COPD: persistent respiratory symptoms & airflow limitations due to airway and/or alveolar abnormalities usually caused by smoking – chronic & irreversible
split between emphysema (destruction of terminal airways = useless airsacs) & chronic bronchitis (mucus = cough)

s/sx: dyspnea, chronic cough, chest tightness, wheezing, depression, anxiety, ankle swelling, weight loss, fatigue, rib fractures; see loss of alveolar attachments, decreased elastic recoil, chronic inflammation, airway fibrosis, luminal plugs, increased airway resistance, mucus

dx: FEV1/FVC < 70% (optional: chest x-ray to exclude other conditions)

@ risk: SMOKERS, occupational exposures, alpha-1 antitrypsin deficiency, oxidative stress, being > 40 years old, female, low SES

staging based on a bunch of factors:
1. severity – CAT or mMRC; CAT < 10 or mMRC 1 is less severe, CAT  > 10 or mMRC > 2 is more severe
2. spirometry – FEV1/FVC ratio – < 70% indicates airflow limitation (stage 1 is >80% predicted FEV1, stage 2 is FEV1 50-80%, stage 3 is FEV1 30-50%, stage 4 is FEV1 <30%) – called the GOLD standard
3. exacerbation risk – 0-1 without hospitalization is low risk, 2+ or any going to the hospital is high-risk (within past year) GOLD

goals: reduce symptoms & risk

non-pharm therapy
stop smoking!!! physical exercise, pulmonary rehab
(also make sure they’re getting vaccinated since any sickness where they might even get a sore throat/cough can be dangerous: everybody gets the flu shot & patients diagnosed between 19-64 y/o should get PPSV23 for pneumonia; if they’re older, they just get the regular vaccine schedule)

pharm therapy: once you’ve decided if a patient is (A) (B) (C) or (D)

(A) LABA (if they have occasional dyspnea, they may qualify for SABA)

(B) LABA -OR- LAMA – can bump up to LABA & LAMA

(C) LAMA alone! – can bump up to LAMA & LABA -OR- LABA & ICS (but LAMA & LABA is preferred)

(D) LAMA alone, then LAMA & LABA, then LABA & ICS, then Trelegy (LAMA & LABA & ICS combo), then maybe Roflumilast or Macrolide – kind of rare to do those options though

if any patients have severe resting hypoxemia (<88% confirmed 2x over a 3W period OR <88% + evidence of pulmonary HTN/peripheral edema/HF/polycythemia) can give supplemental O2 therapy

*important thing! none of the medications that are approved for COPD have actually been shown to modify the long-term decline in lung function*

so what are the meds?

Aformoterol = Brovana – Neb BID
Formoterol = Perforomist – Neb BID
Indacaterol = Arcapta – DPI QD
Olodaterol = Striverdi – SMI QD
Salmeterol = Serevent – DPI BID

Aclidinium = Truvada – DPI BID
Glycopyrrolate = Seebri – DPI BID
Umeclidinium = Incruse Ellipta – DPI QD
Tiotropium = Spiriva – DPI/SMI QD

Glycopyrrolate & Formoterol = Bevespi – MDI BID
Glycopyrrolate & Indacaterol = Utibron Neohaler – DPI BID
Umeclidinium & Vivanterol = Breo Ellipta – DPI QD
Tiotropium & Olodaterol = Stiolto Respimat – SMI QD