I. ASTHMA https://t.

me/ph_clinic_world

 Asthma is a chronic inflammatory disorder of the airways causing recurrent episodes of wheezing, breathlessness,
cough, and chest tightness, particularly at night or early in the morning

 Diagnosis

1. Episodic symptoms of airflow obstruction are present.

2. Airway obstruction is reversible (forced expiratory volume in 1 second [FEV1] improves by 12% or more after
short-acting β2-agonists [SABAs]).

Asthma COPD

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Nonproductive Cough Productive

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Reversible FEV1 Irreversible
Cough is worse at night and early in the morning Throughout the day

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related to allergies and environmental triggers History of smoking or exposure to other irritants
Reversible lung damage Irreversible

C
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If ≥ 3 features use diagnosis and treatment for asthma. If ≥ 3features use diagnosis and treatment
for COPD.

ACOS ra
If a similar number of features exist for both asthma and COPD, consider a diagnosis of ACOS
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Persistent airflow limitation with features of both asthma and COPD.
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 Exercise-induced bronchospasm
Presents with cough, shortness of breath, chest pain or tightness, wheezing, or endurance problems during exercise.
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Diagnosis is made by an exercise challenge in which a 15% decrease in FEV1 or peak expiratory flow occurs before and
after exercise, measured at 5-minute intervals for 20–30 minutes.
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Spirometry
Component What It Measures Normal Values
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FEV1 Volume of air exhaled forcefully in Normal is ≥ 80%

the first second of maximal In asthma, reversibility is shown by an increase in FEV1 ≥ 12%
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expiration after SABA

FVC The maximum volume of air that Reported in liters and percentage predicted
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can be exhaled after full Normal adults can empty 80% of air in < 6 s
inspiration
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FEV1/FVC Differentiates between Normal: Within 5% of predicted range, which varies with age;
ratio obstructive and restrictive disease usually 75%–80% in adults
Decreased in obstructive disease (asthma, COPD) (< 70%)
Normal or high in restrictive disease (pulmonary fibrosis)

Classification of Asthma Severity in Adults and Children

Components Intermittent Mild Persistent Moderate Persistent Severe Persistent

Frequency of ≤ 2 days/wk > 2 days/wk but not Daily Throughout the day
symptoms daily

SABA; used for ≤ 2 days/wk > 2 days/wk but not Daily Several times a day
symptom control daily

Nighttime awakening ≤ 2 times/mo 3 or 4 times/mo More than once More than once
weekly but not nightly weekly

Interference with None Minor limitation Some limitations Extremely limited

normal activity

FEV1 (% of normal > 80% > 80% > 60% to < 80% < 60%

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FEV1/FVC Normal Normal Reduced 5% Reduced > 5%

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Exacerbations 0 or 1/yr ≥2/yrc ≥2/yrc ≥2/yrc

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requiring oral steroids

Recommended step Step 1 Step 2 Step 3e and consider Step 4 or 5 and

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for initiating short course of oral consider short course
treatment steroids of oral steroids

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Step No controller needed
ra
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1
Step Low-dose ICS
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2
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Step Low-dose ICS plus LABA or medium-dose ICS alone

3 Alternative: Low-dose ICS plus LTM or theophylline
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Step Medium-dose ICS plus LABA

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4 Alternative: Medium-dose ICS plus LTM or theophylline

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Step High-dose ICS plus LABA and tiotropium with history of exacerbations d
5 consider omalizumab with allergic asthma and consider IL-5 antagonist if eosinophilic
asthma
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Step High-dose ICS plus LABA plus systemic corticosteroids consider omalizumab with
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6 allergic asthma and consider IL-5 antagonist if eosinophilic asthma

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Use SABA PRN

SABA > 2 times/wk (excluding pre-exercise doses) indicates inadequate control and need to step up
treatment

Assessing Asthma Control in Adults and Children

component Well controlled Not well controlled Very poorly controlled

symptoms <2 days/week >2 days/week Throughout the day
SABA <2 days/week >2 days/week Several time aday
Night awakenings <time/ month 1-3 time week >4time week
Interference with activity none Some limitation Extremely limited
FEV1or peak flow >80 of predicted personal 60-80% of predicted <60% of predicted personal
best personal best
Exacerbation requiring oral 0 or 1/ year >2 year >2 year
steroid
action Maintain current step; Step Up one step ; Consider short course OCs ;
regular follow up every 1-6 Reevaluate in 2 - 6 weeks step up one or two steps ;
month ; Consider step Reevaluate in 2 weeks
down if well controlled ≥ 3
month

Medium Dose ICS

Low-Dose Medium-Dose (mcg/day) High-Dose (mcg/day)

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(mcg/day) Steps 3 and 4 Steps 5 and 6

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Steps 2 and 3
Fluticasone 100-300 mcg >.300-500 150 - 300 mcg

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200-400 children
Beclomethasone 80-240 mcg > 240–480 >480

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Mometasone 200 400 >400
Budesonide 180 -600 mcg 600-1200 >1200

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400-800 children
Budesonide (Susp. For .5mcg 1 2 mg
neubilization)
Ciclesonide 160 ra 320 640
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Anticholinergic Short Acting : Ipratropium
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Long Acting : Tiotropium - Aclidinium

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SABA Salbutamol ( Albuterol ) - Levalbuterol

SE : Tachycardia - Hypokalemia - Hypomagnesemia - Hyperglycemia - Tachyphlaxis .
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LABA Slmetrol - Formetrol - Indacterol ( only COPD )

Not For Acute Symptoms
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Should not be used as monotherapy in asthma ; must be added on ICS

Drugs Methyl xanthine Theophyllin : Not for acute relieve SE : Insomnia- Seizures - Tachycaria
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Dose: Adults : 400 - 600 mg / day Children : Start at 10 mg/kg/day

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Leukotriene Modifiers EX: Zafiruleukast - Montelukast - Zileuton

SE : Hepatotoxicity (Exc. Montelukast) so monitor LFT
FDA Caution : Risk of neuropsychiatric events ( behavior and mood changes ,
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agitation , depression , insomnia , suicidal thinking )

Montelukast : FDA approved in children ≥ 1 years old
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Zafirlukast : Children ≥ 5 years Zileuton : only for those ≥ 12

years old
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Monoclonal antibodie Omalizumab: Use in ≥ 12 yr - Second-line therapy - Expensive

FDA Cautions: Slightly increased risk of cardiovascular and cerebrovascular serious
adverse events, including MI, unstable angina, TIA, PE/DVT, pulmonary HTN; no
increased risk of stroke or CV death

Monitoring
1. Peak flow monitoring
Symptom-based and peak flow–based monitoring have similar benefits; either is appropriate for most patients.
Symptom-based monitoring is more convenient.
Personal best peak expiratory flow rate (PEFR), not predicted PEFR, should be determined if using peak flow–based
asthma action plan.
Personal best PEFR is the highest number attained after daily monitoring for 2 weeks twice daily when asthma is under
good control.
2. Spirometry (only used if 5 years or older)
At initial assessment then At least every 2 years or more

Asthma Action Plan

Zone Signs and Symptoms Treatment

Green Doing well Keep on your medications
PEFR 80%–100% of personal best Use SABA if needed
Yellow Getting worse; Use SABA: 2–4 puffs; repeat in

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increased frequency of symptoms (e.g., coughing, 20 min if needed; reassess 1 hr

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wheezing, chest tightness, or dyspnea); nighttime If complete response at 1 hr:
awakenings; decreased ability to do normal activities Use SABA + OCS burst + Call

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PEFR 50%–79% of personal best 911

Red Medical alert Use SABA: 4–6 puffs; repeat in

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(e.g., marked coughing, wheezing, or dyspnea); 20 min if needed; reassess 1 hr
inability to speak more than short phrases; use of + OCS burst from beginning

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accessory respiratory muscles; drowsiness If complete response or poor
PER < 50% of personal best response at 1 hr:
ra Go to ED or Call 911
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Classifying Severity of Asthma Exacerbations in the Urgent or Emergency Care Settinga
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1. Mild to moderate exacerbation (FEV1 of 40% or more)

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O2 + MDI SABA ± OCs

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2. Severe exacerbation (FEV1 less than 40%)

O2 + high dose MDI SABA + ipratropium ± OCs
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3. Impending or actual respiratory arrest

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O2 + nebulized SABA + ipratropium + IV CS + ICU ± IV Mg or heliox

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Note: Main Component in all Exacerbations management is oxygen

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OCs Burst
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Adult dose:
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% of Prednisone 40–80 mg/day in one or two divided doses until peak expiratory flow reaches 70predicted

Pediatric dose:
(12 years or younger): 1–2 mg/kg in two divided doses (maximum 60 mg/day) until peak expiratory flow reaches 70% of
predicted
Managing Exacerbations: ED or Hospital After Repeat Assessment

1. Moderate exacerbation (FEV1 40%–69%)

a. Inhaled SABA every 60 minutes
b. Oral corticosteroid
c. Continue treatment for 1–3 hours if improvement
2. Severe exacerbation (FEV1 of 40% or less); no improvement after initial treatment
a. Oxygen
b. Nebulized SABA plus ipratropium; hourly or continuous
c. Consideration of adjunctive therapies

3. If good response to above treatment and maintained for at least 60 minutes

a. Continue inhaled SABA.
b. Continue OCS course.
c. Consider initiating an ICS (if patient is not already taking one

4. If incomplete response (FEV1 40%–69%), admit to hospital ward

a. Continuation of inhaled SABA

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b. Systemic corticosteroids (oral or intravenous)

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c. Consideration of adjunctive therapies

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5. If poor response (FEV1 of 40% or less), admission to intensive care
a. Continuation of inhaled SABA, hourly or continuously
b. Intravenous corticosteroid

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c. Consideration of adjunctive therapies
d. Possible intubation and mechanical ventilation

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Asthma in Pregnancy

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Asthma may increase the risk of perinatal mortality, hyperemesis, vaginal hemorrhage, preeclampsia, complicated labor,
neonatal mortality
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Medications
Preferred controller: Budesonide ICS (only category B ICS± Albuterol as needed
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Control
LABAs are category C; Salmeterol preferred. Or LTMs montelukast (category B).
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Prednisone adverse effects: cleft palate, preeclampsia, gestational diabetes, low birth weight, and prematurity.
If acute Exacerbation
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Prednisone should be used, if necessary, for acute exacerbations in pregnancy.

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Additional Vaccines: Adults with asthma (19–64 years) should receive:

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1. The 23-valent pneumococcal polysaccharide vaccine (PPSV23

2. Influenza vaccine every fall or winter
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https://t.me/ph_clinic_world
 II. CHRONIC OBSTRUCTIVE PULMONARY DISEASE COPD

1-Obstructive bronchiolitis

2-Emphysema

Diagnosis and assessment of COPD

i. Dyspnea
ii. Chronic cough
iii. . Chronic sputum production
iV wheezing

 spirometry is the gold standard.

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a. Spirometry revealing an FEV1/FVC less than 70% of predicted is the hallmark of COPD. Bronchodilator

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reversibility testing is no longer recommended.
 Therapy Goals

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1. Relieve symptoms.
2. Reduce the frequency and severity of exacerbations.

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3. Improve exercise tolerance.
4. Improve health status.

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5. Minimize adverse effects from treatment

 Patient assessment and selection of therapy

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a. GOLD guidelines combine symptoms (on the basis of symptom scores), airflow limitation (on the basis of post-
bronchodilator FEV1), and frequency of exacerbations to determine patient risk group and recommended treatment
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GOLD Guidelines
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Patient Group Characteristic Assessment of airflow Exacerbation history Symptom Score

Limitation Per year
(spirometry gold)
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A FEV1 ≥ 50% Low risk Gold 1:mild (FEV≥ 80) mMRC 0–1
Fewer GOLD 2: moderate (FEV 0 or 1 (not leading CAT < 10
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symptoms 50–79) to hospital

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admission
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B FEV1 ≥ 50% Low risk Gold 1:mild (FEV≥ 80) mMRC ≥ 2

More symptoms GOLD 2: moderate (FEV 0 or 1 (not leading CAT ≥ 10
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50–79) to hospital
admission
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C FEV1 < 50% High risk mMRC 0–1

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Fewer GOLD FEV ≥ 2 or ≥ 1 leading CAT <10

symptoms 3 (30–49 to hospital
) admission
GOLD FEV
4 < 30
D FEV1 < High risk mMRC ≥ 2
50% More symptoms GOLD 3 30–49 ≥ 2 or ≥ 1 leading CAT ≥ 10
GOLD 4 < 30 to hospital
admission
 GOLD Guidelines: Pharmacotherapy for Stable COPD

Table 12. GOLD Guidelines: Pharmacotherapy for Stable COPD

Patient Group Recommended First Recommended Alternative(s)
Choice Treatment
Intensification
A Bronchodilator Continue, stop, or try N/A
alternative class of
bronchodilator

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B LABA or LAMA LAMA + LABA N/A

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C LAMA LAMA + LABA LABA + ICS
(treatment

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intensification)
D LAMA + LABA LAMA + LABA + ICS LAMA (initial

C
treatment)
or

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LABA + ICS (initial
treatment)
or
ra LABA + ICS + PDE-4
inhibitora (treatment
C
intensification)
or
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LAMA + LABA +
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PDE-4 inhibitora
(treatment
intensification)
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Pharmacotherapy for COPD is used to decrease symptoms, complications, or both not been shown to modify the long-
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term decline in lung function,

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Smoking cessation is a critical component of COPD management.

Bronchodilator
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 symptomatic management.
 SABA/SAMA combination recommended over SABA monotherapy.
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 The principal bronchodilator are β2-agonists, anticholinergics, or a combination. Theophylline not

recommended unless other long-term bronchodilators are unavailable or unaffordable.
 Inhaled therapy is preferred.
In moderate-severe COPD,
LAMAs >LABAs to prevent exacerbations
Regular treatment with a long-acting (LA) bronchodilator
is more effective and convenient >regular SA bronchodilators therefore, SA only used as needed.
Combining bronchodilators
improve efficacy or fewer adverse effects >increasing dose of single bronchodilator.
Triple therapy
Adding tiotropium to a LABA/ICS combination (triple therapy) improves lung function and health-related quality of life
and reduces the number of exacerbations (level of evidence B).
LA anticholinergic
delays first exacerbation, reduces the overall number of exacerbations and related hospitalizations, improves symptoms
and health status.
LABAs
improve health status, quality of life, and FEV1 and decrease COPD exacerbation rate.
no effect on mortality and rate of decline of lung function.
do not have the same potential safety concerns as with use in asthma
Indacaterol is LABA with a significantly greater bronchodilator effect than salmeterol and a bronchodilator effect similar
to that of tiotropium .
LA anticholinergic versus LABAs:
Tiotropium is more effective than LABAs in preventing exacerbations and hospitalization but not in overall

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hospitalization or mortality.

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ICSs in stable COPD
 Moderate to high doses ICSs improve symptoms, lung function, and quality of life and decrease the exacerba-

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tions
 Long-term treatment with ICSs should not be used outside their indications because of the risk of pneumonia
and possible increased risk of fractures after long-term exposure

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 Long-term monotherapy with ICSs not recommended; less effective than ICS/LABA combination.
 Chronic treatment with OCSs should be avoided because of an unfavorable benefit-risk ratio.

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Phosphodiesterase-4 As a daily treatment to reduce the risk of COPD exacerbations in patients with1- severe
inhibitor: Roflumilast ra
COPD (Category C,D) 2-chronic bronchitis 3-frequent exacerbation
500 mcg orally once daily - decrease exacerbations
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Contraindications: Moderate to severe liver impairment; use in nursing mothers
Precautions: Weight loss (monitor); psychiatric events including suicidality (monitor;
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weigh risk-benefit ratio in patients with preexisting psychiatric illness).

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α1-Antitrypsin For young patients with severe hereditary α1-antitrypsin deficiency and established
augmentation therapy emphysema,
Patients with α1-antitrypsin deficiency usually are white, usually develop COPD at a
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young age (younger than 45 years), and have a strong family history.
Smoking cessation essential for all patient groups A–D)
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therapy
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Vaccinations Influenza vaccine annually (essential for all patient groups A–D)
PPSV23 (Pneumovax) once before age 65; then follow CDC recommendations for
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pneumococcal vaccination at age 65 and older

The 13-valent pneumococcal conjugate vaccine (PCV13; Prevnar) once after age 50 and
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at least 1 year after PPSV23

Azithromycin Chronic azithromycin for prevention of COPD exacerbations
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lengthened time to first exacerbation, decreased rate of exacerbations, and improved

quality of life in patients with COPD at increased risk of exacerbations, at the expense of
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risk of hearing decrements and increasing macrolide-resistant organism colonization

. β-Blockers  long-term treatment with β-blockers reduces risk of exacerbations and improves
survival,
 It is too early to recommend β-blockers for the treatment of COPD, but β-
blockers should not be withheld in patients with COPD who also have heart
disease, chronic heart failure, or other cardiovascular conditions in which β-
blockers are beneficial

Statins  Reducing exacerbations and COPD-related mortality

 No significant effect of simvastatin on the number of severe COPD exacerbations
 per person-year
 Statins provide a clinical benefit in patients with COPD who have no other
cardiovascular disease risk factors.

 No pharmacologic therapy
a. Home oxygen therapy
b. Pulmonary rehabilitation

 Management of Acute Exacerbations of Chronic COPD

 Spirometry is not accurate during an exacerbation and is not recommended.

 . Pulse oximetry can be used to determine the need for supplemental oxygen, which should be given in severe

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exacerbations.
 Inhaled bronchodilators (inhaled SABAs with or without SA anticholinergics) are the preferred treatment of

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COPD exacerbations (level of evidence C).

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 Systemic corticosteroids should be used in most exacerbations
 OCS dose for outpatient treatment: 40 mg of oral prednisone once daily for 5 days is recommended in
the GOLD guidelines (level of evidence B

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 Antibiotic treatment should be initiated for exacerbations if the criteria below are me
 increased dyspnea, increased sputum volume, and increased sputum purulence.

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 Antibiotics should be given if all three cardinal symptoms are present
 ii. Antibiotics should be given if two of the three cardinal symptoms are present and if increased sputum
purulence is one of the symptoms (
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 iii. Antibiotics should be given to patients with severe exacerbations requiring mechanical ventilation
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 The recommended duration of antibiotic treatment is usually 5 to 7 days
 The usual initial antibiotics for uncomplicated COPD include azithromycin, clarithromycin, doxycycline,
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trimethoprim/sulfamethoxazole, and amoxicillin, with or without clavulanate.

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 . In complicated COPD with risk factors, amoxicillin/clavulanate, levofloxacin, and moxifloxacin are the antibiotics
of choice
 Comorbid diseases
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 , severe COPD (FEV1 lessthan< 50% of predicted),

 more than 3three exacerbations/year,
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 antibiotic use in past 3 months

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 patient is at risk of Pseudomonas infection

Administer high-dose levofloxacin (750 mg) or ciprofloxacin and obtain sputum culture.
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Risk factors
 : Four or more courses of antibiotics in past year
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 , recent hospitalization (past 90 days)

 , isolation of Pseudomonas during past hospitalization
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 , severe COPD (FEV1 less than 50% of predicted)

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