Module 5

Chronic Obstructive Pulmonary Disease(COPD)

Scott K. Stolte, Pharm.D.

Pre-Assessment Exercise

Question #1

Which drug is considered first line therapy for COPD?a. Oral theophyllineb. Inhaled corticosteroidc. Inhaled cromolynd. Inhaled ipratropium

Question #2

The most common form of COPD is

a. Emphysemab. Alpa1-antitrypsin deficiencyc. Chronic bronchitis d. Asthma

Question #3

Which of the following is the biggest risk factor for COPD development?a. Outdoor pollutionb. Occupational dust exposurec. Indoor pollutiond. Cigarette smoking

Question #4

Which of the following is a common early sign or symptom of COPD?a. Dyspnea at restb. Chronic cough c. Decreased FVC and increased FEV1d. Abnormal chest x-ray

Question #5

COPD has a higher mortality rate than asthma.a. True b. False

Choose your option below.Next Topic: Overview of COPD

Overview of COPD

COPD

• 16 million diagnosed in the U.S.• Estimated prevalence

– Mild disease 6.9% of adults 25-75 years old– Moderate disease 6.6%

Burden of COPD: Morbidity

• “Confronting COPD in America” Survey Results• Phone interview of 573 COPD patients• The following % of patients reported their COPD

limits them in:– Ability to work 51%– Normal physical exertion 70%– Household chores 56%– Social activities 53%– Sleeping 50%– Family activities 46%

Burden of COPD: Mortality

• 4th leading cause of death• COPD mortality trends generally track several

decades behind smoking trends• In the US, COPD mortality for both men and

women have been increasing• In the U.S. in 2000, the number of COPD

deaths was greater among women than men

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Of the six leading causes of death in the U.S., only COPD has been increasing steadily since 1970

Cost to Society

• Total Costs = $37.2 billion– Direct = $20.9 billion– Indirect = $16.3 billion

• 75% of costs for exacerbations Indirect

44% Direct56%

$20.9 billion

$20.9 billion

A disease state characterized by airflow limitation that is not fully reversible. The airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases

Key Point:

• Airflow obstruction in COPD is primarily irreversible

Obstructive Lung Disease

Chronic Bronchitis

Emphysema

Asthma

AAT

AAT, alpha1-antitrypsin deficiency

Cystic Fibrosis

COPD

• Chronic Bronchitis– Chronic productive cough for 3 months in each of 2

successive years, other causes of productive chronic cough have been excluded

• Emphysema– Permanent enlargement of the airspaces distal to

the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis

Choose your option below.Next Topic: Pathophysiology, Presentation and Diagnosis of COPD

Pathophysiology, Presentation and Diagnosis of COPD

Clinical Presentation

• Symptoms– Cough may first become apparent after upper

respiratory infection (URI)– Cough worsens and persists– Sputum turns yellow, green, tan, or brown– Exacerbations may be triggered by respiratory

infections, irritants, and pollution– Exacerbations may be recurrent and may be the

only outward sign of underlying disease

Signs and Symptoms

• Cough – Present intermittently or every day– Often present throughout the day

• Sputum production– Tenacious

• Dyspnea on exertion – Present every day– Described as “increased effort to breath”

or “gasping”

The natural course of COPD is slow and

insidious

When to Consider COPD

• Chronic cough• Chronic sputum• Recurrent episodes of acute bronchitis• Dyspnea (persistent or progressive)• Risk factors (i.e., tobacco exposure, family

history)

Differential Diagnosis of COPD

• Asthma• Heart failure • Bronchiectasis• Tuberculosis

COPD ASTHMA

Differential Diagnosis: COPD and Asthma

• Onset in mid-life• Symptoms slowly

progressive• Long smoking history• Dyspnea during

exercise• Largely irreversible

airflow limitation

• Onset early in life (often childhood)

• Symptoms vary from day to day

• Symptoms at night/early morning

• Allergy, rhinitis, and/or eczema also present

• Family history of asthma

• Largely reversible airflow limitation

Pathophysiology

• Chronic airflow limitation characteristic of COPD is caused by:– Small airway disease

• Chronic inflammation causes remodeling and narrowing of small airways

– Parenchymal destruction • Also due to inflammatory processes• Leads to loss of alveolar attachments to small

airways and decreases lung elastic recoil

Pathophysiology Continued

• Destruction of alveolar tissue– Loss of elastic recoil– Reduction in surface area for gas exchange – Diminish ability of airways to remain open during

expiration • Patient must work harder to breathe

Major Pathological Abnormalities That Contribute to Airflow Limitation

• Lumen obstruction by mucus• Changes in density of alveolar lining fluid• Increased wall thickness and decreased airway

diameter• Smooth muscle contraction• Loss of alveolar attachments

Risk Factors for COPD

• Host Factors– Genes

• Alpha-1 antitrypsin deficiency

Alpha-1 Antitrypsin (AAT) Deficiency-Related Emphysema

• AAT – lung protector• 5% or less of cases of emphysema• ~100,000 Americans have deficiency• Symptoms begin between 32-41 years old• Smoking accelerates the lung damage

Risk Factors for COPD

• Host Factors– Genes – Airway hyperresponsiveness– Lung growth

• Related to processes occurring during gestation and exposures during childhood

Risk Factors for COPD

• Exposures– Individual’s total burden of inhaled particles– Each type of particle (size and composition) may

contribute a different weight to the risk

Interactive Check Point

What proportion of smokers will develop COPD with continued smoking?

a. 5 percentb. 10 percentc. 20 percentd. 50 percente. 100 percent

Interactive Check PointAnswer

c. 20 percent

This often-quoted statistic that only 20% of smokers develop clinically significant COPD is misleading and greatly underestimates the toll of COPDApproximately 80 to 90 percent of COPD deaths are caused by smoking. Female smokers are nearly 13 times as likely to die from COPD as women who have never smoked. Male smokers are nearly 12 times as likely to die from COPD as men who have never smoked

Risk Factors for COPD

• Exposures– Tobacco smoke

• The most important risk factor for COPD • At least 20% of smokers develop COPD• 85% of cases of COPD caused by smoking • Variables: age at starting to smoke, total pack-

years and current smoking status

Risk Factors for COPD

• Exposures– Occupational dusts and

chemicals• 19.2% of cases overall, 31.1%

of never-smokers

Risk Factors for COPD

• Exposures– Indoor and outdoor air pollution

Risk Factors for COPD

• Exposures– Infections – Socioeconomic status

Diagnosis of COPD

• History• Physical exam• Laboratory data• Spirometry

Diagnosis of COPD

• History• Smoking• Typical course

– Asymptomatic for first 2 decades of smoking– After 25-30 years, mild dyspnea with or without

morning cough– Then comes dyspnea on exertion (DOE),

increasing sputum production and worsening cough

Diagnosis of COPD

Physical exam• Barrel chest• Rales and rhonchi• Prolonged expiratory phase• Cyanosis• Pursed-lip breathing

Diagnosis of COPD

Laboratory data• Arterial blood gases are major monitoring tool in

very severe disease

Diagnosis of COPD

Spirometry• Used for diagnosis and assessment of

disease severity• Forced expiratory volume in the first second

(FEV1)– Usually expressed as % of total volume of air

exhaled

Spirometry: FEV1

• Normal = 80% of forced vital capacity (FVC)• Begins to decline at age 35

– Generally declines at rate of 25-30 ml/yr• Decline steeper in smokers

Spirometry: FEV1

• “Gold Standard” test for determining reversibility of airway disease and bronchodilator efficacy

• Highly effort dependent

Stage I: Mild FEV1/FVC < 0.70 FEV1 > 80% predicted

Stage II: Moderate FEV1/FVC < 0.7050% < FEV1 < 80% predicted

Stage III: Severe FEV1/FVC < 0.7030% < FEV1 < 50% predicted

Stage IV: Very Severe FEV1/FVC < 0.70FEV1 < 30% predicted

Classification of COPD Severityby Spirometry

Staging of Disease

Stage 0: At Risk• Characterized by chronic cough and sputum

production• Lung function measured by spirometry is normal

Staging of Disease

Stage I: Mild COPD • Characterized by mild airflow limitation• Usually, but not always, patient has chronic

cough and sputum production

Staging of Disease

Stage II: Moderate COPD• Worsening airflow limitation• Progression of symptoms with shortness of

breath (SOB) typically on exertion

Staging of Disease

Stage III: Severe COPD• Severe airflow limitation and/or clinical signs of

right heart failure• Quality of life is very appreciably impaired• Exacerbations may be life threatening

Choose your option below.Next Topic: Overall Management of COPD

Overall Management of COPD

Goals of COPD Management

• Relieve symptoms • Prevent disease progression• Improve exercise tolerance• Improve health status• Correct secondary physiologic alterations• Prevent and treat complications• Prevent and treat exacerbations• Reduce mortality

ATS/ERS Guidelines

• American Thoracic Society (ATS)/European Respiratory Society (ERS) – http://www.thoracic.org/sections/copd/– Last update: 2005

Global Initiative for Chronic Obstructive Lung Disease (GOLD)

• Evidence based recommendations for the clinical management of COPD

• Published April 2001• Endorsed by World Health Organization and US

National Heart, Lung and Blood Institute• www.goldcopd.com

Healthy People 2010 COPD Goals

• Reduce deaths from COPD among adults (> 45 years old)– Baseline 123.92/100,000– Target 62.31/100,000

• Reduce the proportion of adults whose activity is limited due to chronic lung and breathing problems– Baseline 2.52% of adults > 45 years old– Target 1.91%

• www.healthypeople.gov

General Management of COPD

• Reduce risk factors• Manage stable disease

– Vaccinations– Drug therapy– Oxygen therapy– Pulmonary rehabilitation

• Manage exacerbations

Risk Factor Reduction:Smoking Cessation

• Can benefit all patients• Stops major underlying cause of COPD• The only measure that will slow progression

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Smoking Cessation

• Brief (3-minute) period of counseling to urge a smoker to quit results in smoking cessation rates of 5-10%

• Numerous effective pharmacotherapies for smoking cessation are available

• Pharmacotherapy is recommended when counseling is not sufficient to help patients quit smoking

• Offer smoking cessation program in pharmacy or have referral information available

Brief Strategies to Help the Patient Willing to Quit Smoking

Schedule follow-up contactARRANGE

Aid the patient in quittingASSIST

Determine willingness to make a quit attempt

ASSESS

Strongly urge all tobacco users to quit

ADVISE

Systematically identify all tobacco users at every visit

ASK

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Risk Factors Reduction : Occupational Exposures and Indoor/Outdoor

Air Pollution

• Occupational– Eliminate or reduce exposure

• Indoor– Eliminate, if possible, indoor wood burning – Limit use of chemicals

• Outdoor– Have patients monitor public announcements of air

quality and, depending on the severity of their disease, avoid vigorous exercise outdoors or stay indoors altogether during pollution episodes

Vaccination

• Pneumococcal and influenza vaccination prevents airway infections– Annual influenza– Pneumococcal 1-2 injections

• Influenza vaccines can reduce serious illness and death in COPD patients by about 50%

Pneumococcal Vaccination

• COPD patients ≥ 65 years old and ≤ 65 years old with an FEV1 < 40% predicted

• Revaccinate after 5 years if– Chronic renal failure – Nephrotic syndrome – Functional/anatomic asplenia – Immunosuppressive conditions – Chemotherapy with alkylating agents or

antimetabolites– High-dose, long-term corticosteroids – < 65 at time of primary vaccination

Vaccination Example

• Vivian is 68 years old with COPD• She received a pneumococcal vaccination at 62• Should she be revaccinated?

Vaccination Example

• Yes, she should be revaccinated• She was < 65 years old and more than 5 years

has elapsed• She should also receive an annual influenza

vaccination

Choose your option below.Next Topic: Pharmacologic Treatment of COPD

Pharmacologic Treatment of COPD

Pharmacotherapy

• Similar to that of asthma patients• Degree of benefit is less

Pharmacotherapy

• Does not modify the long-term decline in lung function

• Unclear if early intervention is of value

Principles of Care

• Stepwise increase in treatment depending on severity of disease

• Regular treatment needs to be maintained at same level for extended periods unless significant side effects occur or disease worsens

• Treatment response is variable between patients and should be monitored closely and adjusted frequently

Bronchodilators

• Central to the symptomatic management of COPD

• Prescribed on prn or regular basis• Inhaled therapy preferred• Choice depends on availability and individual

response• Long acting agents are more effective and

convenient• Combining bronchodilators may improve

efficacy and decrease the risk of side effects (vs. increasing the dose of single agents)

Commonly Prescribed Bronchodilators in COPD

albuterol/ipratropium (Combivent®)Combination agents

tiotropium (Spiriva®)Long-acting anticholinergic agents

salmeterol (Serevent®), formoterol (Foradil®), formoterol fumarate(Perforomist®), arformoterol (Brovana®)

Long-acting β2 agonists(LABA)

ipratropium (Atrovent®)Short-acting anticholinergic agents

albuterol (Proventil®, Ventolin®, generic), pirbuterol (Maxair®)

Short-acting β2 agonists (SABA)

Interactive Check Point

Anticholinergic bronchodilators mediate their effects through which receptor?

a. Beta receptorb. Muscarinic receptorc. Acetylcholine receptord. Dopaminergic receptor

Interactive Check Point Answer

b. Muscarinic– Anticholinergic bronchodilators such as

ipratropium and tiotropium work by blocking muscarinic cholinergic receptors on the bronchial smooth muscles which increases bronchodilation and helps to decrease salivary secretion

Drug Therapy:Anticholinergics

• Initiate when patient experiences significant symptoms on a regular basis

Anticholinergics

• Ipratropium– Available as solution for nebulization and aerosol

with and without HFA– Inhaler

• Initial: 2 puffs tid-qid• Maximum: 12 puffs/day• HFA type does not require shaking

Anticholinergics

• Tiotropium– Dry powder inhaler (DPI)– Administered once daily

• Dissociates more slowly from muscarinicreceptors

• 1 capsule qd with HandiHaler– Possibly more effective than ipratropium and equal

to salmeterol

Important Points about Anticholinergics

• Slower onset of action than β2 agonists – not for acute use

• Don’t stop use just because symptoms improve

Combination Therapy

• Anticholinergic and β2 agonist– Some studies showed benefit– Proper sequence if given as separate products is

unclear

Combination Therapy

• Ipratropium 21 mcg and albuterol 120 mcg/ puff inhaler (Combivent®)

• Ipratropium 0.5 mg/albuterol 3 mg for nebulizer(DuoNeb®)

• Indicated for COPD • Dose: Initially 2 puffs qid; max 12 puffs/ 24

hours• Contraindication: hypersensitivity to soya

lecithin, soybeans, or peanuts

Drug Therapy: β2 Agonists

• Used in chronic and acute management• Alternative first line therapy• Produce less bronchodilation in COPD than in

asthma • No significant advantages of levalbuterol

(Xopenex®) over albuterol for COPD

Long Acting β2 Agonists

• Salmeterol (Serevent Diskus®)– 1 inhalation bid

• Formoterol (Foradil Aerolizer®)– 12 mcg capsule inhaled bid

• Formoterol fumarate (Perforomist®)– 20 mcg/12 hours

• Arformoterol (Brovana®)– 15 mcg bid via nebulizer

• Greatest benefit in patients with significant bronchodilator response

Long Acting β2 Agonists

• Role in Therapy:• Consider use in patients who:

– Are not adequately controlled with combination bronchodilator therapy

– Have difficulty complying with more frequent administration schedule

– Have nighttime or early morning symptoms

Drug Therapy: Theophylline

Actions: • Prevention of diaphragmatic fatigue

– Improvement of cardiac output– Reduction of pulmonary vascular resistance

Theophylline

Potential Roles: • May reduce overnight declines in pulmonary

function• For patients less adherent with or less capable

of using an inhaler• For patients with cor pulmonale

Drug Therapy: Corticosteroids

• 10-20% receive benefit with oral therapy– Likely these patients have concomitant asthma

• No reliable predictors to identify clinical responders

• Individual clinical trial necessary

Corticosteroid Clinical Trial

1. Obtain baseline spirometry2. Give inhaled corticosteroid daily for 6 weeks to

3 months3. Repeat spirometry4. A 15% or greater improvement in FEV1 or

increase of 200 ml is significant5. If positive, attempt to lower dose while

maintaining efficacy6. If negative, discontinue

Inhaled Corticosteroids (ICS)

• Adding an ICS to bronchodilator treatment is appropriate for symptomatic COPD patients with an FEV1 < 50% predicted (Stage III: Severe COPD and Stage IV: Very Severe COPD) and repeated exacerbations

• An ICS combined with a LABA is more effective than the individual components– Fluticasone/salmeterol (Advair®)

Salmeterol and Fluticasone Propionate and Survival in Chronic Obstructive Pulmonary Disease

NEJM 2007;356:775-789.• Pt Pop: 6,112 patients with COPD (FEV1 < 60%

predicted)• Therapy: Randomized to salmeterol 50 mcg bid

+ fluticasone 500 mcg bid OR salmeterol OR fluticasone OR placebo X 3 years

• Results:– All cause mortality rates were 12.6% in combination

group, 15.2% in placebo group, 13.5% in salmeterol group and 16% in fluticasone group

– Combination therapy was associated with significant improvements in health status, lung function, and frequency of exacerbations

Corticosteroids

• Based on lack of evidence of benefit and the large body of evidence on side effects, long-term treatment with oral corticosteroids is not recommended in COPD

Pharmacotherapy: Expectorants and Mucolytics

• Little evidence of value• Guaifensin 600-1200 mg bid may provide

subjective benefit• Widespread use cannot be recommended on

basis of present evidence

Pharmacotherapy: Antibiotics

• Indicated for infections only• Prophylactic, continuous use has been shown to

have no effect on frequency of acute exacerbations

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Pharmacotherapy: Antioxidant Agents

• No effect of n-acetylcysteine on frequency of exacerbations, except in patients not treated with an ICS

Success of pharmacotherapy for chronic management of COPD is limited by the irreversible

nature of the disease

Supplemental Oxygen Therapy

• To correct hypoxemia and prevent secondary organ damage

• Use 18-20 hours daily to maintain oxygen saturation > 90%

Long-term oxygen therapy has been shown to prolong survival and improve quality of life

Pulmonary Rehabilitation Programs

• Involve general physical conditioning, breathing exercises, muscle training, nutritional assistance and education

• Such programs have been shown to decrease physician office visits and phone calls and improve quality of life

Role of Peak Flow Monitoring

• Little evidence of value unless patient has significant reversible component

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COPD and Co-Morbidities

• COPD patients are at increased risk for: – Myocardial infarction– Angina– Osteoporosis– Respiratory infection– Depression– Diabetes– Lung cancer

COPD and Co-Morbidities

• COPD has significant extrapulmonary (systemic) effects including: – Weight loss– Nutritional abnormalities– Skeletal muscle dysfunction

Therapy at Each Stage of COPD

Add oxygen if chronic respiratory failure; Consider surgical options

Add inhaled corticosteroids if repeated exacerbations

Add one or more long acting bronchodilators; Add rehabilitation

Active reduction of risk factors; influenza vaccination Add short acting bronchodilator PRN

FEV1/FVC < 0.70FEV1 <30% predicted or FEV1 <50% plus chronic respiratory failure

FEV1/FVC < 0.70FEV1 30-50% predicted

FEV1/FVC < 0.70FEV1 50- 80% predicted

FEV1/FVC < 0.70FEV1 ≥ 80% predicted

IV: Very SevereIII: SevereII: ModerateI: Mild

www.goldcopd.com

Stepped Care Approach

• Mild COPD– Risk factor reduction– Inhaled SABA prn

Stepped Care Approach

• Moderate COPD– Risk factor reduction– PRN inhaled SABA– Regular treatment with 1 or more bronchodilator– Pulmonary rehab is an option

Stepped Care Approach

• Severe COPD– Risk factor reduction– PRN short acting agent– Regular treatment with 1 or more bronchodilator– ICS if repeated exacerbations– Treatment of complications– Rehabilitation

Stepped Care Approach

• Very Severe– Same as severe– Plus

• Long term oxygen if in respiratory failure• Surgical options (lung reduction, lung

transplant)

Choose your option below.Next Topic: Management of COPD Exacerbations

Management of COPD Exacerbations

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Management of COPD Exacerbations

• An exacerbation of COPD is defined as “an event in the natural course of the disease characterized by a change in the patient’s baseline dyspnea, cough, and/or sputum that is beyond normal day-to-day variations, is acute in onset, and may warrant a change in regular medication in a patient with underlying COPD”

Acute Exacerbations of COPD

• Mild to Moderate COPD– Exacerbation is associated with increased

breathlessness, often accompanied by increased cough and sputum production

• Severe COPD– Exacerbations may be associated with acute

respiratory failure

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COPD Exacerbations

• Causes– Infection of the tracheobronchial tree – Air pollution

• 1/3 have no known cause

Management of COPD Exacerbations

• GOLD and ATS/ERS guidelines• Severity varies

– Mild – home treatment– Moderate – hospitalization– Severe – respiratory failure

Home Management of Mild Exacerbation

• Increase dose and/or frequency of existing bronchodilator therapy

• If not already used, add anticholinergic until symptoms improve

• Short course of systemic corticosteroids • Antibiotic if infection is present

Antibiotics in Exacerbations

• More beneficial in patients with more severe exacerbations rather than mild

• First line agents = narrow-spectrum– Streptococcus pneumoniae, Haemophilus

influenzae, Moraxella catarrhalis

Bronchodilators in Exacerbations

• First line agents = SABA and anticholinergic bronchodilators– Both equally effective– Anticholinergics may be better tolerated

• May be used together for additional improvement• Adding a methylxanthine is not routinely

recommended

Corticosteroids in Exacerbations

• If not currently on, use systemic corticosteroids for up to 2 weeks for moderate to severe exacerbations

• Optimal dose and duration unknown

Prevention of Exacerbations

• Regular use of bronchodilators and ICS (depending on severity)

• Education– Important role for pharmacists

Exacerbations affect the quality of life and prognosis of patients with COPD

Choose your option below.Next Topic: Application Exercise

Application Exercise

Management of COPD

Case Presentation

• Evelyn is a 82 year old woman who resides in an assisted living facility

• Past medical history: HTN, stroke, essential tremor, mild dementia, 40 pack year smoking history

Case Presentation

• Current issues: Gets “winded” walking to dining room, cough with copious sputum production, both hands shake continuously, difficulty walking up stairs

• Has frequent respiratory infections in winter• She worked for many years as a secretary in

Maine

Case Presentation

• Current medications:– Lisinopril 40 mg qd– EC ASA 325 mg bid– Omeprazole 20 mg qd

What risk factors for COPD does she have?

a. Tobacco smoke and occupational dusts b. History of infections and smokingc. Smokingd. Alpha-1 antitrypsin deficiency and smoking

Best Answer

c. SmokingShe has a 40 pack year history of smoking. Pack years is determined by multiplying the number of years of smoking by the number of packs per day (i.e., 1 pack/day x 10 yrs = 10 pack years)Her history of recent infections is not a risk factor. History of numerous childhood respiratory infections is a risk factor.

What symptoms suggest she has COPD?

a. Dyspnea on exertionb. Dyspnea on exertion, cough, and sputum

productionc. Hand tremor and difficulty walkingd. Dyspnea on exertion, cough, sputum

production, and difficulty walking

Best Answer

b. Dyspnea on exertion, cough, and sputum productionShe has the classic symptoms of COPD. Her tremor and difficulty walking are unrelated to COPD. Her history of frequent respiratory infections also suggests a diagnosis of COPD

Case Presentation

• A diagnosis of COPD was confirmed with spirometry– FEV1/FVC is < 70%– FEV1 = 75% of age predicted value

Based on the GOLD staging system, which stage disease does she have?

a. Stage Ib. Stage IIc. Stage IIId. Stage IV

Best Answer

b. Stage II– Stage II or moderate COPD is defined as

FEV1/FVC < 0.70 and FEV1 50- 80% predicted

– Based on her FEV1/FVC of < 70% and FEV1of < 75% of age predicted value she has Stage II or moderate disease

Which medication regimen should she be started on?

a. Albuterol inhaler 2 puffs prn b. Triamcinolone inhaler 6 puffs bid plus

albuterol inhaler 2 puffs bidc. Ipratropium inhaler 2 puffs qidd. Tiotropium 2 inhalations bid plus albuterol

inhaler 2 puffs prn

Best Answer

d. Tiotropium 2 inhalations bid plus albuterol inhaler 2 puffs prnA long acting anticholinergic should be initiated with a short acting β2 agonist for acute use. Her inhaler technique will need to be assessed. She may require the use of a holding chamber because of her tremor

Which vaccination should she receive annually?

a. Influenzab. Pneumococcal pneumoniac. Influenza and pneumococcald. Influenza, pneumococcal, and haemophilus

Best Answer

a. InfluenzaShe should receive an annual influenza

vaccination. In addition she should receive a pneumococcal vaccination if one has never been administered or she was < 65 years old when given

Summarize Action Plan for Evelyn

• Start combination long acting anticholinergic and short acting β2 agonist prn

• Demonstrate use of DPI to insure drug delivery• Consider holding chamber use• Monitor use• Monitor symptoms and activity• Review vaccinations

– Influenza annually– 2 doses of the pneumoccal vaccine dosed 5 years

apart

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