Clinical Simulation Exam Template

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RTBoardReview Simulation 28 – 62 Year-old Man with Dyspnea and Cough Condition/Diagnosis: Severe COPD (Chronic Bronchitis)

Take-Home Points

• COPD is a chronic progressive disease characterized by generalized airway obstruction that is not fully reversible with treatment (i.e., the FEV1/FVC after bronchodilator is less than 70% of predicted). Airflow limitation is associated with inflammation due to inhalation of noxious particles or gases, especially tobacco smoke. • To help guide treatment, COPD is staged according to its severity as follows:

I: Mild II: Moderate III: Severe IV: Very Severe • FEV1/FVC < 70% • FEV1/FVC < 70% • FEV1/FVC < 70% • FEV1/FVC < 70% • FEV1 ≥ 80% pred • FEV1 50-80% pred • FEV1 30-50% pred • FEV1 < 30% pred OR • SOB on exertion • SOB on exertion • FEV1 < 50% pred • repeated exacerbations + chronic resp failure

• Typical maintenance therapy ranges by stage as follows (see table and list following for more detail on the common inhaled drugs and antibiotics used to treat COPD): o Stage I/Mild - short-acting beta-agonist (SABA) as needed o Stage II/Moderate - regular use of long-acting beta-agonist (LABA) or long- action muscarinic antagonist (LAMA); consider adding an oral PDE-4 inhibitor to the LABA/LAMA regimen o Stage III/Severe - add inhaled steroids if repeated exacerbations; oral steroids if exacerbations + oral antibiotics if sputum turns purulent o Stage IV/Very Severe - add long-term O2 if justified; consider surgical Rx, e.g. lung volume reduction surgery for emphysema • Treatment for exacerbations includes: SABA (add ipratropium to enhance broncho- dilation and allow lower SABA doses); inhaled and systemic steroids (30-40 mg oral prednisone daily); course of antibiotics if increased dyspnea and purulent sputum, O2 therapy to maintain SpO2 ≥ 90%. • Disease management should be implemented for all COPD, to include o Smoking cessation and avoidance of other triggers/risk factors o Preventive care (healthy lifestyle, flu + pneumococcal vaccinations, exercise) o 'Stepped' treatment to control/reduce symptoms (above) o Patient education appropriate to the disease stage o Self-management 'action' plans to deal with exacerbations o Pulmonary rehabilitation, ideally with community support o Psychological counseling as needed o Ongoing monitoring and follow-up (at least twice per year, more often if severe) • Long-term home O2 if justified for COPD patients who meet one of the following criteria o For continuous O2 either: . a PaO2 ≤ 55 torr or a SpO2 ≤ 88% at rest on room air OR . a PaO2 of 56-59 torr or SpO2 ≤ 89% in association with specific clinical conditions, e.g., cor pulmonale, CHF, erythrocythemia (hematocrit > 56%) o For exercise O2: a PaO2 ≤ 55 torr or a SpO2 ≤ 88% during exercise on room air

The following table and list outline the common inhaled drugs & antibiotics used to treat COPD.

Generic Brand Delivery & Adult Dose Name Name(s) Preparation & Frequency Short Acting Beta Agonists (SABAs) Albuterol Proventil SVN 0.5% 0.5 mL q4-6 hr Ventolin MDI (90 mcg/puff) 2 puffs q4-6 hr DPI (200 mcg/cap) 1 cap inhalation q4-6 hr Bitolterol Tornalate SVN 0.2% 1.25 mL tid/qid MDI (37 mcg/puff) 2 puffs q6 hr Levalbuterol Xopenex SVN 0.31, 0.63 or 1.25 mg/3 mL unit dose 3.0 mL dose tid MDI 45 mcg/puff 2 puffs q4-6 hr Pirbuterol Maxair MDI (200 mcg/puff) 2 puffs q4-6 hr Terbutaline Bricanyl DPI 500 mcg/inhalation 2 inhalations q4-6 hr Long Acting Beta Agonists (LABAs) Formoterol Foradil DPI 25 mcg/cap 1 cap bid Salmeterol Serevent MDI (25 mcg/puff) 2 puffs bid DPI (50 mcg/blister) 1 blister inhalation bid Arformoterol Brovana SVN 15 mcg/2 mL vial 1 vial bid Olodaterol Striverdi Respimat MDI (2.5 mcg/puff) two puff daily Indacaterol Arcapta DPI 75 mcg/cap 1 cap inhalation daily Short-Acting Muscarinic Antagonists (SAMAs) aka Anticholinergic Bronchodilators Ipratropium bromide Atrovent SVN 0.2% 2.5 mL dose tid/qid Atrovent HFA MDI 17 mcg/puff 2 puffs q6 hr Long-Acting Muscarinic Antagonists (LAMAs) aka Anticholinergic Bronchodilators Tiotropium bromide Spiriva DPI 18 mcg/capsule 2 inhalation daily Aclidinium bromide Tudorza Pressair DPI 400 mcg/inhalation 1 inhalation bid Adrenergic + Anticholinergic Combinations Ipratropium bromide + DuoNeb SVN 0.5 mg ipratropium + 2.5 mg albuterol 3 mL unit dose qid Albuterol Combivent Respimat 'Soft mist' inhaler ipratropium 20 mcg/puff + 4 inhalations/day albuterol 100 mcg/puff Umeclidinium bromide + Anora Ellipta DPI 62.5 mcg umeclidinium + 25 mcg 1 inhalation daily Vilanterol vilanterol Corticosteroids (ICSs) Beclomethasone Vanceril MDI (40 mcg/puff) 2 puffs bid Beclovent MDI (80 mcg/puff) Budesonide Pulmicort Turbuhaler DPI 200 mcg/inhalation 1-3 inhalations bid Ciclesonide Alvesco MDI 80/160 mcg/puff 1 puff daily Flunisolide AeroBid MDI (250 mcg/puff) 2 puffs bid Fluticasone proprionate Flovent MDI 44/110/220 mcg/puff 2 puffs qid Mometasone Asmanex DPI 110/220 mcg/inhalation 1 or 2 inhalations daily Corticosteroids + Adrenergic Combinations Fluticasone + Salmeterol Advair Diskus DPI 100, 250 or 500 mcg fluticasone + 50 1 inhalation bid mcg salmeterol Budesonide + Formoterol Symbicort MDI 80 or 160 mcg budesonide + 4.5 mcg 2 puffs bid formoterol Mometasone + Dulera MDI 100 or 200 mcg mometasone + 5 mcg 2 puffs bid Formoterol formoterol Fluticasone + Vilanterol Breo Ellipta DPI 100 mcg fluticasone + 25 mcg 1 inhalation daily vilanterol

• Mild to moderate exacerbations (typically out-patient oral administration) o First-line antibiotics . Doxycycline (Vibramycin) . Trimethoprim-sulfamethoxazole (Bactrim DS, Septra DS) . Amoxicillin-clavulanate potassium(Augmentin) o Macrolides . Clarithromycin (Biaxin) . Azithromycin (Zithromax) o Fluoroquinolones . Levofloxacin (Levaquin) . Gatifloxacin (Tequin) . Moxifloxacin (Avelox) • Moderate to severe exacerbations (typically in-patient IV administration, sometime used in combination) o Cephalosporins . Ceftriaxone (Rocephin) . Cefotaxime (Claforan) . Ceftazidime (Fortaz), o Antipseudomonal penicillins . Piperacillin-tazobactam (Zosyn) . Ticarcillin-clavulanate potassium (Timentin) o Fluoroquinolones . Levofloxacin . Gatifloxacin o Aminoglycoside . Tobramycin (Tobrex)

Follow-up Resources:

Standard Text Resources:

Des Jardins, T & Burton, GG. (2011). Chronic Obstructive Pulmonary Disease: Chronic Bronchitis and Emphysema (Chapter 11). In Clinical Manifestations and Assessment of Respiratory Disease, 6th Ed. Maryland Heights, MO: Mosby-Elsevier.

Wilkins, RL & Gold, PM. (2007). Chronic Obstructive Pulmonary Disease (Chapter 4). In Wilkins, RL, Dexter, JR & Gold, PM. (Eds). Respiratory Disease: A Case Study Approach to Patient Care. 3rd Edition. Philadelphia: F.A. Davis.

Useful Web Links:

AARC Clinical Practice Guideline (2007). Oxygen therapy in the home or alternate site health care facility —2007 revision & update. http://www.rcjournal.com/cpgs/pdf/08.07.1063.pdf

Global Initiative for Chronic Obstructive Lung Disease (2015). Pocket guide to COPD diagnosis, management, and prevention. http://www.goldcopd.org/uploads/users/files/GOLD_Pocket_2015_Feb18.pdf

Institute for Clinical Systems Improvement (2013). Diagnosis and management of chronic obstructive pulmonary disease (COPD). 9th ed. https://www.icsi.org/_asset/yw83gh/COPD.pdf

National Health Service. National Institute for Clinical Excellence. (2011). Chronic obstructive pulmonary disease quality standard (QS10). https://www.nice.org.uk/guidance/qs10