ࡱ> rtq@ ubjbj (vuu       ###8#TN$j5^%^%^%^%^%^%^%^%4444444$\6R84- )^%^%))4  ^%^%$5x-x-x-)  ^% ^%4x-)4x-x-/  =0^%R% p#+p 01:50j50,9\,9=0    =0h9 0^%n&x-0''^%^%^%44!# -X#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 Definition The American Thoracic Society defines COPD as a disease state characterized by the presence of 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.  Clinical Presentation  Predominant Emphysema Predominant Chronic Bronchitis Age 60+ 50+ Dyspnea Severe Mild Sputum After dyspnea starts Before dyspnea starts Bronchial infection Less frequent More frequent Respiratory insufficiency episodes Often terminal Repeated PaCo2 (mm Hg) 35-40 50-60 PaO2 (mm Hg) 65-75 45-60 Hematocrit 35-45 50-60 Cor Pulmonale (rt. Vent. Hypertrophy) Rare Common 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  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 Outcomes* *Reference of Guidelines Used -Smoking cessation -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 GOLD-(Global Initiative for Chronic Obstructive Lung Disease) Treatment Options** (Non-drug and Drug Therapy include all therapeutic classes/agents available and preferences per treatment guidelines) **See Treatment Options Table  Non-drug therapy: -Smoking cessation -Pulmonary rehabilitation (physical/breathing exercise) -Psycho-social support -Health education Drug Therapy: -B2 agonists (short acting/long acting) -Anticholinergics (short acting/long acting/combination SABA+anticholinergic in inhaler) -Methylxanthines -Inhaled glucocorticsteroids (combination LABA+glucocorticosteroids in inhaler) - Systemic glucocorticosteroids Monitoring (Efficacy and Toxicity Parameters)  **See Treatment Options Table      Tri Nguyen, PharmD Candidate 2007 Pharmacotherapy Presentation Pharmaceutical Care Rotation University of Maryland School of Pharmacy Happy Harrys Pharmacy Patient Care Center, Perryville, MD /9KPQR^_`acdopuv E F ¾|tl^lRl|l^lGhh`HCJaJhYhYCJH*aJ jhYhYCJaJhYCJaJhYGCJaJh`HCJaJhho 5CJaJh5CJaJhYG5CJaJhhYG5CJaJh@@hYG5h@@h] 5ho hrrhYG5 hrr5hrrhrr5 h05hFhYG5CJaJh0h05>*CJaJh05CJaJ/QR_`abcdp @ $IfgdY$If$a$gdrr$a$gdYGt q r 9 : L M ~~~~~~~~~~~~~$Ifzkd$$Ifl0* $ t0644 la p q r 8 9 GHINQnoƾ~umummbmWhhCJaJh  h  CJaJh  CJaJh  >*CJaJhA>*CJaJhAhACJaJhAhA>*CJaJhACJaJh\iCJaJhWCJaJhYGCJaJhCJaJhCJaJhho 5CJaJh5CJaJhYG5CJaJh@@hYG5h@@h] 5hYG" "o~zkd_$$Ifl0* $ t0644 la$Ifo?@jkGHļ||tlldlXhaha5CJaJhaCJaJhsCJaJhR,CJaJ jhjhjCJaJhjCJaJh$]CJaJ jh";h";CJaJh";CJaJhsh2%G5CJaJh2%GCJaJhYGCJaJhh5CJaJh5CJaJh5CJaJhYG5CJaJhhYG5CJaJo@Hij~zkd$$Ifl0* $ t0644 la$If01hijp|ph`X`X`XL`XLhVsxhVsx>*CJaJhVsxCJaJh+CJaJhYGCJaJhhyy5CJaJhyy5CJaJh5CJaJho 5CJaJhYG5CJaJhhYG5CJaJh@@hYG5h@@h] 5 hA5hYGhh2%GCJaJh>2CJaJhaCJaJ jhR,hR,CJaJhR,CJaJha5CJaJjklmnop $Ifgd+K$ $Ifgd] $Ifpeee $Ifgd+K$kd$IfK$L$lF # 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