Académique Documents
Professionnel Documents
Culture Documents
Asthma
Onset
Usually childhood
Risk factors
COPD
Usually >40 years of age
Atopy MC predisposing
factor
Symptoms
Nasal polyps
Eczema
Samter's triad =
ASA/NSAID allergy +nasal polyps
Triggers:
Allergens
Environmental
Disease states
Infections
Emotions
Exercise
Medications
Occupational
History
Airflow
Limitation
Cigarette Smoking/
exposure to smoke
Air pollution
Occupational exposure to
dust and chemicals
Alpha-1 antitrypsin
deficiency (decreased inhibition of
proteases that break apart the alveoli
Neutrophil
of COPD
Cyanosis (lips and
fingernails)
Frequent respiratory
infections
Barrel chest
Response to Good
Steroids
and
Bronchodila
tors
Poor
GOLD Criteria
1-4 from mild to severe based on predicted FEV 1 score (age weight ethnicity height)
Used to classify degree of airflow limitation and risk for sudden dramatic change in air flow
GOLD
Classification
of Airflow
Limitation
GOLD 1
Mild
GOLD 2
Moderate
GOLD 3
Severe
GOLD 4
Very Severe
Characteristic
Spirometric
Classification
Exacerbations
per year
CAT
mMRC
Low Risk
Less Symptoms
GOLD 1-2
< 10
0-1
Low Risk
More Symptoms
GOLD 1-2
> 10
>2
High Risk
Less Symptoms
GOLD 3-4
>2
< 10
0-1
High Risk
More Symptoms
GOLD 3-4
>2
> 10
>2
Metered
Dose
Inhalers
(MDI)
Dry Powder
Inhalers
(DPI)
Powder form
Requires quick forceful breaths
Case Study
AJ is a 59 year old coal miner who presents to your private practice complaining of worsening
shortness of breath.
He has had a chronic cough with sputum production for a few years now that hes been treating
Past
Medical/Surgical History:
Atrial
Fibrillation
Hypertensio
Social history:
Smokes on
Occasiona
Hyperlipide
mia
Allergies: NKDA
Medications:
Enalapril 20mg daily
Warfarin 5mg daily
except 2.5 on MWF
Simvastatin 40mg
daily
Metformin 500mg
twice a day
Guaifenesin Cough
Syrup (non-prescription)
What
What
What
What
Family History:
Father
passed away from a heart
attack (age 40)
Mother alive
with type 2 diabetes, HTN
and hyperlipidemia
Immunization History:
Received his flu shot last yea
Unknown history of Pneumo
Vaccines
Vitals:
Labs:
Pre-diabetes
ALT 27 U/L
AST 28 U/L
ALK PHOS 59 U/L
TC
282 mg/dL
LDL 169 mg/dL
HDL 43 mg/dL
TG
150 mg/dL
HbA1c 6.2%
INR 2.3
BUN 16
SCr 0.83
His FEV1 score was 70%. Under the GOLD criteria, how would the patients COPD classified?
GOLD category 2 (<80% PREDICTED)
You evaluate the patient and find out that he has a CAT score of 9, mmRC of 1 and no previous
exacerbations. (CAT <10 AND mMRC 1 = less symptoms (either category A or C)
What is his current Combined Assessment Classification?
Stage A
Quit smoking
AJs disease state progresses further and you place him on Salmeterol 50mcg/inhalation. He goes home
and loses the labeling for the medication. What dose did you mean to prescribe to the patient?
1 inh BID
AJs throat gets irritated from using the Serevent Diskus and the patient has stopped using the inhaler
altogether because he feels it is making him cough more. Whats an alternative medication that you could
prescribe?
Nebulizer
AJ is currently in the ED with a severe shortness of breath and a fever. You are called in for a pulmonary
consult as the ED is short staffed today. What are some recommendations you could make to the ED
physician in order to manage the his exacerbations?
O2
Systemic steroids
What are some additional therapy options that could be utilized for him?
Case #2
A new patient, CJ, presents with a FEV1 Score <40% predicted, a CAT Score of 9 and mMRC of 1. He was
hospitalized 3 times this year. How would you stage this patient?
Stage C
Arformoterol (Brovana) + Beclomethasone (Qvar) HFA --> yes both are nebulizers, good if
bedridden
CJ comes back to the clinic after seeing you for a year. His condition is worsening and you are considering
adding on other medications. You found out his medications had changed due to whats available on the
insurance formulary. He is currently on Ipratropium (Atrovent), Theophylline and Budesonide (Pulmicort).
What changes in therapy should we make assuming his Combined Assessment Score has not changed?
A.
No changes needed at this time
B.
Change Pulmicort to Symbicort (Budesonide/Formoterol) (ICS + LABA)
C.
Add on Daliresp (Roflumilast)
Add on Fluticasone (Flovent HFA) and consider switching from Ipratropium (Atrovent) to Alubetrol
D.
(Proair RespiClick)