Pharmacotherapy of _____ by HC120519094736

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									                           Pharmacotherapy of ____COPD___________________
                                            Tri Nguyen, PharmD Candidate 2007

Epidemiology Prevalence:
                    -1996 over 16 million COPD sufferers (14.2 million chronic bronchitis, 2 million emphysema)
                    -4th most common cause of death in U.S.

                    Cost burden:
                    -COPD is the second leading cause of disability in the U.S.
                    -1997 over 13 million physician office visits for COPD and 634,000 hospitalizations
                    -Economic impact estimated at greater than $23 billion annually


Disease State       The American Thoracic Society defines COPD as a disease state characterized by the presence of
Definition          airflow obstruction due to chronic bronchitis and emphysema where airflow obstruction is generally
                    progressive, maybe accompanied by airway hyperreactivity and maybe partially reversible. Chronic
                    bronchitis is defined as recurrent mucus secretion into the bronchial tree with cough occurring on most
                    days during a period of 3 months of the year for at least 2 consecutive years. Chronic emphysema is
                    defined as abnormal permanent enlargement of the airspaces distal to the terminal bronchioles
                    accompanied by destruction of their walls.

                    The NHLBI and WHO have proposed that COPD be redefined as a disease characterized by
                    progressive airflow limitation caused by abnormal inflammatory reaction to the chronic inhalation of
                    particles.

                    Disease Staging:

                    Stage 0: -chronic symptoms, exposure to risk factors, normal spirometry
                    Stage 1 (Mild) : FEV1/FVC <70%, FEV1 > 80%, with or without symptoms
                    Stage 2: (Moderate): FEV1/FVC <70%, 50%< 80%, with or without symptoms
                    Stage 3 (Severe): FEV1/FVC < 70%, 30%< FEV1 < 50%, with or without symptoms
                    Stage 4 (Very Severe): FEV1/FVC < 70%, FEV1< 30% or presence of chronic respiratory failure or
                    right heart failure


Patho-
physiology          Inflammation in the peripheral airways and lung parenchyma is the predominant process in COPD.
                    Macrophages activated by irritants (smoke, allergens) release neutrophil chemotactic factors. Activated
                    macrophages and neutrophils release proteinases that break down connective tissue in the lung
                    parenchyma leading to emphysema and mucous production (bronchitis).
                    Chronic bronchitis:
                    -Hyperplasia, hypertrophy of mucous-producing glands from irritants excessive tracheobronchial
                    mucus secretion inflammation and narrowing of bronchioles with fibrosis, and irregularity.
                    -Changes in bronchioles over several yearsimpaired ventilation and hypoxemiapulmonary HTN
                    due to hypoxemia with subsequent right ventricular failure (cor pulmonale).
                    -Persistent hypoxia stimulates erythropoiesis leading to secondary polycythemia (increase RBCs)
                    -Increase mucous production, stagnation, plugging and lack of ciliary movement of mucous leads to
                    increase respiratory infections
                    Emphysema:
                    -Destruction of walls within the acinus (alveolus) diminishes surface area for gas exchange results in
                    loss of elastic recoil (essential for compression of distal airways during expiration).
                    -Emphysema results in a loss in ventilation (V) as well as perfusion (Q) resulting in greater dyspnea
                    compared to bronchitis patients who experience impaired ventilation without significant loss in
                    perfusion.
Tri Nguyen, PharmD Candidate 2007                                   Pharmacotherapy Presentation – Pharmaceutical Care Rotation
University of Maryland School of Pharmacy                            Happy Harry’s Pharmacy Patient Care Center, Perryville, MD
                                                        Predominant Emphysema                 Predominant Chronic
                                                                                              Bronchitis
                      Age                               60+                                   50+
                      Dyspnea                           Severe                                Mild
                      Sputum                            After dyspnea starts                  Before dyspnea starts
                      Bronchial infection               Less frequent                         More frequent
Clinical
                      Respiratory insufficiency         Often terminal                        Repeated
Presentation
                      episodes
                      PaCo2 (mm Hg)                     35-40                                 50-60
                      PaO2 (mm Hg)                      65-75                                 45-60
                      Hematocrit                        35-45                                 50-60
                      Cor Pulmonale (rt. Vent.          Rare                                  Common
                      Hypertrophy)




Risk Factors

                      Major Risk Factors                                  Minor Risk Factors
                      Smoking                                             Air pollution
                      Age                                                 Race
                      Male gender                                         Nutritional status
                      Existing impaired lung function                     Family History
                      Occupation                                          Respiratory Tract Infections
                      α 1-antitrypsin deficiency                          Bronchial reactivity


Diagnosis
                    Pulmonary Fx tests: (reduced in chronic bronchitis (CB) and/or emphysema (E) patients)
                    -Forced expiratory volume (FEV1)
                    -Forced vital capacity (FVC)
                    -FEV1/FVC ratio
                    -Forced expiratory flow (FEF)
                    Arterial blood gases: (see clinical presentation for differentiation)
                    Chest Roentgenogram: (cx x-ray)
                    -CB flattened diaphragm, loss of peripheral vascular markings, bullous lesions and retrosternal air
                    space
                    -E increased bronchovascular markings in the lower lung field
                    Other Labs:
                    -CBelevated Hgb and Hct (secondary to erythropoiesis caused by hypoxemia)


Desired
Therapeutic         -Smoking cessation
Outcomes*           -Improvement in chronic obstructive status
                    -Treatment and prevention of acute exacerbations
                    -Reduction in progression of disease
                    -Improvement in physical and psychological well-being
                    -Reduction in mortality, hospitalizations, days of lost work
*Reference of
Guidelines Used     GOLD-(Global Initiative for Chronic Obstructive Lung Disease)

Tri Nguyen, PharmD Candidate 2007                                    Pharmacotherapy Presentation – Pharmaceutical Care Rotation
University of Maryland School of Pharmacy                             Happy Harry’s Pharmacy Patient Care Center, Perryville, MD
Treatment
Options**           Non-drug therapy:
                    -Smoking cessation
(Non-drug and       -Pulmonary rehabilitation (physical/breathing exercise)
Drug Therapy        -Psycho-social support
– include all       -Health education
therapeutic         Drug Therapy:
classes/agents      -B2 agonists (short acting/long acting)
available and       -Anticholinergics (short acting/long acting/combination SABA+anticholinergic in inhaler)
preferences         -Methylxanthines
per treatment       -Inhaled glucocorticsteroids (combination LABA+glucocorticosteroids in inhaler)
guidelines)         - Systemic glucocorticosteroids




**See Treatment
Options Table

Monitoring

(Efficacy and       **See Treatment Options Table
Toxicity
Parameters)




Tri Nguyen, PharmD Candidate 2007                                  Pharmacotherapy Presentation – Pharmaceutical Care Rotation
University of Maryland School of Pharmacy                           Happy Harry’s Pharmacy Patient Care Center, Perryville, MD

								
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