribed Combivent® 2 puffs 4
times daily and is also given an
albuterol MDI for as needed use up to
4 puffs in 24 hours. He reports back
in 4 weeks stating that his symptoms
are improved but he does report using
his as needed albuterol inhaler 3-4
times per day. What will you
recommend for CR at this time?
Case 1

A. Add tiotropium (Spiriva®) 1 inhalation per day

B. Add formoterol (Foradil®) 1 inhalation BID


C. Add mometasone (Asmanex®) 1 inhalation
at bedtime
D. Switch from Combivent® to Spiriva® 1
inhalation per day
Case 1
Moderate:
 Scheduled 1+ bronchodilators:
albuterol/ipratropium
+/salmeterol or
formoterol
Could also consider switch to tiotropium
Case 1

CR did well for 1.5 years on Combivent® 2
puffs four times daily, Foradil® 1 inhalation
twice daily, and albuterol as needed. Then,
he began to have an increase in his
symptom frequency with increased dyspnea
and clear sputum production. Spirometry
revealed a FEV1 reduction to 45%. His PaO2
is 65. His CBC shows a normal white cell
count and CR has no fever. What should be
recommended for CR at this time?
Case 2

JD is a 67 year old white male with a 5
year history of emphysema/COPD. He
presents today complaining of fever,
increased sputum production (now
greenish), malaise, increased use of
his albuterol inhaler for the past 2
days, and increased dyspnea. Is JD
having an acute exacerbation? What
should be done for JD now?
COPD Exacerbation

Symptoms
– Use of accessory respiratory muscles
– Paradoxical chest wall movements
– Worsening or new onset central cyanosis
– Development of peripheral edema
– Hemodynamic instability
– Signs of right heart failure
– Reduced alertness
Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease
(GOLD) 2007. Available from: http://www.goldcopd.org; accessed February 2008.
COPD Exacerbation:
Treatment

Antibiotics: Recommended if 2 or more
are present:
– Increased dyspnea
– Increased sputum production
– Increased sputum purulence
Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease
(GOLD) 2007. Available from: http://www.goldcopd.org; accessed February 2008.
COPD Exacerbation:
Treatment

Antimicrobial Options:
– Mild exacerbation:






Beta lactam +/- beta lactamase inhibitor
Tetracycline
Macrolide
Trimethoprim/sulfamethoxazole
2nd or 3rd generation cephalosporin
Ketolide
– Moderate exacerbation:


Beta lactam/beta lactamase inhibitor
Respiratory fluoroquinolone (levo, moxi)
– Severe (hospitalized with risk of pseudomonas)


Fluoroquinolone (cipro, levo 750)
Beta lactam with pseudomonas activity
Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease
(GOLD) 2007. Available from: http://www.goldcopd.org; accessed February 2008.
COPD Exacerbation:
Treatment

Bronchodilators:
– Particularly short acting 2 agonists for
symptoms +/- anticholinergic

Corticosteroids
– SCCOPE (inpatient)
– Oral or IV (switch to oral as soon as possible)
– If continued over 2 weeks-must taper
Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease
(GOLD) 2007. Available from: http://www.goldcopd.org; accessed February 2008.
Niewoehner DE, Erbland ML, Deupree RH, et al. Effect of systemic glucocorticoids on exacerbations of chronic obstructive
pulmonary disease. Department of Veterans Affairs Cooperative Study Group. New Engl J Med 1999;340:1941-1947.
Case 2

JD is going to be treated outpatient.
What will you recommend?
Case 2

Bronchodilator:




Continue albuterol as needed but caution against > 12 puffs per day
Could add anticholinergic at this point
Is JD’s treatment maximized? Is he in need of inhaler education?
Antibiotic:
– Mild exacerbation:






Beta lactam +/- beta lactamase inhibitor
Tetracycline
Macrolide
Trimethoprim/sulfamethoxazole
2nd or 3rd generation cephalosporin
Ketolide
– Moderate exacerbation:


Beta lactam/beta lactamase inhibitor
Respiratory fluoroquinolone (levo, moxi)
One More Time…
1.
What are the 2 main subsets of COPD?
2.
What national guidelines are used to dictate management
of COPD patients?
3.
What is the primary non-pharmacological management
strategy for COPD?
4.
Name 2 inhaled anticholinergics commonly used in the
management of COPD.
5.
What FEV1/FVC percentage defines COPD?
6.
At what FEV1 percentage are inhaled corticosteroids
indicated in COPD management?
Questions ???