COPD vs Asthma

Asthma
Onset

Usually childhood

Risk factors

COPD
Usually >40 years of age

Atopy MC predisposing
factor

Symptoms

Nasal polyps
Eczema
Samter's triad =
ASA/NSAID allergy +nasal polyps
Triggers:
Allergens

Environmental

Disease states

Infections

Emotions

Exercise

Medications

Occupational

Variable from day to day (triggered by

exercise, emotions, dogs, allergens)

History

Airflow
Limitation

Cigarette Smoking/
exposure to smoke
Air pollution
Occupational exposure to
dust and chemicals
Alpha-1 antitrypsin
deficiency (decreased inhibition of
proteases that break apart the alveoli
Neutrophil

eliastinase break up elastins that

give alveoli structure
Respiratory infections
Pneumonia, TB

Chronic usually continuous symptoms,

particular with activity (exercise)
Dyspnea
Wheezing
Fatigue
Chronic cough
Sputum production
Spirometry (FEV1/FVC <
0.70)
Main indicatory

of COPD
Cyanosis (lips and
fingernails)
Frequent respiratory
infections
Barrel chest

History of Allergies, Rhinitis, and

Eczema.
Family History of Asthma

History of exposure to noxious particles

Reversible, improves with treatment

Irreversible, progressive despite treatment

Response to Good
Steroids
and
Bronchodila
tors

Poor

GOLD Criteria
1-4 from mild to severe based on predicted FEV 1 score (age weight ethnicity height)
Used to classify degree of airflow limitation and risk for sudden dramatic change in air flow
GOLD

Classification
of Airflow
Limitation

FEV1 Comparison (Degree

of Airflow Limitation)

GOLD 1

Mild

FEV1 80% predicted

GOLD 2

Moderate

50% FEV1 < 80% predicted

GOLD 3

Severe

30% FEV1 < 50% predicted

GOLD 4

Very Severe

FEV1 < 30% predicted

Combined Assessment for COPD Staging

Patient

Characteristic

Spirometric
Classification

Exacerbations
per year

CAT

mMRC

Low Risk
Less Symptoms

GOLD 1-2

< 10

0-1

Low Risk
More Symptoms

GOLD 1-2

> 10

>2

High Risk
Less Symptoms

GOLD 3-4

>2

< 10

0-1

High Risk
More Symptoms

GOLD 3-4

>2

> 10

>2

Metered
Dose
Inhalers
(MDI)

Delivers an aerosolized dose of the medication

Requires slow and deep breaths

Products that end in HFA and Respimat

Should be used with spacer device

Dry Powder

Inhalers
(DPI)

Powder form
Requires quick forceful breaths

Products include Ellipta, Diskus, Handihaler,

Neohaler, Pressair and Aerolizer

Cannot be used with spacer device

Case Study
AJ is a 59 year old coal miner who presents to your private practice complaining of worsening

shortness of breath.
He has had a chronic cough with sputum production for a few years now that hes been treating

with over the counter cough syrups.

He often goes to the free clinic offered by a hospital 40 miles away but he felt too tired to drive

that far today.

Recent Medical History

Hospitalized for
Pneumonia 6 months ago

Past

Medical/Surgical History:
Atrial

Fibrillation
Hypertensio

Social history:
Smokes on
Occasiona

Hyperlipide
mia

Allergies: NKDA

Medications:
Enalapril 20mg daily
Warfarin 5mg daily
except 2.5 on MWF
Simvastatin 40mg
daily
Metformin 500mg
twice a day
Guaifenesin Cough
Syrup (non-prescription)

What

What

What

What

Family History:
Father
passed away from a heart
attack (age 40)
Mother alive
with type 2 diabetes, HTN
and hyperlipidemia

Immunization History:
Received his flu shot last yea
Unknown history of Pneumo
Vaccines

Vitals:

Labs:

Pre-diabetes

ALT 27 U/L
AST 28 U/L
ALK PHOS 59 U/L
TC
282 mg/dL
LDL 169 mg/dL
HDL 43 mg/dL
TG
150 mg/dL
HbA1c 6.2%
INR 2.3
BUN 16
SCr 0.83

BP: 130/80 mmHg

HR: 80
RR: 22
Temp: 97.4 (axillary)
O2 Sat: 94%
PaO2: 60 mmHg
Weight: 207 lbs
BMI: 34

are the patients risk factors for COPD?

Chronic cough, smoking, coal miner, recent infection
factors differentiates his symptoms from Asthma?
Older, chronic cough & sputum, worsening SOB, no allergies, hx of exposure
are current indicators of COPD?
Fatigue, worsening SOB, infections
is currently missing from vitals/labs?
Spirometry, FEV1/FEV

His FEV1 score was 70%. Under the GOLD criteria, how would the patients COPD classified?
GOLD category 2 (<80% PREDICTED)

You evaluate the patient and find out that he has a CAT score of 9, mmRC of 1 and no previous
exacerbations. (CAT <10 AND mMRC 1 = less symptoms (either category A or C)
What is his current Combined Assessment Classification?
Stage A

What measures would you like to take now?

SABA (albuterol) or SAMA

Immunizations (flu and PCV)

Quit smoking

AJs disease state progresses further and you place him on Salmeterol 50mcg/inhalation. He goes home
and loses the labeling for the medication. What dose did you mean to prescribe to the patient?
1 inh BID

AJs throat gets irritated from using the Serevent Diskus and the patient has stopped using the inhaler
altogether because he feels it is making him cough more. Whats an alternative medication that you could
prescribe?
Nebulizer

AJ is currently in the ED with a severe shortness of breath and a fever. You are called in for a pulmonary
consult as the ED is short staffed today. What are some recommendations you could make to the ED
physician in order to manage the his exacerbations?

Increase the dose, change to a combo, increase the frequency

Abx for cardinal symptoms

O2

Systemic steroids

What are some additional therapy options that could be utilized for him?
Case #2
A new patient, CJ, presents with a FEV1 Score <40% predicted, a CAT Score of 9 and mMRC of 1. He was
hospitalized 3 times this year. How would you stage this patient?
Stage C

What medications would be appropriate in this patient?

Umeclidinium 62.5mcg/Vilanterol 25mcg (Anoro Ellipta)--> Not initial tx

Budesonide (Pulmicort) --> Not at monotherapy (ICS)

Albuterol (ProAir)--> yes for the short-acting

Fluticasone/Salmeterol (Advair HFA)--> yes (LABA + LAMA)

Fluticasone/Salmeterol (Advair Diskus)--> yes (LABA + LAMA)

Arformoterol (Brovana) + Beclomethasone (Qvar) HFA --> yes both are nebulizers, good if

bedridden
CJ comes back to the clinic after seeing you for a year. His condition is worsening and you are considering
adding on other medications. You found out his medications had changed due to whats available on the
insurance formulary. He is currently on Ipratropium (Atrovent), Theophylline and Budesonide (Pulmicort).
What changes in therapy should we make assuming his Combined Assessment Score has not changed?
A.
No changes needed at this time
B.
Change Pulmicort to Symbicort (Budesonide/Formoterol) (ICS + LABA)
C.
Add on Daliresp (Roflumilast)
Add on Fluticasone (Flovent HFA) and consider switching from Ipratropium (Atrovent) to Alubetrol
D.
(Proair RespiClick)